Shekhar Saxena is Professor of the Practice of Global Mental Health at the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health. He was interviewed by Virginia Berridge in 2024 for the Addiction Lives series.
Virginia Berridge: Well I thought maybe we could start, I’ve been looking at what you answered to the interview questions and maybe we could start with your early career and how you first became involved in the addictions area.
Shekhar Saxena: Sure, my entry into the area of addictions was not a preplanned entry. I was a psychiatrist, working in India, that is my home country and was involved in technical work, as well as teaching and to some extent in research in the overall area of mental health when I was given a possibility to have a scholarship and go to London to do a Diploma in Addiction Behaviours. So I thought in view of the growing issues of addictions in India, it might be a good idea to do that and become more formally qualified in tackling the coming threats to the society in India. And I took the chance and came to London for a one-year diploma in the Addiction Research Unit. Actually, I learnt so much during that period, which was quite applicable to my working situations in India that it became, not an exclusive, but one of the major areas of my work, for the next 35 years or so. And I really learned a lot from that very initial one year experience.
What sort of things stand out from that year in your memory?
Um, I think one thing that stood out was that when it comes to addictive behaviours we are all the same. We are just human beings who have the same tendencies, same vulnerabilities and the same proclivities in a way – in the middle of varying and sometimes drastically different environment and different substances – but the human mind reacts the same way. And I think that was a major lesson that I learned, that it’s an interaction between the substance, the person, and the environment. And that kind of triangle has worked for me to solve, and to understand a variety of issues related to addictive behaviour and that I think was the very basic knowledge that has helped me over the years in a variety of ways and I think that it stood out as one of the major lessons from my one year.
Yes and you mentioned the portacabin offices of the Addiction Research Unit being very chilly at the time!
Yes the physical structure was very basic. It was an academic environment in an area that wasn’t even appreciated that much in the UK at that time, so it was a struggle to have resources for the kind of research which Professor Griffith Edwards and the colleagues were planning to do and actually doing, along with teaching and policy advice. But yes, the people were very warm and welcoming and it worked out as one of the periods that I really enjoyed. Just to think about it, I had worked as a fully qualified psychiatrist for about eight years before I went there and here I was again a student. That was difficult to adjust to in the beginning, but it worked out just very well, because I had no patients waiting outside my room and I had no research papers to finish and it was just a learning environment that I really enjoyed.
Yes and was there a thought that you might stay in England and work, or did you always intend to return to India?
My intention was always to return to India and continue with my work with this added pot of knowledge that I’d gained. But yes, there was an opportunity for me to be able to continue working in London and actually it was informally offered to me. But I thought about it and I said I will be one of the addiction specialists in a city that had at least a couple of hundred even at that time and in Delhi, I will perhaps be the first formally qualified addiction specialist and would be one in a city of many millions, or will I be one of the hundreds and I think that’s why I saw very clearly, that I can have more possibility to contribute to the world and to my country in a substantial way if I returned back, which I did.
So you returned to India and what happened then?
I returned to India and continued with my faculty job in my parent institute. I was still doing both kind of work, the mental health work that I had been doing, but also additional work on addictions that I was given in view of my recent qualification and it just worked out very well, because the addiction field was expanding. Many more people needed help and also I could start a training programme in India, for training more people in addictive behaviours. In fact it coincided with the foundation of a Centre of Excellence for Addictive Behaviours, which I contributed to and I think I was very lucky to be there at the right time, at the right place, for this to happen in a substantial way.
Was that in Delhi, the Centre, yeah?
That’s correct, it was in fact part of my Institute, but it was an advanced centre which was established just around that time when I returned and it was coincidentally a very opportunistic event, so that I could help our country move in a very substantial way to that area of work.
So the whole field was taking off in India was it at that time?
