Lessons from Erwadi

By R. Srinivasa Murthy

THE ERWADI tragedy has yet again highlighted the need for organised mental health care in the country. The media has reported about similar situations in Hyderabad, Ranchi, Ahmedabad, and Patiala. There is need to view the tragedy in the larger perspective of the national situation and in a longer time frame. The inhuman conditions in mental asylums were the focus of an National Human Rights Committee Report released last year.

According to the Report, ``38 per cent of the hospitals still retain the jail like structure that they had at the time of inception... patients are referred to as inmates and persons in whose care the patients remain through most of the day are referred to as warders''. The report also notes that ``the deficiencies in the areas described so far are enough indicators that the rights of the mentally ill are grossly violated in mental hospitals''(p.50). As recommended by the NHRC, there is an urgent need to transform these mental hospitals into genuine centres of care and treatment and not let them remain custodial institutions.

In a survey carried out in the mid-1990s in Tiruchi, of the 198 patients attending a psychiatric facility, 45 per cent had sought treatment from either Hindu, Muslim or Christian healers - 49 per cent in rural areas and 39 per cent in urban centres. The proportion of patients seeing a faith healer was inversely related to the monthly income. A recent study found that only 12 per cent believed that the supernatural was a cause for schizophrenia. The educated more often named heredity or multiple causes; the less educated named supernatural forces as a cause. In a similar study in 1999, from Bangalore, Chennai, Delhi, and Mumbai, similar observations were reported. Thus, it is important to recognise that the belief in non-medical explanations depends on the level of education, place of residence, availability of information and access to mental health care.

The patients in Erwadi and in many other mental hospitals are there because of long-standing illness and their inability to care for themselves. This often gives the impression that mental illnesses are incurable and life long. This is not true, especially when the illness is diagnosed early and proper treatment provided. Schizophrenia, often associated with chronicity, is seen as only one short episode with complete recovery in nearly a third of the affected. Only about 10 per cent need long term care. Further, studies from a number of centers in India have shown that the disability is less in those receiving treatment. Factors contributing to chronicity and disability are (i) delay in seeking treatment, (ii) irregularity and incomplete treatment, (iii) lack of support from family, and (iv) inadequate rehabilitation support. All of these are areas suitable for intervention by public health measures. For a large majority of the mentally ill, lifelong illness or disability is totally avoidable. Patients are generally sent to live in mental hospitals or faith-healing centres because there is no one to care for them, or because their parents have become too old, etc. This is not to deny that there may be some who will need to be committed to an institution. But their number is small.

India has about 30,000 hospital beds for psychiatric care. More than half of the beds in the mental hospitals are for long-term patients. Even if we were to consider that the average stay is about one month, we have about 1,80,000 bed-months. A very conservative estimate of people requiring hospital care, at sometime, would be not less than 2 per thousand, which means for the 1 billion population there is need for 2 million bed-months.

In India, a majority of the mentally ill live with their families, which have been a part of the care programme for a long time. In the last 50 years, efforts have been taken to involve them in care during the period of hospitalisation. Educational programmes for the family members have been organised, partnerships between professionals and families have been formed and self-help groups of families have come up in a number of cities. In a way the current primary carers of the mentally ill are the families. What the families need is support to carry on doing what they feel they want to for their ill family members, with support from professionals and the state. The numbers not cared for and sent to institutions is less than 1 in 10. Families need recognition and support to carry on providing the care.

From a situation of no organised mental health care at the time of Independence, currently, the issues are seen as part of the public agenda. Witness the formulation of the National Mental Health Programme (1982), the integration of mental health with primary health care at the district level (2000), the proposed allotment of Rs. 150 crores for mental health care during the Tenth Five Year Plan.

The overall effect has been the movement to recognise mental health as an important issue in the community and services to move beyond mental hospital care to care by the community. The area of rehabilitation for the patients with various forms of disabilities due to mental disorders is making beginnings in the country. Centres of day care, half-way homes and long-stay facilities are coming up gradually, especially in the big cities. Two masters programmes for training rehabilitation personnel at Richmond Fellowship, Bangalore, and at the Father Muller Hospital, Mangalore, have been started. However, there is gross shortage of these facilities leading to greater burden on the families and further deterioration of the ill persons.

State responsibility. The Mental Health Act, 1987, places the responsibility for planning and monitoring on the State. It has also structures to carry out the functions. Unfortunately, not all States have formed the State level Mental Health Authority or initiated the process of planning of state health services, licensing of the hospitals and related matters. The full implementation of the MHA provisions would go a long way to meet the needs of the mentally ill. In the country, there is greater growth of private sector psychiatry than public sector investment in mental health care. For the rural population, for the poor, the marginalised groups, the state has the main responsibility to organise care.

The wide variations across the country demand that plans are developed for each of the States and Union Territories, besides a national programme. There is a need for mental health departments in the health Ministries in the States and at the CEntre. All the psychiatric care facilities should be upgraded - better trained personnel, treatment and rehabilitation facilities, living arrangements and community outreach activities. All the medical colleges should have independent departments of psychiatry to ensure increased undergraduate training in psychiatry.

There should be at least a 10-bed separate psychiatry ward in every district hospital. Integration of mental health with primary health care should be achieved to facilitate early identification of patients, regular treatment and reintegration into the community. This can be achieved by training all the primary health care personnel, providing essential drugs, and including mental health in the regular health information system. All general hospitals should have separate psychiatry wards.

The mass media should be used for educating the public about mental disorders. The Government should support the families of the mentally ill by providing community-based services and financial aid. The Persons with Disabilities Act, 1995, should be properly implemented and the facilities available to physically handicapped (reservation for employment, social benefits, travel facility etc.,) should be provided to people with mental disorders too.

Special schemes needed to support voluntary agency initiatives for treatment and rehabilitation of the mentally ill. More training centres essential for developing manpower. Research on issues central to the understanding and treatment of mental disorders should receive support from the Indian Council of Medical Research. The road is long and calls for continuous effort but it is never too late to start.

(The writer is Professor of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore.)

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