The death by fire of 28 persons while still in chains in a 'mental home' in a Tamil Nadu town draws attention to the lack of facilities for humane and scientific treatment of the mentally ill in the country.
THE chain is blackened and the ring is horribly twisted but still fastened to the charred stump - of a leg. Mentally challenged and physically shackled he was, yet Murugaraj had desperately tried to free himself. Twenty-seven more mentally ill people died with him in the early hours of August 6 when a fire engulfed the thatched roof of the Moideen Badusha Mental Home at Erwadi, a fishing village 27 km south of Ramanathapuram town in southern Tamil Nadu. They were stripped of dignity when they lived - chained, confined and ill-treated. The manner of their death was even worse.
Their death highlights the deplorable state of mental health care in the country and the need for the government to reach out to the mentally ill. Caught up in economic, social, cultural, religious and legal problems, most of the mentally ill persons are deprived of the right kind of treatment. Many of them end up being exploited at homes that are set up illegally. They are denied even the basic human rights.
Such homes proliferated at Erwadi, which is known for the dargah of Quthbus Sultan Syed Ibrahim Shaheed Valiyullah, a Moroccan who came to India to propagate Islam. Legend has it that Shaheed Valiyullah, who died in 1198, appeared in the dream of his descendant Nalla Ibrahim Valiyullah and told him to build a tomb for him at a particular place and maintain it. Thus the dargah was built and it is looked after by the descendants of Nalla Ibrahim. It is believed that Vijaya Regunatha Sethupathy, the Raja of Ramanathapuram, got an heir to his throne after he offered prayers and drank the water at the dargah, which is considered to be holy, for 41 days. The king endowed over 6,000 acres (2,400 hectares) to the dargah. This apparently is at the root of the belief that the holy water and the oil from a lamp in the dargah can cure all ailments.
People have been coming to the dargah for the last 200 years in search of a cure, mostly for mental disorders. About 1,000 pilgrims, belonging to different religious groups, visit the dargah every day. When the flow of cure-seekers increased, 'homes' came up to take care of the mentally ill.
According to dargah committee manager Mursal Ibrahim, these homes proliferated in the last 10 years. Ironically, many of them are run by persons who were brought to Erwadi 15 to 20 years ago for a cure, or by those who came here with their wards. The person who ran the Moideen Badusha Mental Home had come to Erwadi from Tuticorin 15 years ago with a mental illness. His home had 43 inmates as on August 6 (28 of them died, nine survived with minor burns and six are missing). Similar is the case of the Darbar Mental Hostel, whose owner Bashir came from Kerala 20 years ago for treatment. The home, run by Bashir and wife Najima, has 15 inmates.
The 17 homes around the dargah together have about 550 inmates, and some 100 patients are kept in the dargah compound. Most of them are chained. They go to the dargah in the evening, drink the water and dab themselves with oil from the lamp. They wait for the "divine command" in their dream to go back home. For the "command" to come it may take anything from two months to several years.
Men and women are kept separately in the dargah. There are a few toilets, and these are used by the pilgrims also. The tank near the dargah is like a cesspool, but many inmates bathe in it. A few go to the sea. While some inmates seem to have been there for long, many come on the "divine call" and stay for a few months. Lakshmi of Chennai has been visiting the dargah for 17 years, and has stayed for periods ranging from six months to a year depending on the "divine command". (Some names of patients in this article have been changed, in order to respect their privacy.)
Those who run the homes pay a rent of Rs.500-700 for the thatched sheds, which do not even have basic amenities. They charge between Rs.500 and 1,500 a month for each inmate, apart from taking an initial deposit. Each home has between 15 and 125 inmates. Some even engage touts who wait at the bus station and the railway station to lure relatives of the mentally ill.
For at least some people, putting their kin in the homes has become an easy way out of family disputes, often relating to property; in some cases even mentally healthy people are admitted to the homes in order to settle scores. For instance, Gowri (22), who was doing her B.Sc. in Psychology in Coimbatore, was left in Erwadi two years ago by her brothers after a property dispute among them made her depressed and moody. She gets a money order from her brothers every month. Murugan (25) was forced to stay in a home so that he is separated from his lover who comes from an influential family. Sundar (38), abandoned in Erwadi, is not sure where he is from. He stays chained and is made to beg.
The only records the homes maintain are the addresses of the patients' kin, to make sure that the money order arrives every month. Some relatives are prompt in sending the money, perhaps just to ensure that their wards do not return home. Defaulting in payment is common, especially by the relatives of inmates from poor families. In such cases the inmates are made to beg, with the binding chains intact so that they do not escape.
No distinction is made among the inmates depending on the nature of their illness or its intensity. They are all chained - mostly six or seven of them together and at times individually - day and night. The plight of those chained together is especially heart-rending. If one needs to answer the call of nature, all the others have to accompany him. It is worse when one of them suffers from diarrhoea or gets an attack of epilepsy, or is violent or has an abnormal sexual orientation.
