In this occasional series we record the views and personal experience of people who have especially contributed to the evolution of ideas in the Journal's field of interest. Raul Caetano qualified in medicine in Brazil. While retaining close academic and cultural links with his native country, he has developed a career as an alcohol epidemiologist with research positions first in Berkeley, California and then at the University of Texas. He has contributed very widely to epidemiological research on drinking but with a sustained ability to develop the important ethnic dimensions of such studies.
THE BRAZILIAN CONNECTION AS RICH ENDOWMENT
Addiction (A): Where were you born?
Raul Caetano (RC): Rio de Janeiro, Brazil.
A: Tell us about your early life experiences including parents and school.
RC: I come from a relatively large family. I have three brothers and a sister, fortunately all alive and well in Rio de Janeiro. Also, in the best tradition of Latin American culture, all my mother's family lived in Rio when I was growing up, and she too had many brothers and sisters. So, I grew up surrounded by my grandparents, and many uncles, aunts and cousins. My father's family was in Portugal, with the exception of two of his brothers. So, I have always had much more contact with my mother's side of the family. I really only met my father's side of the family as an adult, when I started visiting Portugal and the Madeira Island, where he was born. I think that growing up surrounded by so many close people with different personalities prepared me for my work in medicine, and maybe psychiatry. A little tongue-in-cheek, it probably also prepared me to work with faculty as an academic dean. My school experience was very stable. I went to a French private school in Rio for the first 3 years of elementary school (I believe that the French I speak today I owe in part to my learning in those early formative years). Then I studied for the next 9 years with Franciscans, and after that it was medical school. I think that much of my aversion to organized religion comes from all those years of experience with the Catholic school.
A: Tell us a little about Brazil and what role it played in your personal and professional development.
RC: Brazilian culture is unique and very rich. Brazil is an immigrant country, and thus a multi-ethnic country, with a large black population and large European (Portuguese, German, Italian) and Asian (Japanese) national groups represented in the population. Brazilian blacks came from Africa as slaves during colonial times. They brought with them rich cultural traditions, which influenced the food, the music, religion and many other aspects of Brazilian life. So, today the country is an amalgam of African and European (mainly Portuguese) culture, all of which is very enriching. It is a resourceful culture. In spite of the tremendous economic growth that has happened there in the last, maybe 10 years, it is still a country with big economic disparities between the few who are very rich and the many who are very poor. Brazilians have learned that they cannot rely on government too much for help, and thus have developed resourceful ways to deal with life difficulties, and remain in good spirits and happy with their lot in life. I still have a great deal of that Brazilian culture in me, although I consider myself acculturated to the American way of life. Certain aspects of Brazilian culture, such as music, are still very much part of my life. Also, I have considerable contact with Brazil, not only family contact but also professional contact. My experience of life in Brazil, my experience of immigration, my knowledge of life in Latin America are all part of my daily life and my professional activities, not only because of my work with ethnic groups in the United States but also because of my professional contacts with colleagues in Brazil and other Latin American countries.
‘I still have a lot of that Brazilian culture in me, although I consider myself acculturated to the American way of life.’
A: Raul, what was your primary motivation to enter medicine?
RC: When I was growing up there were many books at my home in Brazil and I very much enjoyed reading. One of the books which my mother had was Freud's Interpretation of Dreams. I found this book fascinating and I wanted to enter a field which involved understanding people's behavior. I discovered as I became older that a degree in medicine was required to be a psychiatrist. When I entered medical training I was unique among my classmates, in that I already knew my desired area of specialization, and I never wavered from that during my medical training at Faculdade de Ciencias Medicas, Universidade do Estado do Rio de Janeiro.
A: Was this the basis of your interest in substance abuse and dependence?
RC: No, actually I first became interested in the social and cultural dimensions of psychiatric diseases and only later in substance abuse. It happened as part of my training in which all young medical students were required to provide services in the poor and low-income neighborhoods in Rio. It was quickly obvious to me that many of the health problems presented by patients coming to our clinics related to the social conditions in which they lived, and many of them were heavy drinkers. I could see a specific opportunity in better understanding psychiatric and drinking problems as linked to the environment in which people found themselves. I actually never expected to be involved in the psychiatry of substance abuse, which happened later during my training in England, but it certainly emerged as a part of my natural curiosity about understanding human behavior.
