It’s one thing to pass an order of prohibition, and another to work on the ground to implement it. In the meantime, the people who suffer the most are alcoholics.

In Bihar, where partial prohibition came into effect on April 1, both alcoholics and medical care providers were caught by surprise by the Nitish Kumar government’s decision to extend the ban on country-liquor to Indian Made Foreign Liquor, or IMFL, on April 6, effectively making Bihar a completely dry state like Gujarat.

So far, three people in the state have died after suffering from alcohol withdrawal syndrome. State government records also show that nearly 200 alcoholic patients have been admitted to government hospitals, and 1,300 been treated without admission since April 1. The common symptoms of alcohol withdrawal include anxiety, depression, fatigue, insomnia, nausea and vomiting, and sweating.

With Tamil Nadu chief minister J Jayalalithaa making promises of phased prohibition if elected back to power in the upcoming Assembly polls, TN (and any other state considering prohibition) first needs to look at what it must have in place before it finalises any prohibition order. In short, it must learn from Bihar’s mistakes.

Phased ban

Alcoholism is not a vice but a psychiatric disorder, classified by the International Classification of Diseases and endorsed by the Diagnostic and Statistical Manual of Mental Disorders, said Dr Harish Shetty, a psychiatrist based in Mumbai. “Stopping the sale of alcohol is the same as stopping the sale of hypertensives or anti-diabetic drugs,” said Dr Shetty. “The government should have consulted health professionals before taking this step.”

The Bihar government did consult public health experts, but only for their technical knowledge on how the ban can be enforced and how de-addiction centres could be set up. It did not ask them whether the ban was feasible to begin with, and whether the state health machinery could handle patients coming to them with withdrawal symptoms. “The decision was political and we were not consulted before the ban,” said Dr PK Singh, head of psychiatry at the Patna Medical College.

It’s also clear that Bihar’s public health machinery had prepared for a partial ban, not a total one. “We started the process about two months ago, not very much ahead of time,” said Dr NK Sinha, state programme officer for de-addiction centres. “We needed to have trained manpower and infrastructure to deal with de-addiction before the prohibition order came into force.”

A de-addiction centre was established in each district hospital complete with air conditioning, television, CCTV and even carrom boards for patients to play with. Bihar also recruited counsellors, and placed a drug inspector at each centre to ensure there was no shortage of drugs. “We prepared for the worst,” said Dr Sinha. “The people who are dependent on alcohol need timely help… Despite detoxification, the relapse rate is very high. We are also ready with anti-craving drugs in case of relapse.”

But despite all the preparations, nobody had prepared for a total ban. All the training too was done keeping in mind that it was a partial ban. “We thought that even if the country liquor is gone, the expensive alcohol is available,” said Dr Sinha. “[We thought] thodi rahat milti logon ko (alcoholics would have felt some relief). We weren’t prepared for a total ban.” Dr PK Singh echoed Dr Sinha. “We were under the impression that the ban would be a partial one.”

Rakhi Sharma, who runs Disha De-addiction Centre, which has six centres all over the state, including Patna, said if health officials knew that the ban was a complete one, they would have prepared differently. “We were a little casual about the ban, because we thought the ban was partial,” she said.

‘Alcoholics are not dispensable’

The surprise extension of the ban to all kinds of liquor therefore caught everyone by surprise. Doctors have panned the state government for treating the lives of alcoholics so casually. “No person should die (because of a decision like this). Medical ethics does not permit it,” said Abhay Shukla, from the Pune chapter of the Jan Swasthya Abhiyaan, an umbrella network for all organisations that work on public health. “Whether the person is an alcoholic or a drug addict, his or her life is not less valuable.”

Of the three men who died after suffering from alcohol withdrawal, one was from Kaimur district. “The man was taking treatment from a quack, and he died within 15 minutes of being admitted in the district hospital,” said Dr Sinha.

Another alcoholic from Katihar district died after refusing treatment in the district hospital. He was later sent to Katihar Medical College, only after he became critical, and died within an hour. Another alcoholic died in Patna.

Dr Shetty said that the government should have given the state’s medical service providers at least six months notice on its move to ban all alcohol. “The problem is that alcoholism is a stigma and people don’t see it as an issue to be dealt with,” said Dr Shetty. “It is the same as in the case of suicide. These are public health problems.”

Timely intervention seems to be the key in cases of alcohol withdrawal. But as is the case across India, Bihar’s public health apparatus is already under major strain. “We have 60% vacancies of medical officers in government hospitals,” said Dr Shakeel-ur-Rehman from the Jan Swasthya Abhiyaan. “Of the approximately 6,700 medical officers we need, we only have 2,700. There are only 532 primary health centres, which would be one for every two lakh people. The World Health Organisation standard is one hospital for every 30,000 people. We have added another burden to this already pathetic system.”

Only psychiatrists can handle chronic and serious cases of alcohol withdrawal, said Dr Vinay Kumar, a psychiatrist based in Patna. But there are only about 70 qualified psychiatrists in Bihar.

Silver lining

But doctors say that there’s one positive development – there are fewer patients seeking de-addiction than they expected. “We were expecting a more chaotic situation,” said Dr Singh.

For instance, in Madhubani district hospital, doctors have been treating two to three patients a day. None have been admitted so far. “My two officers who were trained for de-addiction are on leave,” said Dr AK Sinha, medical officer in charge of the hospital. “We are managing well though.”

In Jamui district hospital, three people were admitted with symptoms of alcohol withdrawal. “The patients were suffering from insomnia and hallucinations,” said Dr Sayyed Naushad Ahmed, the deputy superintendent of the hospital. “The patients are poor, and daily wage workers. They are even malnourished which only accentuates the symptoms.”

Rakhi Sharma of Disha Deaddiction Centre said the low numbers of patients could possibly be because some alcoholics had kept a stash that may run out in a few days. “Or they are able to satisfy their cravings with other substances,” she said. The Disha centre recently got a case where a 30-year-old man addicted to country liquor switched to other substances and got very sick. “The patient switched to all kinds of other substances such as ganja (weed), bhang,” said Sharma. “He was very violent when he was referred to us.”

Prohibition no solution

A 2015 paper published in the British medical journal, The Lancet, authored by psychiatrist Dr Vikram Patel, discussed how governments could try to reduce the burden of mental health problems in their countries. It suggested that the problem of alcohol and other illicit drug use could be tackled by regulating the availability and demand for alcohol by, say, raising taxes, banning advertisements, and penalising risky behaviours related to alcohol, such as drunk driving.

“There is no mention of prohibition (as a recommendation to address the problem of alcoholism),” said Dr Patel, who is a professor at the London School of Hygiene and Tropical Medicine. “The simple reason is that it has failed in every country where it has been attempted by criminalising both the trade and the user. Instead of adopting a public health approach as the rest of the world does, India’s political leaders are backing a failed policy to win votes.”