The inmates huddle together in small thatched sheds, which are mostly left open in the sides. A typical home, measuring 100 sq ft, houses about 20 persons. In some homes, men and women are kept together. Fungal infections and skin diseases are common among them as they do not wash themselves regularly. They are allowed to bathe in the tank once in two or three weeks. The inmates get no medical attention; beating is the only treatment.
Few homes have kitchens. The inmates are malnourished and weak. Most of them get only the food offered by the pilgrims. It is hardly an environment to treat the mentally ill. Yet people come to Erwadi, believing stories of people having been cured.
IT is not as if the condition of the homes was not known earlier. Only, successive governments have failed to act. In July 1998, I.Nazneen, Principal of the Women's Arts College at Ramanathapuram, brought to the government's notice the inhuman treatment of the mentally ill at the Sultan Alayudeen Dargah at Goripalayam in Madurai and asked the authorities to look into the affairs of all faith-healing centres, including Erwadi. The District Collector dismissed her findings as a "gross exaggeration". Nazneen then made a representation to the National Human Rights Commission.
The NHRC, under the chairmanship of Justice M.N. Venkatachaliah, urged the State government to address the issue urgently. As nothing was done in spite of repeated reminders, the NHRC deputed D.R. Karthikeyan, who was Director General (Investigations) then, to probe the state of affairs at the homes in Goripalayam and Erwadi. Karthikeyan confirmed Nazneen's findings.
The dargah management committee and the Society for Community Organisation Trust, a Madurai-based non-governmental organisation, also made representations to the NHRC. The NHRC set up a committee under the chairmanship of Prof K.S. Mani of the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, to study the condition of the mentally ill at Goripalayam and Erwadi. The NHRC sent the committee's report to the State government along with its recommendations. The State government took no action.
It was only when eight inmates of the Erwadi homes died owing to diarrhoea in April 2000 that the State government set up a District Mental Home Regulatory Committee. The committee recommended that the homes should register themselves with the respective local bodies; inmates should not be chained; basic amenities such as toilets should be provided; nutritious and hygienic food should be offered; the sheds should be made pucca; and the inmates should be admitted to hospitals through the dargah haqdar management committee. These recommendations were not implemented. The Dargah Committee has also been urging the Collector to close down the homes.
The only fallout of the recommendations, according to Dr. A. Ganesan, Deputy Director, Health, Paramakudi, who was on the Regulatory Committee, was that a primary health centre (PHC) was set up at Erwadi and Health Department personnel started visiting the homes once in two weeks. Health Department personnel, who had only monitorial powers, could not do much beyond recording in the inspection books their observations about the poor hygiene and the absence of infrastructure at the homes.
The PHC is of little help. According to S. Paneerselvam, who runs the New Limras Mental Home which has 120 male inmates, it is practically impossible to take inmates who require quick medical attention to the PHC, which is 3 km away. But, according to S. Vijayakumar, District Collector of Ramanathapuram, although a psychiatrist was posted at the PHC and the inmates were given slips that would facilitate treatment at the Government Hospital in Ramanathapuram, none from the Erwadi homes visited the hospital.
In September 2000, People's Watch, a Madurai-based human rights organisation, sought the NHRC's intervention in the case of Murugan after verifying a complaint that he was forcibly lodged at a home in Erwadi. K.R. Venugopal, the NHRC's Special Rapporteur, conducted a probe and the Commission issued a notice to the Chief Secretary to the Tamil Nadu government and the State's Director-General of Police on October 3, 2000.
Governmental inaction is glaring. But its greatest blunder is the failure to implement the Mental Health Act, 1987. Section 4(1) of the Act states: "The State government shall establish an Authority for Mental Health with such designation as it may deem fit... to be in charge of regulation, development and coordination of mental health services... and supervise the psychiatric hospitals and mental homes (including places where the mentally ill may be kept or detained)." Section 6(1) prohibits the running of a home for the mentally ill without a licence. According to Section 11(1b), the licensing authority can revoke the licence if the maintenance of the "home is being carried on in a manner detrimental to the moral, mental or physical well-being of the inpatients." None of the homes in Erwadi meets the standards set by the Act.
THE August 6 fire, which is believed to have been caused by an overturned kerosene lamp (though sabotage is not ruled out and an investigation is on) seems to have galvanised the administration at last. The District Collector has sent a report to the State government with suggestions to improve the conditions of the homes and regularise them.