Absolutely. And again surprisingly, or maybe not surprisingly, alcohol had been a problem in India for a long time and was growing. But it was the initiation of some of the opioid drugs, which became a more well-known threat and that’s what led to the foundation of this Centre, rather than the ‘drug’ that we all knew for a long time and had lived with. So it was the threat for pure drugs which came from outside the borders of India, but was involving a lot of young people, which became actually a policy catalyst for much more attention and much more resource had been given to the area of addictive behaviours.
And you mentioned a policy initiative that you contributed to, the Narcotic Drugs and Psychotropic Substances Act, could you tell me something about that?
Yes with the increased attention amongst the public, as well as amongst the policymakers it became very clear that there has to be a law which governs the penalty, the legal penalties, as well as the healthcare for people who are having addiction behaviours, especially with the drugs as I mentioned earlier. And the Government of India decided to start a process of having a new law, which was in this area and this is the law that they started working on and I was one of the people who provided technical advice to the Ministry of Law for having that law, having that Act which eventually became the law. And one of the features was, in fact one of the sensitive points was, should it be a legal and penal process that people who are taking drugs should go to, or should it be a health aspect and there was a raging public debate on that, which actually reminded me of my time in London, where again this process was going on. So it was from a perspective of health, I fiercely argued for penalties to be there for people who are obviously spreading drugs and benefitting by selling drugs, but for an average user of drugs, it should be the health part, which should be the pre-dominant part. So that was a major issue for discussion and eventually it worked out reasonably well, I should not say perfectly well, but reasonably well for the Indian law to have at least a small quantity perspective, so that people caught with a small quantity of drugs were actually deemed not to be breaking the law in a big way and were given help, through treatment and recovery, rather than being confined to jails and prisons and subject to the full force of the law, which was one of the thoughts that was prevalent.
And when was that Act passed?
That Act was passed in 1985 and I contributed to its initial development as well as to its subsequent revisions.
Yes. Yes and that approach, has that approach been maintained in the intervening years in India?
Absolutely. In fact, with the revisions of the law, which has happened after that, at least a couple of times. The approach of a differing level of penalties for people who are just users versus people who are pedlars has continued and in fact has been strengthened more. So that Indian law is fairly strong, but has clear differentiation between people who break the law in a small way versus those who break the law in a big way.
Yeah. So then you were back in India for ten years and then you moved to the World Health Organisation, when was it you went there?
I went there initially in 1998, which is about a little more than nine years after I returned to India and that was initially for my work related to mental health, but it was the same department that was responsible for both areas, the Department of Mental Health and Substance Abuse. So very soon I found my interest to be, now very much at a global level to contribute to the effort of the World Health Organisation in the area of addictive behaviours and contributed to some extent for, in the area of alcohol as well as of drugs, and the relationship between drugs and HIV, which then became even more of a stronger focus of my work in the future. One of the highlights of that period was the continuing discussion and technical contribution of the WHO in the area of alcohol for the global strategy that was built and then agreed upon by the member states for the health aspects of alcohol, how countries should deal with that and that became a primary interest for me.
Was that a difficult issue to get on the agenda?
Very much so, in fact that was the first time the World Health Organisation was talking about alcohol and its health impact being the primary driver for alcohol-related policies rather than the revenue and the profits dimension and economic dimension that were prevalent before that. But it was very difficult to actually begin the discussion and lead the foundations of the of how the world and in effect the countries should view alcohol just as an ordinary economic commodity, or as a substance that has addictive potential, but also has a major health impact. And that discussion lasted for many years, before an agreement would be achieved in the countries that are the member states of WHO, to pass the global strategy at a formal level. I remember that as a major achievement of WHO, which I was fortunate enough to contribute to.
Yeah and was it an issue when you first went to WHO, or did it gradually emerge onto the agenda, because you had the Framework Convention on Tobacco Control which was happening at a roughly similar time wasn’t it?
