Tuesday, May 26, 2009

Alcoholism as a symptom of addiction

Hi. My name is Jeff, and I am an addict. When I was in college, I studied for the MCATs consistently, non-stop for four months. The more I studied, the more I kept on thinking about studying and the more I ended up studying. When I wasn’t studying, I felt that I should be studying to the point of being self-destructive. I was surrendering friendships and fun, losing touch with old friends and not making new ones, besides my MCAT books. My downstairs neighbor commented that she was often in our apartment hanging out but never saw me since I was never there. Instead, I was studying. I stopped exercising, started getting anxious, and I thought it was all normal and that it would only make the test go better. When I took the actual exam, I had actually studied too hard and could not physically put my brain through the verbal section. My brain was fried, burnt out, and said ‘no more’ at the time I needed it the most. I ended up doing poorly on the verbal section, forcing me to retake the MCATs.


My behavior was compulsive, progressive and self-destructive, all signs of an addiction. Was I addicted to studying for the MCATs? No, but my dependence on it does point to an underlying addiction. So how could I be dependant on MCAT studying without being addicted to it? This is an important distinction to make and one that is essential in my alcoholism and deaddiction project in Jamkhed.


What happens when our brain receives information? And how does that information then turn into action? Studies have come to find that our limbic system, or more specifically our amygdale, plays a large role in the actions we make. Previously it was understood that our feelings were simply derived from our actions, yet brain imaging studies have shown that the amygdale actually responds to information collected before the action takes place. Thereby, our actions are in large part a reflection of our feelings. This has had a great deal of importance in addiction medicine, showing that to truly treat an addiction you must go to the root of the cause, which involves feelings rather than simply thought and action.


In our life, we have both good feelings and bad ones. Both are strong, but it is usually the negative ones that burden us. These negative feelings derive from unhealthy relationships with friends, family, money, work, society and ourselves. These negative emotions exist in all of us and drive us to need good feelings, largely determining our behavior in life. With alcoholism, the good feeling is found in a bottle, with the drive to alcohol propagated by our underlying negative feelings. Alcoholism is thereby a dependency on alcohol to achieve that good feeling, similar to dependencies on gambling, drugs, eating, sex, exercising and many other behaviors. The dependency increases as tolerance increases and chemical imbalances create a need for it beyond emotion. Yet originally behind that dependency is a different addiction – a disease of our emotions in which we are reliant upon negative emotions. The dependency can change while the addiction remains, as often we find alcoholics who stop drinking but turn to workaholics, or who stop tobacco yet take on gambling, or quit eating and switch to exercise. The addiction has little to do with the alcoholism but rather the alcoholism serves as a symptom of addiction.


Further, studies have shown that similar chemical imbalances are achieved in the brain by alcohol, working, gambling, shopping, sex and drugs (1). This research has shown that the same pleasures can be achieved regardless of the dependence. The significance is that what is important is not the dependence which creates the pleasure but rather the addiction that drives the need for a pleasure. Therefore, removing the alcohol from an addict may remove that specific dependency but the addiction will drive the man to find a new dependant behavior. This is regardless of the fact that it may be much more difficult for a man to quit his dependence on alcohol or drugs than exercise or eating due to higher tolerance and cravings.


Addiction counseling and rehabilitation must focus on the understanding that the removal of alcohol from the addict will not solve the whole problem but that the underlying negative emotions must be addressed. Deeper examination is necessary of the addict’s relationship with the world around him and with himself. For this reason, the Twelve Step Program (used by Alcoholics Anonymous and other groups) is such a success. The twelve steps focus on the concept that that we are powerless over alcohol. To make amends, we must deeply examine ourselves and repair those relationships that have been harmed and harmful. It is a focus on examining the emotions and the struggle within ourselves, not with the bottle or with the actual dependency.


In Jamkhed, Friday and Saturday were spent with an addiction doctor and counselor from Pune Adventist Hospital. To update from a previous post Beginning part two of the alcohol and hypertension study: a 2nd and more successful meeting was held with the village where hypertension was discussed, results from the study shared, and the issue of alcohol only touched upon. Connections were kept with the Indiranagar village as we identified men in the village who were open to discussing alcohol. A partnership was made with Pune Adventist Hospital’s deaddiction program and they just recently came to Jamkhed for a two-day session with our three counselors focusing on both theory and logistics.


At this point, the plan is for the counselors to meet throughout the week and continue to discuss the theory behind addiction, using AA’s The Big Book as a guide. Simultaneously, one of the counselors (a recovered alcoholic) will begin to meet with men from Indiranagar who want to quit three times per week, eventually taking them through the twelve steps. Once a solid group has formed, an awareness program will be launched and the Pune Adventist group will return to run a five-day detox center. Most importantly, at this point the outlook looks promising and achievable. If the steps as planned are taken, the project has a bright (although difficult) future for CRHP and the men who deserve the opportunity to quit drinking and treat their addiction if they so desire.