On August 10, the government announced a series of measures to regulate the functioning of homes for the mentally ill. It has ordered the immediate closure of all homes functioning in thatched sheds. Other homes should obtain a licence within a month and no home can be set up without a licence. A cell will be set up in every district under the chairmanship of the Collector to ensure that the homes conform to norms. The government has also ordered that the inmates of all homes be "unchained" immediately and those prone to violence be admitted to government hospitals. It has decided to take the inmates of all the homes at Erwadi into its care; those who are "actually mentally ill" will be moved to government hospitals and the others sent back to their families, or to old-age/destitutes homes run by the government or reputed non-governmental organisations (NGOs). Those who are not mentally ill but are abandoned by their families will get an old-age pension (regardless of their age) under the category of destitutes.
The District Mental Health Programme, sanctioned last year by the Centre, will be implemented immediately in Ramanathapuram and Madurai districts. Each district will get Rs.1 crore. According to Health Minister S. Semmalai, Rs.57 lakhs has been released by the State government for the programme in the two districts. Psychiatrists will be posted at all the 25 district headquarters hospitals. Only 14 have psychiatrists now.
In the wake of the Erwadi tragedy, the Centre has ordered the mapping of all "faith-healing" centres for the mentally ill in the country. Union Health Minister C.P. Thakur has ordered the implementation of the guidelines for maintaining minimum standards in homes for the mentally ill. The Centre also plans to modernise all mental health hospitals in the country.
Thulkarni Badsha, former secretary of the dargah committee, said that the dargah management was ready to participate in any programme initiated by the State government to improve the condition of the homes. Some home-owners, who maintain the infrastructure and keep the conditions of hygiene at reasonably good levels, have appealed to the Collector not to close down the homes. Says Paneerselvam of the New Limras Mental Home: "After the district administration issued strictures (unofficially, following the death of eight inmates in April 2000), I spent Rs.4 lakhs to upgrade all amenities to conform to the standards set by the District Mental Homes Regulatory Committee. The government should differentiate between homes."
On August 9, Dr. K. Balagurunathan, Deputy Director in the District Health Department, examined the inmates in all the homes in Erwadi and ordered the transfer of 10 patients (by August 11, the number rose to 20), who were prone to violence, to the Government Hospital in Ramanathapuram. A clinic has been set up in a room given by the dargah committee to treat the others. The government plans to create a separate ward for the mentally ill at the Ramanathapuram hospital. Says State Health Secretary Syed Munir Hoda: "The government is looking at the social, legal and medical issues to deal with the problem. A comprehensive programme for the mentally ill will soon be put in place." The Departments of Health, Social Welfare and Law would be involved in the programme.
Various political parties are conducting independent inquiries into the Erwadi incident. There is, however, a general sense of caution as the issue involves "religious faith".
Immediately after the incident on August 6, the police arrested Moideen Badusha, his wife Suraiya Begum and relatives Badsha and Mumtaj. The government announced a solatium of Rs.50,000 each to the families of the 28 people who died (Rs.15,000 from the National Calamities Fund and Rs.35,000 from the State Relief Fund); Rs.15,000 to the families of the inmates with major burn injuries; and Rs.6,000 for the families of those with minor burns. While the families of 15 of the inmates who died claimed the ex-gratia payment, money has been disbursed to only seven families as in the case of others the legal heirs of the victims could not be ascertained. (Only the amount from the National Calamities Fund was disbursed; the rest would be distributed later.) The Collector has asked the relatives of the inmates of the other homes to take back their wards. Only a fourth of the inmates have been taken back by their families.
The families hesitate to take their kin back because, according to Dr. C. Ramasubramanian, a psychiatrist and a member of the District Mental Home Regulatory Committee, many of them consider the homes a convenient place to abandon their mentally ill wards in order to escape the stigma attached to mental illnesses (see interview). Myths that mental illnesses are incurable and contagious and the lack of proper medical infrastructure for the treatment of such diseases are also factors that have influenced the decision of the relatives of the inmates of these homes. As a result, such homes have proliferated. There are about 35 of them around various temples and dargahs in Tamil Nadu.
According to Dr. Rama-subramanian, some 70 million people are mentally ill in the country. According to the publication Mental Health in India 1950-2000, 2 per cent of the population is affected severely and 20 per cent in varying degrees. But, according to estimates, there are hardly 10,000 hospital beds in India for the mentally ill. The only mental hospital in Tamil Nadu is the Institute of Mental Health in Kilpauk, Chennai, with 1,800 beds.
Dr. Ramasubramanian said that in recent times the treatment for mental illnesses has made rapid advances. The condition of most inmates of the homes for the mentally ill can be improved with the right medicines. But with their families unwilling to take them back and with a dearth of hospitals to treat them, what is the choice before them? Says Dr. Ramasubramanian: "Treating the mentally ill does not stop with medicines. It involves a multi-dimensional approach including rehabilitation and integration into the family and society."
According to Nazneen, this complex problem can be addressed only through a sustained programme of education and awareness generation, along with improving the infrastructure for treatment and providing medicines free or at subsidised rates. Says Nazneen: "We hope the martyrs of Erwadi will open the eyes of the people and the authorities."