That’s correct. But alcohol was not an issue when I joined WHO to begin with in 1998 and it gradually came up, one could say even on the back of the Tobacco Treaty, because there are of course many similarities between the two, and many differences also. But having, in a way, won the battle with the tobacco industry the WHO became a little more confident to deal with other substances. So in an indirect way it did help to form the groundwork for the alcohol strategy.
And there was opposition to it presumably from all sorts of interests.
Absolutely. In fact, there was vehement opposition from some of the member states, though not all. Most of them were from the west and they were major exporters and producers of alcohol deriving a substantial amount of revenue from alcohol for domestic production and consumption, but also from exports. They would not want health aspect to in any way influence their trade and commercial strategies. So it was many years of work put on the technical side to collect the evidence that alcohol is directly and indirectly responsible for millions of deaths and a substantial amount of disease morbidity and disability. But also on the political side to prepare the groundwork for negotiation and to get the help of countries that were in the forefront of the movement towards health being the major logic for how we deal with alcohol, rather than the commerce of it. And so it was both a political and diplomatic work, but also a lot of technical work to present the evidence in a way that became convincing and of course then wait for the issue to come up on the political agenda. But it did happen and it was very good that it did happen because after that WHO has been of course very active in the area of alcohol strategy at a global level.
Yes how has that strategy continued, what sort of impact has it had longer term?
The strategy was formally agreed in 2010, but after that also WHO has been very active and in fact later on the strategy became a formal action plan, which in WHO’s parlance is stronger than just a strategy. So it has had a major impact. But I would qualify my statement when I say major impact, it has had a major impact in one way for making the public much more aware and has had an effect on policies of many countries. But I also see that the alcohol industry is even more powerful compared to the time that I was talking about and so in many countries the battle continues unabated. And in some countries, there has been a setback legally so that the industry is actually winning the policy discussions. And some of the policy initiatives that are health oriented have actually been diluted, because of the commercial considerations of the alcohol industry.
The Action Plan was adopted only fairly recently wasn’t it, 2022?
That’s correct it was just two years back that the Action Plan was agreed and of course the Action Plan has many more, I won’t say much more teeth, but at least it’s very much more specific about the actions that countries need to take. However, WHO’s strategies and action plans are not legally binding.
No.
So they are in the form of recommendation to countries and commitment of countries to do that, but but still countries find many times reasons to at least delay, if not deny some of the provisions of the action plan, they themselves have signed.
Yes, so what sort of provisions have been opposed, what is in the Action Plan?
The industry is very keen to highlight the personal responsibility of people and the value of informing them, so that their job finishes at informing people that there could be some harms, because of consuming alcohol in a variety of ways, but doing nothing more about it. Although the strategy and action plan emphasised the value of regulations in many spheres as to who can buy it, who can consume it and in what quantities and also who can drive after drinking and who cannot, and also what are the economic aspects of the alcohol trade, which if properly managed can actually at a population level decrease markedly the harms because of alcohol. So the pricing policy, the tax policies, and also the value of providing care to people who are at risk of becoming addicted and dependent and those are the issues that the industry doesn’t like. It doesn’t like the regulation aspect. So they say we will have self-regulation, which we know has not worked and will not work. So those are the issues which the industry is still propagating but the global action plan is a very strong further step in the direction of guiding countries as how to double up the best possible alcohol policies.
Yes. So in this period when all this was going on, you had become Director of the Department of Mental Health and Substance Abuse, hadn’t you.
Yes that was the period of the year 2010 to the year 2018 and I was fortunate enough to be directing the Department’s technical activities on mental health and substance use and abuse and that was a very good opportunity for me to contribute to the efforts from both sides. And I also enjoyed the fact that the two areas were together in the same department, because there is obviously a lot of cross-fertilisation between the expertise of people with mental health background and also from the addiction background. But we also had in the department, sociologists and political scientists who we needed quite badly for the kind of things that we were trying to do and that really became a very good opportunity for me to harness the technical expertise of the department to continue to work this area of policy work.