A: What was it about the environment that caught your attention?
RC: Working in poor areas of a developing country it was impossible not to realize that the economic status of people, their overall living conditions, were associated with tremendous life stresses that contributed to their mental health problems and many times to heavy drinking. This was before the field of addiction studies had much evidence about the importance of the environment, especially how low-cost alcohol availability can contribute to alcohol-related problems.
A: Brazil has a reputation of being a relatively heavy drinking country. Could this have contributed to what you were observing?
RC: Yes, Brazil has had a long tradition of selling low-cost alcohol in a relatively unregulated environment. For example, a popular drink, cachaca, even today can cost as low as less than a dollar for a 750-ml bottle. There were few economic barriers to people obtaining large amounts of alcohol for heavy drinking. Now we know that although the country has a high rate of abstention, it also has a high frequency of binge drinking and a high rate of alcohol dependence.
A. What is cachaca?
RC: In most cases cachaca is a clear spirit, distilled from sugar cane. It can also have a beautiful amber color, depending on how it is aged. It is 40% alcohol, and very popular in Brazil. Cachaca can be drunk pure or can be mixed with fruit or a variety of fruits. The most famous Brazilian drink is the ‘caipirinha’, a mixture of cachaca, sugar and lemon juice. More recently, there has been a revival of speciality distillation of cachaca, with small distilleries with very sophisticated production lines and products, some of which are quite expensive. I have seen bottles of chacaca in Brazilian supermarkets for as much as $US100 dollars.
DEVELOPING AN INTEREST IN EPIDEMIOLOGY
A: How did your interest in epidemiology begin?
RC: In the 1960s and 1970s the field of psychiatry was changing or expanding away from a total emphasis on clinical care and treatment in big isolated psychiatric hospitals to a strong interest in community psychiatry. Such attention to the community brought with it the need for psychiatry to better understand the association between community and social factors and mental health problems, especially from a public health perspective. The natural source of tools to obtain this information was epidemiology, long an essential part of medicine, especially preventative medicine and public health. This view was shared by one of my early mentors in psychiatry in Brazil, Professor Eustachio Portella Nunes, who was chair of the department of psychiatry in the state medical school in Rio, where I was a young assistant professor. As a result of this interest in the department, we entered into discussions with the Pan American Health Organization (PAHO), and PAHO then sent a consultant to work with us, Alejandro Tarnopolsky, who was in England working in psychiatric epidemiology. Alejandro suggested to me then that a good way to learn psychiatric epidemiology was to combine a time of study at the London School of Hygiene and Tropical Medicine and a time of actual work in psychiatric epidemiology at the University of London's Institute of Psychiatry, more specifically at the Institute's General Practice Research Unit, which at that time was headed by Michael Shepherd, professor of epidemiological psychiatry at the Institute. This was in the mid-1970s, and I was in London from 1973 to 1976. While in London I was encouraged to contact Griffith Edwards for further training, this time in the epidemiology of alcohol. At that time Griffith was the director of the Institute of Psychiatry's Addiction Research Unit. He helped me obtain a fellowship from the UK's Medical Research Council, which then supported my work with him for 2 years. Griffith was especially important in the development of my life-long interest on substance abuse and epidemiology.
A: How did you end up in California?
RC: This came about as the result of a number of factors. When I left England and returned to Brazil in 1976, during a conversation Griffith mentioned to me that if I ever felt I needed more training I should go to the United States, where there were many opportunities for training in alcohol epidemiology. He then mentioned Berkeley, California as one of the places, but also Harvard and the University of Washington in Seattle with Marc Schuckit. It was hard for me at that time to see my career developing fully in Brazil, and after a year-and-a-half there I decided to come to California to the School of Public Health at UC Berkeley for further graduate studies and to obtain a PhD in epidemiology. I completed that degree in 1983. I should also say that I corresponded with Don Cahalan, who was then director of the Alcohol Research Group (ARG), prior to going to California, and Don sent me a very encouraging letter that sealed my decision to go to Berkeley.
