‘The scale of the problem is immense’

Interview with Dr Sanjeev Jain of NIMHANS.

One of the buildings on the NIMHANS campus.

Dr Sanjeev Jain is a Professor of PSychiatry at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, the leading institute in India for the diagnosis and treatment of and research into mental heath problems. In an interview to Frontline , he talked at length on the state of mental health care in India, the scale of the problem, the paucity of funds for the sector, and other issues. Excerpts:

What was the state of the psychiatric facilities that India inherited at Independence?

Colonialism ensured that we had some hospitals, but these hospitals were the job of the government; people themselves were not running them. The mental hospitals in Madras [Chennai], Bangalore [Bengaluru] and some other places, had waves of massive improvement in the 1920s and they became so-called modernised mental hospitals. The total number of psychiatrists in India at Independence was around 60, and there were some 35 to 40 mental hospitals. After Independence, the investment in health care fell dramatically (mental health care specifically), but percentage-wise we are spending the same or less compared with what the colonial government spent on health and this continues today.

Can you briefly discuss the scale of mental health problems in India?

The scale of the problem is immense. Some 6-7 per cent of the population suffers from mental illnesses. Of this, 2-3 per cent constitute those with intellectual disabilities and severe mental illnesses like schizophrenia, manic depressive disorders, delusion disorders, autism, behavioural problems, epilepsy with behavioural disorders, etc., who require mental hospital care at some point of time. With appropriate treatment, half of them will be able to live fairly independent productive lives. About a third will not improve at all and the remaining will require frequent hospitalisation. Even a conservative estimate of the number of severely mentally ill who require prolonged treatment will come up to five to eight million.

We have 20,000 beds in the government sector and a similar number in the private sector. Of these, 8,000 beds are occupied by the severely mentally ill who require long-term treatment. Now, in a country that has five million ill people, only 8,000 are in hospital. What about the rest? The vast majority of them are being looked after by their families, and we have no way of assuring the health of the people being looked after by their families in the community. These people are severely impaired. They need to be provided shelter and dignity over a long period. With so many people below the poverty line and drugs and treatment costing so much, what is the burden on the family? Patients in India seem to be dependent on the charity of family members or pittances from the government. That is not a life of dignity. The welfare state has a responsibility to look after these people.

What is the current strength of psychiatrists in India?

Now we have almost 6,000 psychiatrists. There has been a 100-fold increase since Independence, so we are not low on manpower. We are training 400 psychiatrists a year, so we can provide one psychiatrist for every district in India. The issue is not one of manpower, it is one of administrative and civic infrastructure to look after large numbers of the mentally ill.

Considering the scale of mental health problems in India, what do you have to say about the Mental Health Care Bill, 2013?

I have not been disappointed with the Bill particularly. The positive points of the Bill include its affirmation of the right to fundamental health care. This means that mental health problems should be treated equally with physical health. This is a big advancement because the whole profession has a kind of stigma. Mental health and physical health are viewed as distinct from each other. This Bill cuts that debate down to size and says that mental health care is part of physical health care.

The Bill makes it explicit that all health care facilities have to have psychiatric facilities, which means they will have to be notified to the government. Every hospital will now be a mental hospital too. In one move, it removes most of the stigma in the administrative sense. Stigma in real life is a different issue. The number of psychiatric beds will increase significantly. The Bill also ensures that all insurance companies will have to provide support for psychiatric services. When you look at all this, it makes very real incremental progress towards mainstreaming psychiatric care.

The Bill also ensures that psychiatric care will be available in every district. This includes long-term care, which will possibly be provided by non-governmental organisations [NGOs] under the supervision of the some statutory body set up by the government. This Bill has been 20 years in the making. It has gone through a lot of meetings and debates and a lot of people have been consulted. In that sense it is a hugely democratic one.

Are we being optimistic about the roles of the NGOs here?

Yes. I think so. There aren’t that many NGOs in the country interested in mental health. NGOs have cycles of funding; sometimes they may not be funded, so how do you ensure continuous service by the NGO sector? NGOs may have other non-policy interests coming in. For example, many of these NGOs are run out of some kind of religious affiliation or some kind of quasi-spiritual commitment. Will they offer equal help to all communities irrespective of their religious or spiritual affiliation like general hospitals? Will they partition their services on the basis of sectarian and communitarian lines? Nobody has thought about these issues but hopefully, as civil society tackles these issues, solutions will emerge.

The assumption that government institutions are bad and NGOs are paragons of virtue is also a funny dichotomy. There are NGOs involved in taking care of people with mental health issues where people are lined up, made to remove their clothes and hosed down. Where is the personhood there? Some NGOs have inadequate facilities. When a person is bereft of intellectual ability we really have to think about the quality of life that he will have. The cost should not be a guiding factor for this.

India ratified the United Nations Convention on the Rights of Persons with Disabilities (CRPD) leading to the Mental Health Care Bill. What do you have to say about this?

The issue about CRPD is a very contentious debate, and I would not like to say much on it except to say that it was signed before the expert debate had occurred within the country. We have signed the document and are now making rules to ensure that we comply. Very few countries have successfully integrated the CRPD within their systems because it is patently over-bureaucratic. In our country, where we do not even have routine methods of inspection of health facilities, what do these fine-sounding words actually mean in real life is anybody’s guess.

What do you have to say about the professionalisation of psychiatric care as provided by the Bill?

It falls short to some extent on that front. India trains around 400 psychiatrics a year and 500-600 psychologists, but as far as the government is concerned most of the mental health care system will be driven by anganwadi workers or untrained health care professionals.

Treating NGOs, lay workers, anybody with experience, as equal mental health professionals has been a major source of distress. The specialisation of the mental health professional has been defined so loosely and it is still unclear as to which Ministry will have jurisdiction over the activities of various mental health care professionals. Medical colleges do not train psychologists and social workers. How will they integrate them into their working pattern? All these things are muddying the water and will have to be resolved.

As far as spending on mental health care and institutional support is concerned, does the Bill meet your expectations?

With the manner in which the mental health policy document in conjunction with the Bill was prepared, the assumption was that processes to provide stable long-term care for at least a brief period would be built in, but the Bill by itself does not provide that. So, we have no assurance that government spending on needs of those with severe mental illness and institutions will actually improve. Take the case of the Amritsar Mental Hospital —half the land there has been sold for a mall and a housing complex. Similar things have happened at the mental hospitals of Thane and Vijayawada.

China has built 500 new mental hospitals in the last 10 years. We aspire to be like the Chinese in many things except for psychiatric care, so there is a peculiar dissonance in this reluctance of the government to actually emulate these models. Why is it that we do not realise that institutions are necessary? Can’t we build an institution where people with mental illness are given affordable housing, care, a protected environment, some entertainment? The Bill does not have any teeth here at all.