When we tell alcoholics that they are wrong and bad people, we are not only wrong about the alcoholics but we are lying to ourselves. We are all addicts. We all face feelings very similar to those of alcoholics, including fear, sadness, resentment, guilt, insecurity, egoism, irresponsibility and shame. The difference comes in our coping mechanisms, as we are able to deal with and hide these feelings from others and ourselves better than is someone who deals with alcoholism. Because of their impaired coping skills, these universal feelings are expressed more openly, allowing us to label and diagnose an alcoholic as some different than ourselves rather than examining our own relation with those feelings. Alcoholics are not mad or bad people but rather are sick with a disease of the emotions. A great first step in helping recovering alcoholics is to recognize that we are not so different after all, and we all face our own addictions.

Tuesday, May 19, 2009

These peanuts are making me thirsty

We walked into the farm beside the new hospital, bent down and grabbed out a couple bushels of plants with roots of peanuts. We sat on the dirt, removing the peanuts from the plant, rubbing the dirt with our hands, opening them and popping them into our mouths. Eating with friends was nothing new, but eating raw food straight from the source was something rarely experienced. At Jamkhed, it has been nice knowing where my food comes from and I have come to appreciate that relationship in health, both by respecting the food and understanding the conditions it came from. The relationship is important at CRHP and is imbedded into us while at Karkut Farm, CRHP’s local farm 20 minutes from the hospital.

All the food made at CRHP comes from Karkut, which I have visited around ten times. At Karkut, we often pick corn from the field and roast it in coal, watch farmers milk cows and place the milk into jars then brought to CRHP, see chickens lay eggs that are put into bags and then into omelets at breakfast, speak with farmers who till the land where eggplant is grown, or walk through fields of sorghum wheat. Karkut serves many purposes, one of which is to provide organic food for the Arole’s, guests and some staff at the CRHP campus.

The farm’s larger contribution comes from harmonizing our relationship with the environment and land. Karkut teaches villagers and farmers about farming techniques, focusing on those which foster a beneficial and sustainable relationship with the environment. Upon initial arrival to Jamkhed, the Arole’s found that men had a rather destructive relationship with their land, unsure of how to best utilize their space and have it provide for them, especially during drought. There was no leveling of land, no water harvesting and farmland was rocky. With the understanding that it was essential to have productive agriculture to reduce child mortality, for families to be happy and mentally at ease, and for nutrition to be discussed, CRHP started the watershed development program and farmer’s clubs. Farmer’s clubs were men who would come together and discuss new techniques and solutions to common problems plaguing their land and crops, as well as displaying good farming techniques. Techniques such as irrigation, farm ponds, proper spacing of land, co-placement of trees and crops and crop rotation are all exemplified and discussed at Karkut.

Karkut also provides the space to be inventive and experimental with farming methods that are affordable and natural. The earth provides for our own needs and when properly utilized can save the trouble, cost and danger of using products usually paid for. The Neem plant, for example, serves many purposes. When planted along the side of the road, it prevents animals from grazing and plant infections from entering. When converted into a liquid, Neem becomes a natural insecticide. When the branches are torn off, many Indians use it as a toothbrush. Or the Moringa tree, which originated from India and is commonly found throughout Africa. The seed pods have been proven to purify contaminated water. The leaves can be prepared similarly to spinach and are low in fats and carbohydrates but contain a high content of protein, calcium, iron, potassium and vitamins A, B and C. Additionally, soil fertilization at Karkut farm is done by worms that eat up old vegetables, soil and cow dung and poop out rejuvenated soil. Thousands of worms squirm away next to the farmhouse producing fertilizer within weeks and at only marginal cost. These methods are all experimented with on the farm and those that are successful then transferred to other farmers.

Karkut also works to reduce stigma associated with HIV/AIDS, as every female farm-worker is HIV positive. Karkut provides them with housing, stability, work and acceptance. This trend started in the mid-nineties when HIV positive women began to present at the hospital sick, stigmatized, alone and depressed. With food, support and love, these women serve an indispensable role in running and maintaining the farm. All receive antiretrovirals from the government and CRHP is not shy to tell their story and raise awareness about their success.

In urban areas, it is all too easy to become disconnected with our food and forget its origins. Living in Atlanta, Boston and New York, I would rarely think about where my food came from, how it got there, who was responsible for growing it, or how my own actions effect its growth. All that was important was my food getting to me when I needed it. Living in a rural area changes this view, not only by eating peanuts straight from the ground or walking on farmland, but from seeing how the rain (and lack of it) affects the mood of villagers, or how suddenly we will not be eating onions because the crop became infected and prices raised. The connection is especially strong from seeing how the health of children and families is dramatically affected by the weather. It is important both as a person and as a doctor to think about the behind-the-scenes view of the food we eat because it is usually grown right next door and plays a large component in our own health as well as that of our community.