A: Was this also a means to begin work with the ARG in Berkeley?
RC: Yes; at that time the ARG was already a National Alcohol Research Center funded by the National Institute on Alcohol Abuse and Alcoholism, and important work in the areas of survey research and alcohol epidemiology was taking place there. In fact, Griffith contributed to my going there because he also wrote me a strong reference and an introductory letter to Don Cahalan who, by the time I arrived, was just retiring from his position as ARG's director.
A: Over this time, as your skills in epidemiology increased, what became of your interest as a clinician?
RC: I would say that epidemiology peaked my interest in understanding the many factors which contributed to mental health problems in general and in substance abuse in particular. As my involvement in epidemiology increased my interest and enthusiasm for clinical practice decreased. I also want to add that although I have not conducted clinical work in many years I am very happy that I went through medical school. My medical training has given me rich insights and experiences as well as opportunity to participate in a large number of interesting research projects that I may not have been able to contribute to were it not for my medical background.
‘My medical training has given me rich insights and experiences as well as opportunity to participate in a large number of interesting research projects that I may not have been able to contribute to were it not for my medical background.’
A: What did this intellectual challenge from epidemiology represent for you?
RC: Mainly it supported my own curiosity about human behaviour, and especially mental health, and how to increase our understanding about the causation of mental disease and human behavior in general. This feels like going full circle from my interest as a boy from a time before I entered medical school.
A: One of your earliest and some of your most recent publications concern measurement of dependence in population surveys. Why has this been an interest of yours for so long?
RC: When I began to learn how to apply epidemiological methods to the study of psychiatric diseases there was considerable attention to developing standardized clinical diagnostic tools. There was a clear realization at the time that psychiatric diagnoses did not have a high rate of inter-rater reliability, and that the development of standard diagnostic criteria was fundamental to advance the field of psychiatric epidemiology. At the Institute of Psychiatry in England, John Wing, who was professor of social psychiatry, had developed the Present State Examination, a standardized psychiatric interview, relatively similar to the Diagnostic Interview Schedule, which was being developed in the United States at the Department of Psychiatry, Washington University in Saint Louis by Lee Robins and others. My interest in diagnostic criteria for alcohol dependence grew out of this early contact with psychiatric epidemiology.
A: How do you see the state of dependence criteria indicators today and do any challenges remain?
RC: I feel that much progress has been made in the measurement of dependence, and the field has some excellent standardized instruments. However, challenges remain. For instance, Tom Babor and I have recently written about the fact that many people (especially in the United States) are identified as alcohol abusers through self-reports of drinking and driving or arrests for drinking and driving. Unfortunately, this event is related strongly to emphasis on police enforcement, official blood alcohol concentration (BAC) level, economic access to an automobile and other factors. The complex interaction of these many factors, some clearly dependent on the social and cultural environment, make it quite difficult to utilize such an indicator as clear sign of a medical diagnosis. The challenge is that the diagnostic indicators of both abuse and dependence are a mixed bag of biological, psychological and social phenomena, which reflects to some extent our understanding of these phenomena, but makes it very challenging to have a coherent unified principle guiding the diagnosis and separating it from the social environment.
RESEARCHING ETHNIC SUBGROUPS
A: Another major theme in your published research over the past 35+years has been on the drinking patterns of ethnic and racial subgroups in the United States and other countries. What stimulated this interest?
RC: My early psychiatric training occurred at a medical school with a strong Institute of Social Medicine in Brazil. So, it was natural to look at subgroup differences across a number of conditions, including socio-economic status. We were encouraged to look at the relationship between personal mental health, economic and social status and community organization (or disorganization). The influence of culture on mental health was clearly obvious to me and my colleagues in these early years. Also, when someone from Latin America, such as me, migrates to the United States, a new identity is developed. All of a sudden I became a member of an ethnic minority, Latinos or Hispanics. This did not bother me at all; in fact, it opened the door for me to look into the development of these secondary identities in migrant populations and led to my interest in studying differences in drinking across ethnic groups. Also, I had been hired by Robin Room at the Alcohol Research group to write a special report on Hispanics, which was part of a larger prevention intervention study funded by the state of California and directed by Larry Wallack. The process of analyzing the Hispanic sample interviewed in that study, plus these personal factors, led to the development of this life-long interest in ethnic differences in drinking in the United States. My PhD dissertation was based on the analysis of that early Hispanic data set that I analyzed at ARG.