And there was a considerable amount of work on mental health as well during the time you were at WHO?
Absolutely. In fact, again just like the alcohol strategy, the World Health Assembly passed the first Mental Health Action Plan in 2013, which was to provide guiding principles of how countries should deal with the issue of mental health and mental illness within the countries. And for the first time there were clear objectives and clear targets and even indicators to the whole world to manage their mental health policy and services, which again was something that WHO did for the first time in its existence of more than seventy years.
Yes so working in that division at that time, it sounds as though it was quite a multidisciplinary enterprise, or who were the leading disciplines at the time?
Well it was partly fortunate, but partly also very much a planned activity, because we called ourselves the Department of Mental Health and not the Department of Psychiatry. And we really followed upon that promise to say that we deal with mental health and addictions in all their dimensions and not simply mental health or psychiatry as a medical discipline. It was the public health approach that we followed, which meant that a variety of disciplines had the possibility to contribute in a very significant way. So we did have psychiatrists as a part of the staff in the department, but more than the number of psychiatrists, there were psychologists, other social scientists and economists, who actually built up the department in a way that it could satisfy the mandate of the department, to guide policies within countries, in their several dimensions and not only as a medical discipline. That was actually done by my predecessors, but I did continue with that effort and I’m happy to note that it’s being continued even further now, after 2018 when I left WHO.
Really, yeah. Who was your predecessor?
Dr Benedetto Saraceno, again a psychiatrist, but very much a reformed psychiatrist, who was heading the department before I did and actually I worked with him closely during his directorship and that was again very much, a mentoring that I received to broad base mental health and addictive behaviours, rather than to confine ourselves into a particular line of clinical work. It was in true sense a policy effort; now we were talking about mental health, rather than about mental illness, which was a very good stand to take.
So more of a public health, what would be called a public health approach now.
Absolutely. In fact, the World Health Organisation is the leading public health institution in the world and we were just following the founding principles of the World Health Organisation and translating them into the areas that we were working in.
Yes. So you finished as Director in 2018 was it?
That’s correct, yes.
So what’s happened since then?
Well I was asked by Harvard University to join its School of Public Health and although WHO felt that at the ripe old age of 62, I was ready for retirement, but I did not agree with that. So I took up a teaching position of being a Professor of Practice at Harvard T.H. Chan School of Public Health and have continued since then my affiliation there. I’ve enjoyed teaching and mentoring the students in the area of public health related to mental health and addictive behaviour and I very much enjoy the less political environment compared to WHO, but there’s still a feeling that I’m contributing to the effort of making these areas more public health orientated.
And have you focused at all on alcohol and drugs, or has it been mental health more generally?
It has been mental health more generally, but I used the experience I had in WHO, but also before that as a practising psychiatrist for teaching the areas of addictive behaviours, alcohol, and drugs. More recently my interest has taken me to another area of addictive behaviour such as gambling and gaming. I am part of the effort to have the Lancet Public Health Commission on gambling published just last month and it was a three-year effort, which I contributed to, along with many other people and I thought that was a challenge and eventually a contribution that I’m proud to have offered and given some inputs to.
Yes could you tell us something about what its work was and what its conclusions are?
Well as I was mentioning earlier the triangle of the person, the environment, and substance in this case, not a substance, but a behaviour always existed in all societies and recently, at least in some countries, increasing gambling and gaming by young people has been a major issue for societies and for policies. And it actually reminds me of my very early initiation into this field by the threat of drugs affecting young people. So perhaps this is the new ‘drug’ that we are dealing with. So I joined the effort of several other people who are much more experts in gambling than I am and contributed to the public health dimension of gambling and gaming and collecting, analysing, and presenting the evidence that the public health, the threat of gambling and gaming has increased substantially in the last few years and there is a lack of suitable regulations in most countries to deal with this newer threat. And industry attention and industry focus on these have increased substantially, especially with the transnational effort of some of these industry majors, which are very much interested in a profit driven direction to use gambling and gaming to spread widely and to get more people involved with that. I thought this was a new public health issue, which had to be tackled with and in a very small way, we have made an effort of at least presenting the evidence and some of the recommendations from the field in this area.
