Beyond Erwadi

The mentally challenged people rescued from Erwadi are in no better a state in their new surroundings. A review of the mental health care scene in Tamil Nadu.

THERE seems to be no real deliverance for the 571 mentally challenged people rescued from the 15 so-called mental homes in Erwadi in Tamil Nadu's Ramanathapuram district in August 2001.

They had come under the Tamil Nadu government's care after all the "mental homes" in Erwadi were closed down following a fire in the Moideen Badusha Mental Home on August 6, which killed 28 inmates who were chained to their positions. Of the 571 persons who were rescued, 152 were sent to the Government Institute of Mental Health (IMH) in Chennai, while 11 patients who had violent tendencies were admitted to the Ramanathapuram Government Hospital. The rest were returned to the care of their families. (Some have returned to their families from the IMH.)

But nothing has changed for them - they continue to live in misery, stripped of dignity and shunned by their families and society. Most of those who were forced back onto their families have been sent to 'faith healing' centres attached to various temples or dargahs. The rest, who remain with their families, are mostly isolated and ostracised.

For instance, Raghu, from one of Erwadi's "mental homes", was sent back to his family in Sikkil in Thanjavur district in August 2001, since the government doctors who examined him soon after the Erwadi incident found him "fit for discharge". But his father, Raghavan, did not know what to do with the "mentally ill" son. Neither did he have the means to rehabilitate Raghu in a private hospital nor could he bear the stigma of having a mentally ill person at home. He had two daughters to be married. In February 2002, Raghu was sent to a 'faith-healing' centre closer home.

Some others like Gowri, who had been admitted to an Erwadi mental home by her relatives allegedly in an attempt to solve a family dispute, and Murugan, who had been left in Erwadi to separate him from his girlfriend, are back at the 'faith-healing' dargah at Erwadi. While the privately run mental homes in Erwadi were ordered closed on August 13, 2001, patients who stayed within the precincts of the dargah were allowed to remain there, provided each had an attendant.

Even for the 152 patients brought to the IMH, the only government hospital for the mentally challenged in Tamil Nadu, life is no different except that they are no longer in chains. Also, according to a psychiatrist at the IMH (who prefers to remain anonymous), "because of the media attention, the Erwadi patients at the IMH get some special treatment".

The patients who were already in IMH, numbering over 1,500, were in a situation hardly better than at Erwadi. The death of some inmates in October 2001 owing to diarrhoea, the collapse of the main building a month later, and some incidents of violent inmates killing each other, brought to light the abysmal conditions at the IMH.

Shunned by family and society, most IMH inmates live without dignity and basic human rights. The plight of some 600 of them who have been in the IMH for decades is especially bad. For them, death may well be the only means of deliverance. For instance, Thangam and Noyola Mary, who had been there for 60 and 50 years respectively, died last year (but no one claimed the bodies). Viswanathan, who has been at the IMH for 20 years, says, "I look forward to the day (of my death)."

Says an IMH psychiatrist: "The IMH follows the 18th century concept of the mental asylum. It is like a concentration camp. Patients are checked once in 15 days. They are paraded outside their wards while a psychiatrist checks each one quickly. There are no doctors. Patients with physical complications are referred to other government hospitals. Some of the 21 wards do not have toilets." The abysmal level of crisis management at the IMH was revealed by the diarrhoea deaths there last year.

According to the psychiatrist, the system followed at the IMH is similar to that followed in jails: lunch is served at 1 p.m. and dinner at 4 p.m. At 5 p.m. all patients are locked in their wards until 8.30 a.m. the next morning, when they are given breakfast. Says the IMH psychiatrist: "Most patients skip dinner as it is too early. Thus most patients eat at 1 p.m. and then only 8.30 a.m. the next day. This is particularly bad for the diabetic, the old and the infirm."

Says the psychiatrist: "Ward 21 is the de-addiction ward. But several patients in this ward abuse heroin and cannabis regularly."

There is no emergency room or an intensive care unit at the IMH. Patients in serious condition are examined just outside the ward. Most often the 'golden hour' is lost by the time these patients are taken to an ICU of a government hospital.