A: How would you describe the status of dependence research across subgroups now?
RC: Certainly we have a much deeper and more expanded understanding of the complexity of the role of culture and social economic status on the development of alcohol dependence. In the early years, we studied dependence almost as if it was triggered solely by an individual's condition. However, the accumulating evidence about subgroup differences clearly provided a very different picture about differences in drinking patterns, alcohol-related problems and, ultimately, alcohol dependence. In the United States, Hispanics, Asians and African Americans differ considerably from each other in use of alcohol and rates of problems and dependence. Even within each of these groups there are important variations in the rate of dependence which relate again to such factors as social economic status, US region in which these groups live, and adoption of US drinking practices, which is dependent upon the age at which someone may have immigrated to the United States. For example, Cuban Americans who immigrated to the United States at the time of the Cuban revolution were typically of much higher social status than other Hispanic immigrants in the United States, and thus the effects of acculturation, gender roles and drinking patterns were often very different among Cuban Americans compared to other Hispanic national groups.
A: How did an interest in drinking and intimate partner violence come about?
RC: Like so much of my career specific areas of study, it occurred serendipitously. I was director of ARG when we were preparing for the 1995 national drinking survey. We had a post-doctoral fellow, Chuck Shafer, who was a psychologist with a specific interest in intimate partner violence. Chuck and I began to discuss the role of drinking in such violence and we hit upon the idea of applying for funds to conduct a complementary set of interviews with the partners of survey respondents in the national survey. As a result of this funding we were, for the first time, able to collect data on 1600 dyads. This was the first time that both partners were interviewed similarly about violence and about their drinking in a large epidemiological survey. The results were fascinating. We re-interviewed these pairs in 2000, and soon after that the National Institute of Alcohol Abuse and Alcoholism in Washington included the grant that supported this research in their Method to Extend Research in Time (MERIT) program, which extended funding in the project for almost another 10 years. The funding for this project will finally end in the spring of 2011, representing more than 15 years of research on this theme.
A: Your resumé shows a recent paper on the drinking behavior of women of child-bearing age. What stimulated this line of research?
RC: Well, serendipity again. I was contacted by the Centers for Disease Control in Atlanta to participate in a US federal task force on prevention of fetal alcohol syndrome. As a result of my participation I became interested in what could be learned about the drinking patterns of women of child-bearing age in different ethnic groups from the US National Surveys. As a result I analyzed the drinking patterns of young women in the most recent national survey conducted by National Institute on Alcohol Abuse (NIAA) and completed a paper on the findings. I have now begun collecting more information about drinking by women of child-bearing age and during pregnancy in my studies, which has created other opportunities for research.
MOVE TO TEXAS
A: In 1998, you left the full-time directorship of the Alcohol Research Group for the School of Public Health of the University of Texas. Why this change, and what has been your experience?
RC: I enjoyed my time with ARG and the full-time experience of research, but two factors influenced my decision to move. I was questioning my life situation at 50, especially the fact that all the funding for my position was dependent upon securing grants. Also, there had been a big change in my life situation. I had a new family with two baby girls and I wanted a more secure job for this family. The offer from the University of Texas was extremely attractive. I would have a key leadership role in developing a regional campus of the School of Public Health, within an outstanding medical center, the UT Southwestern Medical Center at Dallas. This is a premier medical center in the United States; for example, there are four active Nobel Prize winners in medicine on campus. Also, I was very interested in returning to a medical center and working close to medicine, but at the same time retaining my public health professional identity. The challenge of integrating a public health program in the medical center was especially interesting and rewarding. Then in 2005 I was offered another interesting position, i.e., Dean of the School of Health Professions at UT Southwestern. I retained my public health appointment and responsibilities, and have especially enjoyed the opportunity to work with professionals from many different aspects of medicine other than those to which I was most exposed in my career. In the United States, schools of health professions train all other health professions besides nurses; that is, physical therapists, nutritionists, physician assistants, radiation therapists and others, and I have really enjoyed working with the diverse faculty, the students and the central campus administration. I also feel very fortunate that I was able to continue my research program and even expand it to work with colleagues in Brazil. Brazil is becoming increasingly sophisticated in alcohol research; I have been engaged with their national alcohol society, and have also collaborated in the development of their first and second national alcohol surveys with colleagues at the Universidade Federal de São Paulo.