Yes, so that has now been published has it?
That has been published actually just a few weeks back and I can send you the link to that. It’s a long publication, just like many Lancet Commissions, but it has major implications for international as well as national policy around gambling and gaming.
Yes and is that something that WHO has also taken up?
WHO is actually part of this commission also, one of the staff members is an author there. But WHO has for many years taken some small steps towards realising the public health trade off for gambling and gaming. In fact even during my period in the WHO, we managed to include gaming disorder as a part of the International Classification of Diseases, eleventh edition, where gambling was anyway there, but the gaming was included, because it’s newer use of gaming technologies, especially using information technology matrix and mobile phones into the hands of young people. So it’s part of the classification, but it’s also trying to level up the evidence base for why gambling and gaming should be seen in the public health dimension. And the Lancet Public Health Commission has continued to make that effort and WHO has contributed and of course will benefit by the publication of this.
So do you expect the same resistance that you had from the alcohol industry, from the gaming industry?
I do. And I fully realise the financial power of the gambling and gaming industry, which is massive. It’s transnational, so we know that alcohol has to be transported in bottles and barrels and gaming can be on the wire, no country is capable of stopping the online gambling and gaming. So this is a new threat which, with new dimensions of this and I see a lot of opposition and resistance from industry in following the recommendations that the Lancet Public Health Commission has recommended.
What sort of recommendations does it make?
First of all, it highlights that gambling and gaming threaten the health of many more people than was realised earlier, or the number of people who have a so called gambling disorder. So the harms are much more, it’s just like the alcohol, the overall harms are much more for people who use gambling compared to who have a dependence diagnosis with the gambling or gaming. So that’s one of the conclusions. But the recommendations basically involve increased regulation at the national level as well as the international level, for countries to become more capable of knowing what is happening and then regulating the industry. So that the vulnerable populations within the country are protected and unabated promotional activities are curbed, so that the eventual public health harms because of gambling and gaming can be kept under control. Nobody is trying and is capable of eradicating gambling and gaming. This is again one of the behaviours that has been there for millennia, but we must need to see, how to control these in a way that protects the health of the people who are living in the country. So that is the direction that the recommendations are going for.
Yeah. Is that an issue that you plan to be involved with over time?
Yes I do plan to continue to be involved in that area also because I see it as an evolving threat, so having contributed to the effort of the Commission, I do need to, I do intend to do more teaching on that, but also contribute to any other policy efforts, including advising countries on how to implement some of the recommendations that have been provided. And also in some way, at least watch from a distance as to how WHO is reacting to this threat and make it possible for them to become much more active in this area.
Yes are there any other areas in the addiction’s field that you would like to focus on in the future?
No I think I’m in the years where I need to really focus on a few areas and not expand my work. So I think that is enough for the time being.
Okay. And looking back how has the field changed in the time that you have been working on it and what have been the challenges and how have those developed over time?
I think there is a big change, but also in some aspects things have remained the same. The change I believe has happened over the last 25 years or so is that the public is much more aware about the process of addiction and lay media as well as social media has been very active in disseminating information on that. Obviously there is also misinformation, but the information content has actually increased a lot. And similar things could be said about the policymakers, they are much more aware about the addictive behaviours. They are, in their way, trying to respond to that threat and even the public health discipline has become much more aware and much more aware about the evidence behind some of these aspects. So that is a change. The second change is that internationally, as well as nationally, policies have advanced and that has made a significant difference to the lives of people in dealing with the threat of addictions in most countries, in a small, or in a bigger way. What has not changed is that the resistance and opposition to the public health policies around addictions have continued and in fact have strengthened. So at that point of time, way back, it was the local industry which was opposed to some of these measures and they were powerful, but their power was limited to a province, or a country and now it has become a much more global issue. And some of the industry partners have actually joined hands, so that they think globally and so the public health policy also needs to think globally, to be able to challenge that. And in fact the industry has become more powerful so, while the awareness has increased, the basic conflict between the profit-making and the public health objectives have exactly remained the same and I feel that industry is able to in some way thwart some of the public health initiatives, in quite an effective way in many low and middle income countries and in some of the high countries, so that remains a persistent challenge.