Thursday, May 7, 2009

It’s more than just a name

Before the money makes its hands into the pockets of local and national politicians, the ideas behind the money make its way into headlines and speeches that dominate the news before elections. Each Indian has the right to vote and the dalits (untouchable caste) comprise over 16% of Indians. This population is thus targeted during the election, showing that while the caste system has been banished upon independence from Britain, the entrenchment of it in every way of life is still very ripe. Programs dedicated to raising the status of India’s poor, providing them better education, housing and food security all appear. This year the message focused on infrastructure, namely roads and electricity, defined as the hot topics for this election.


Election Day is a madhouse, with a good rate of turnout from all castes and both genders, upwards of 55% in Jamkhed. Advertisements to vote dominate the radio and speeches are made in many villages and towns pre-election. On Election Day, party representatives line the streets handing out money and attracting swing voters. This year’s election is dominated by three parties: United Progressive Alliance, National Democratic Alliance, and the Communist Party. The UPA is largely formed by the Congress Party, started by Nehru (India’s first PM) and Gandhi and synonymous with Indian politics for the last 60 years. NDA is largely formed by the BJP, a more fundamentalist Hindu party attempting, among many other things, to restore power to the Hindu population. The Communist Party is formed by three to four smaller parties on the basis of secularism, including no casteism, in addition to opposing globalization and U.S. relations.


The party that has been most helpful to the dalits is the Congress Party, although many programs instituted to help the neediest of Indians have failed to make their mark, as only 1% of India’s GDP is spent on health while malnutrition is suffered by 55% of children living in rural areas and 45% in urban areas. The caste system is supposed to be banned yet still exists, according to Dr. Arole, in the mind of every Indian in every village. Although land is supposed to be distributed equitably, much of the good farmland in Maharashtra continues to be controlled by Brahmins and Marathas (upper-caste Hindus) and worked on by dalits and Muslims. Although inter-caste and love marriages occur, every parent I have met seems to be faced with the incredible difficulty of pairing their son/daughter with someone on the same caste. For one lower-caste family at CRHP, their daughter is enrolled higher education and they are having difficulty finding a son-in-law in their same caste but of reputable education and standing.


The caste system is set so that it is nearly impossible to escape a line of work simply based on your last name. In Jamkhed, ‘Dadar’ typically cleans roads and works for the municipality, ‘Shindi’ are businessmen, ‘Madari’ are snake-charmers, and ‘Dukre’ are stone workers. It is possible to escape and create your own name, but on the contrary it is sometimes said that this delegation of responsibilities according to last name is good and useful for India, ensuring that every task is accounted for. However, when a system institutes a profession from birth with little chance for individual thinking and felt opportunity, human development becomes static. Much has been written about the social structure of India with its caste hierarchy but a system that enforces a subcaste to clean bathrooms and carry a bucket of human feces on their head keep the spirit stagnant and ignored.


Saying the situation today is as bad as it was when CRHP first entered villages in 1970 is incorrect. When Drs. Mabelle and Raj Arole first went into villages, caste was one of the greatest barriers to overcome and enable health. Low castes usually lived in the outskirts of the village, on area owned by landlords who lived within the village. Dalits were often not allowed to enter the homes of the high caste, or if so, could not touch anything. In some villages, dalits were prohibited from drawing water from the common pump, waiting for a high caste member to come and pump for them. They would not drink from the same cup of water, afraid of contamination. In school, the children would play among their own caste and sit in sections according to caste, at times only taught by teachers from their own caste. Malnutrition and disease was much higher in the dalit section outside the village. Further, the system was reinforced by a belief that this discrepancy in life was deserved from a past life and justified by a belief of moral superiority of the high caste.


To overcome these caste barriers, CRHP used unique techniques. One was use of a water diviner, who was encouraged to place a water well only in the dalit section of the village, forcing the high caste to walk into this section and confront the realities of other villagers. Children were used to break false beliefs about contamination as different castes would bring water from their homes to pour into a cooking pot, sharing the common food together. The village health worker, commonly a dalit, would display her value by entering high caste homes, delivering high caste babies, and proving necessary to rid villages of disease. Over time and with the help of villagers and awareness campaigns, caste discrimination has been lessened while caste distinction still remains. In non-CRHP project villages, caste discrimination continues to remain and CRHP has had to drop projects in some villages because the issue of caste could not be overcome. Government programs plentifully exist that attempt to raise the status of the untouchables, many initiated by Dr. Ambedkar (a hero among Maharashtran’s – his portrait can be seen on the wall of every village house) but it is fascinating to see how villages and events utilize caste to their advantage.