‘Brazil is becoming increasingly sophisticated in alcohol research . . .’
A: You have been in the field of substance abuse and addiction studies for well over 35 years. What changes and progress have you observed?
RC: In the 1960s and 1970s the field was focused on alcoholism and on the people out there who were ‘drinking themselves to death’. In the 1980s the field developed a much richer understanding of problem drinking, substance abuse and the phenomenon we call ‘dependence’. A major part of this developed from research findings stemming from public health and the key potential role of public policy to reduce problems and harm. For example, we had the seminal book by Bruun et al. , which established a public health approach to reducing alcohol problems at the population level. This book was followed by Alcohol Policy and the Public Good by Edwards et al.  and then the two volumes of Alcohol: No Ordinary Commodity by Babor et al. [3,4]. Such books have transformed the field of substance abuse research towards a greater focus on policy and how to prevent problems and respond to heavy drinkers, not all of whom are dependent. Also we have substantially altered and improved the way in which we respond to dependent drinkers from a major focus on in-patient and residential treatment to improved care within ambulatory and out-patient settings. Also we have a much more developed scientific knowledge about which treatment modalities can work and which are unlikely to be effective, as well as the substantial development of medications for improved treatment. Research methods have improved tremendously as well, especially our capability for data analysis, with new analytical techniques and a tremendous increase in computing power, which allows us to conduct analysis using laptop computers that we could only analyze in main-frame machines 30 years ago.
A: With many years of experience in the United States, what observations do you have about the organization of addictions research, the unique roles of national research centers and the role of informal and formal research networks in the United States?
RC: Addictions research in the United States has benefited enormously from the existence of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). These two institutions of the National Institutes of Health have provided organized and consistent funding to the field. For the most part this funding has been free of politicking, which has enabled the field to organize and grow considerably in the past 40 years. The consistent stream of funding provided by the two institutes has allowed university-based research to grow, and with it there has also been a growth in teaching addiction sciences and recruitment of young scientists into the field. NIAAA's National Alcohol Research Center program, which has been in existence since the late 1970s, has created a unique string of centers of excellence in alcohol research across the United States that does not exist in any other country in the world. These centers support research projects and act as incubators for a number of other projects, attracting scientists and providing outstanding programs for pre-doctoral and post-doctoral training in the alcohol field.
This is why the present re-organization of NIAAA and NIDA in one larger institute is so worrisome for many of us in the field. Obviously, the present system is not perfect. There are many in the United States, I think, who will say that the present funding system is biased and favors basic science and medical research at the expense of research in the social sciences. I do not think, however, that the system is broken. Thus, as we say in the United States, if it is not broken, do not fix it.
A: What worries you the most about the future?
RC: Within the United States, and perhaps across the world, current major economic problems have resulted in reduced funding for scientific research on substance abuse and its prevention and treatment. I am especially concerned that reduced funding opportunities will make it more difficult to attract bright young people into the field. Another major concern in the United States is the potential merger within the United States National Institute of Health of the National Institute for Drug Abuse and the NIAA, which I mentioned above. Frankly, right now we do not know the effect on research funding of such a potential merger. It could work well but it could also result in disaster, with considerable implications for the field or alcohol and drug abuse research.
LOOKING TO THE FUTURE
A: Looking over your publications, which ones are especially important to you?
RC: While difficult to create a short list, below are examples of papers which may not always represent my most important contributions but are specific papers I really had fun writing. Some other papers represent the first papers that I wrote with a particular data set and perhaps broke the mould because they had a particular design (e.g. longitudinal) or a particular focus not very common in the literature.