Yes and where do you see the whole field going now? You seem optimistic to some extent.
I am cautiously optimistic; I say that because it’s the people who are going to make a difference. It’s not the public health researchers, it’s not the public health advisors to policies that will make the real change. They contribute and I count myself as one of them and I did contribute. But the real change comes when people want a change, because politicians react to their constituents, their voters, and that’s where the real change will come, when they become more aware and they become more empowered and both are necessary. I think the information content has increased, but the empowerment has not increased. So community groups like the movement that we saw way back in India when women joined hands to say, we will not allow alcohol to be sold in our village, because our men folks are getting harmed because of that, our children are not going to school, because we don’t have any money to pay the fee, because my husband spends all his income on alcohol. And some of these local movements were very successful. You need this kind of empowered movement by people to really make a big difference and that’s where I’m optimistic that these forces will become much more powerful and will actually effectively oppose some of the initiatives that are directed towards the profit making and not about the public health for people with addictive behaviours.
So it seems a big contrast between what you say is happening at the global level, with more globalisation amongst some key players, but also quite strong action at the local level and you talk very interestingly about what happened in India against alcohol. Was that in the eighties?
Yes that was in eighties and nineties, although I must say that some of those movements eventually were overridden by vested interests, but I’ve seen that happening and having succeeded to some extent. And yes you are right that the process are now much more global and the initiatives are not yet global, but I’m optimistic that the public health forces and the community forces will join hands and will become more powerful, so that an active opposition to the profit making on the grounds of addictive behaviours will decrease. So I still remain optimistic.
Good. Looking back over your career, one question we ask is who have been the people who have influenced you, who has been the greatest influence on you?
I would say several people, but the first person that comes to my mind is Professor Griffith Edwards, who was my teacher, my mentor and a supporter of my efforts for many years and I owe a great deal to him.
Yes, yes. Well, several of our interviewees have mentioned Griffith Edwards, yes. And anyone else going forward in your career?
Um, there are many people who are my teachers, as well as my colleagues and friends and I would count you as one of them. You did teach me back in 1988 and 89 and it taught me the value of looking back as we move forward and that is a lesson that I still remember from my discussions with you.
Well, it’s good of you to say that. Well, I think we are getting to the end of the interview, is there anything you think you’d have liked to have been asked that I haven’t asked you?
I think we have covered a lot of ground, so no. Well maybe one thing. I think we need to really prepare, the public health students much better in the area of addictive behaviour. If we really want to make a big contribution on the public health front, we need to teach public health to students of all kinds, masters of public health and doctorate-level students and in fact even at undergraduate level, some basics about addictive behaviours, so that they can double up the kind of perspectives that will be, that would be good for them to carry, even if the vast majority of them will not work in the area of addictive behaviour, because we need to broad base and democratise and popularise some of the concepts that we have amongst them, that we ourselves have talked about for decades. But we haven’t been able to impart that to the mainstream public health community and that I believe is the challenge that we haven’t been able to successfully overcome.
I guess addiction, it’s always been rather an uneasy add-on within public health hasn’t it?
Yes, uneasy, difficult, but necessary.
Yes and more so as more topics and subjects get embraced under that heading I would guess, yeah.
Absolutely.
Yeah if we’re talking about gambling as well.
Absolutely yes.
Well, I think, is there anything else you would like to add?
Except to say, thank you so much for inviting me, as well as having a very interesting chat.
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