Says another IMH psychiatrist: "Treatment at the IMH is not holistic. Addressing the social context - environmental and social stress - is not considered important. The focus is narrow, and is limited to neuro-transmitters and genetics. Rehabilitation, occupational therapy and social integration are poor. That is why most inmates remain there for decades." There seems to be no protocol for drug treatment. The mentally challenged seem to be dumped at the IMH for life.

When this correspondent approached the IMH Director for comments, he refused to talk and denied her permission to visit the hospital premises.

According to an administrative staff member, the IMH is plagued by many problems. Many inmates, though cured, continue to remain at the IMH as the addresses given at the time of admission are false. The arrears that "old" patients owe the IMH add up to over Rs.3 lakhs. Although the number of in-patients (1,654) is lower than the sanctioned bed strength of 1,800, maintenance has become difficult, with several 'basic servant' posts remaining vacant for long. For instance, of the sanctioned 202 posts of warders, 47 are vacant, while 20 of the 79 sanctioned posts of ayahs are vacant. Of the 91 sanctioned posts of male sanitary workers, 28 remain vacant, as do 12 of the 20 sanctioned posts of dhobis.

WITH just one bed for every 40,000 patients and one psychiatrist for every one million patients, India's infrastructure for treating the mentally ill is abysmal. The only comprehensive report on the 37 mental hospitals in the country, brought out by the National Human Rights Commission (NHRC) in 2001, points to the scanty availability of facilities such as beds, medicines and toilets; insufficient professional help; and inadequate treatment and rehabilitation facilities. Lack of awareness and infrastructure forces families of the mentally challenged to resort to witchcraft, black magic and faith-healing. Professional help is hardly sought. The NHRC report also points to the deprivation of human rights to the mentally ill.

The mental health care system in Tamil Nadu has been in a deplorable state, with successive governments failing to act on the various reports and studies on the plight of the mentally ill. The Erwadi tragedy, which caught the attention of even the international media, forced the State government to act. It decided to implement, after 14 years, certain sections of the Mental Health Act, 1987, and announce some measures to deal with the situation. The State Human Rights Commission, which studied the cause of the Erwadi incident, came up with 19 recommendations including penal action against private mental homes operating without a licence.

Among the immediate measures announced by the State government were the closure of all "mental homes" functioning in thatched sheds and the "unchaining" of all inmates. The government also made it mandatory for anyone setting up such a home to obtain a licence, as stipulated by the Mental Health Act, 1987. It also ordered the setting up of a monitoring cell under the Collector in every district to make sure that the homes conform to norms. The government also launched the District Mental Health Programme (DMHP) in Ramanatha-puram and Madurai districts, with help from such rehabilitation centres as Shristi in Madurai run by the M.S. Chellamuthu Trust under the guidance of the psychiatrist Dr. C. Ramasubramanian. The IMH is to be the nodal agency for the programme. The basic idea of the DMHP is to provide primary mental health services on a sustained basis and to put in place a system for early detection of mental disabilities and treatment.

Under the DMHP, the Ramanathapuram district administration conducted a survey of the district, identified over 25 handicapped and mentally challenged persons and provided them with a rehabilitation package that included treatment and vocational training. According to Ramanatha-puram Collector S. Vijayakumar, this programme will continue. Seven such centres for rehabilitating handicapped people, including the mentally challenged, are to be set up in the State soon.

In August 2001, soon after the Erwadi incident, the Supreme Court suo motu issued notices, on the basis of media reports on the tragedy, to the State and Central governments asking them to submit a "factual report" and ordered the mapping of all faith-healing homes in the country. This process is under way. The Centre also ordered the implementation of the guidelines for maintaining minimum standards in mental homes.

Says Dr. Ramasubramanian: "A piecemeal approach will not help the millions of hapless mentally ill people and their families. Treating the mentally ill does not stop with medicines. It involves a multi-dimensional approach including rehabilitation and integration into the family and society." This should be the approach of all mental hospitals, including the IMH. The complex problem of mental health care can be addressed only through a sustained programme of education and awareness generation, along with improving the infrastructure for treatment. It is important to expand, encourage and push community-based treatment and rehabilitation. The system of "care givers" started by the government early this year, by which youth in the rural areas are trained to take care of the mentally ill in the local areas, needs to be expanded. While the government seems to have taken some steps in the right direction, a lot depends on sustaining them.