- • Caetano R., Ramisetty-Mikler S., Rodriguez L. A. The Hispanic Americans Baseline Alcohol Survey (HABLAS): rates and predictors of alcohol abuse and dependence across Hispanic national groups. J Stud Alcohol Drugs 2008; 69: 441–8.
- • Caetano R., Field C. A., Ramisetty-Mikler S., McGrath C. The five-year course of intimate partner violence among White, Black, and Hispanic couples in the U.S. J Interpers Violence 2005; 20: 1038–57.
- • Caetano R., Cunradi C. Alcohol dependence: a public health perspective. Addiction 2002; 97: 633–45.
- • Caetano, R. The identification of alcohol dependence criteria in the general population. Addiction 1999; 94: 255–67.
- • Caetano R. Prevalence, incidence and stability of drinking problems among Whites, Blacks and Hispanics: 1984–92. J Stud Alcohol 1997; 58: 565–72.
- • Caetano R. When will we have a standardized concept of alcohol dependence? Br J Addict 1987; 82: 601–5.
- • Caetano R. Alcohol dependence and the need to drink: a compulsion? Psychol Med 1985; 15: 463–9.
- • Caetano R. Ethnicity and drinking in northern California: a comparison among Whites, Blacks and Hispanics. Alcohol Alcohol 1984; 19: 31–44.
- • Caetano R., Edwards G., Oppenheim A. N., Taylor C. Building a standardized alcoholism interview schedule. Drug Alcohol Depend 1978; 3: 185–97.
A: Raul, we have asked much about your professional accomplishments, but what are your interests outside your professional life?
RC: When I am not at work I am mostly with my family. We take vacations together, and the kids (Lauren is 14 and Helena is 12) usually decide where we go. My oldest daughter, Izabel, has been on her own for a long time. Brazil is a frequent destination because my family is there. Hawaii is also a frequent place to go. The kids love it. My wife's parents had a vacation place there, so she is used to the islands. I have a close working relationship with alcohol researchers in the Department of Psychiatry of the University of Hawaii, and my interest in water sports really draws me to Hawaii. So, it is a place that we all enjoy. As far as reading is concerned, I am a relatively eclectic reader, but I tend to favor crime novels: the kind of stories where the central character is a middle-aged, hard-drinking, divorced police detective, who is solving crimes while fighting the city bureaucracy and trying to maintain his love affair with some lady. Like many other millions of people in the world I enjoyed tremendously the trilogy that began with Stieg Larssen's The Girl with the Dragon Tattoo. These do not really fit the description of the crime novel that I just gave you, but I still enjoyed the trilogy. Right now I am reading two books. One of them is a crime novel by Joseph Wambaugh, Hollywood Moon, which tells stories centered on the daily lives of cops on the beat in Los Angeles, more precisely in Hollywood. I am also reading S. C. Gwynne's Empire of the Summer Moon, which is a historical account of the wars between the Comanche and the US cavalry during the second part of the 1800s, when US colonization was expanding into what is now the Southwest of the US and especially Texas, where I live now. I find it especially fascinating to learn about how incompetent the US government was in dealing with the Comanche, and also learn about the sites and places where soldiers and Indians fought one another and which are sometimes just about 50–100 miles from where my house is now.
A: Are you looking ahead for your retirement, and what are some challenges or interest which still remain for you?
RC: I certainly have enjoyed the rather diverse set of research and professional interests of my career. Like most others in my age group I am beginning to feel the pull between professional and non-professional interests. I am an avid board sailor, and I want to go back to the San Francisco Bay Area and sail again while I can do it and enjoy it. However, before I retire, some of the challenges in which I am interested include continuing my recent research on differences in drinking and its consequences across Hispanic national groups and domestic violence among intimate partners. Within the Hispanic groups, I would like to understand more about the origin of the differences between these groups, about the association between immigration and drinking and mental health status. In terms of domestic violence, I see much of the severe violence as related to existing psychiatric problems and how these problems are expressed in violence between intimate partners, and I would like to learn more about this relationship.
‘I would like to understand more about the . . . association between immigration and drinking and mental health status.’
The opinions expressed in this interview reflect the views of the interviewee and are not meant to represent the opinions or official positions of any institution or organization the interviewee serves or has served.