TRIBUTE

Keshav Desiraju: Architect of India’s mental health policy

Print edition : October 22, 2021

Keshav Desiraju. Photo: The Hindu ARCHIVES

Kesav Desiraju addressing a workshop on alternative crops to tobacco held in Guntur in November 2011. He contributed tremendously to tobacco control. Photo: The Hindu

Mentally ill persons presenting a memento made by them Keshav Desiraju, who was then to the Health and Family Welfare Department, Special Secretary, in Madurai on June 15, 2012. Photo: The Hindu archives

Keshav Desiraju (1955-2021), former Union Health Secretary, was the driving force behind India’s mental health care policy. He was not only assiduously engaged in understanding public health issues, he sought to introduce good governance in the health sector.

IN 2010, when Keshav Desiraju, a 1978 batch Indian Administrative Service officer, was posted as Additional Secretary in the Union Health Department, Sujatha Rao, who was then Health Secretary, told him, “You must give some focus to mental health.” The advice was made in the context of a report submitted by NIMHANS (National Institute of Mental Health and Neuro Sciences) on the scale and magnitude of mental illness prevailing in the country. The report had flagged the high cost of treatment of mental disorders in comparison to other ailments and health conditions. “I told him this in a fairly routine manner. I did not push him…. During my entire tenure, I would have talked to him about this four or five times. But he took it seriously,” Sujatha Rao said, recalling Desiraju’s biggest contribution to the nation.

Desiraju pursued the issue of mental health doggedly and, with the support of a variety of stakeholders, formulated a mental health policy that helped place mental health in the social justice space. This resulted in the passing of the Mental Health Care Act, 2017, a year after Desiraju retired from service. The Act came into force in May 2018.

“Usually, you cannot credit one individual in government with framing a policy or completing a project because it takes a lot of effort on the part of the entire machinery. But in the case of the mental health policy, Keshav was the driving force,” Sujatha Rao said.

There were many obstacles in the way. The first challenge was to identify the stakeholders who could contribute to the government’s policy. Then the Health Department had to engage with the Social Welfare Department which lay exclusive claim to any issue relating to disability. Changing the framework of policy making to a rights-based, humane approach was the third challenge. By 2014, when Desiraju was unceremoniously removed from the post of Union Health Secretary, he had completed the work on drafting and finalising the Mental Health Care Bill, 2013.

Framing the rules that accompany a piece of legislation is a tedious, procedure-ridden, time-consuming process. After the passage of the Bill in both Houses of Parliament, Desiraju approached Lav Agarwal, the then Joint Secretary (Health), offering his services in framing the rules, Agarwal asked Desiraju to head the committee. Desiraju agreed. From start to finish, this piece of legislation took almost a decade to come to life; and had to pass through two coalition governments, one led by the Congress (2009-14) and the other by the Bharatiya Janata Party (since 2014).

Desiraju passed away in Chennai on September 5 at the age 66. In a tribute in The Hindu on September 9, Dr Vandana Gopikumar, founder-trustee, The Banyan, and Ravi Chellam, a life-long friend of Desiraju, wrote: “Desiraju recognised poverty, deprivation and poor social networks as predictors for poor health and mental health outcomes. Therefore, it was not a surprise that as the architect of India’s Mental Health Policy and Mental Health Care Act, he emphasised mental health care as a basic right for every citizen, placing the onus on the state to find both funding and developing a road map to ensure appropriateness and accessibility of care. This was his biggest win.”

Every person involved in the Indian health sector has at least one anecdote connected to Desiraju to recall. M.R. Rajagopal, founder and Chairman, Pallium India, an institution that strives to improve access to palliative care, wrote a note to friends on how India’s National Programme for Palliative Care (NPCC) was born: “Nine years ago, I was to attend a side event on access to palliative care at a World Health Assembly in Geneva. Discreet enquiries in Delhi had brought in the information that Shri Desiraju, would be attending the meeting, that he had a reputation for integrity, pragmatism and intelligence…. I finally tracked him down in a cafeteria during a recess.

“I was ready with my elevator-pitch, introduced myself and invited him to our side event at lunch hour the next day. He spoke three words, ‘I will come’. And he came. He was there all through the one-hour programme at lunch break, during which I had seven minutes to speak about the lack of access to palliative care in India and the need for a palliative care policy for every country. Within two weeks of his return to India, I got an invitation from the Ministry of Health to attend a meeting in Delhi. He had put Dr Sudhir Gupta (then Deputy Director General of Health Services and the creator of India’s Transplantation of Human Organs Act) in charge, who got together representatives of various organisations, and in a few months India’s NPPC was created.”

On-the-ground experience

As Union Health Secretary, Desiraju refused to sit in Delhi and confine himself to tweaking policy on various health sector issues. In 2013, soon after he took charge as Union Health Secretary, he called up Yogesh Jain, a public health physician who runs a non-governmental organisation in rural Chhattisgarh. The reason: he wanted to spend two days in the rural area to understand firsthand health care delivery issues in a backward and rural State.

“He called up one afternoon to say that he wanted to come and learn from us. This was for me most unusual because I have interacted with several administrators and technical officers but none of them had made such a request,” Jain recalled at a virtual condolence meeting for Desiraju.

Although Desiraju was aware of the public interest petition that Yogesh Jain had filed against the Health Ministry in connection with the use of a particular vaccine without investigating its adverse effects, he included Yogesh Jain in the steering group of the National Health Mission because of his contribution to rural health care, particularly for the marginalised. In all the years that Desiraju was associated with policy-making in the public health sector since 2008 (first as Principal Secretary, Uttarakhand) it was the on-the-ground experience he gained that perhaps set him apart from others of his ilk.

It was because of this quality of engaging with grassroots “experts” and understanding the issue in its totality, says the public health expert Julius Sen, that “he was able to develop a policy, legal framework, institutional arrangement and budget for a subject that is very low as a policy priority. That speaks volumes about his determination, but also suggests that not everything is as politicised or polarised as we perhaps think.”

Julius Sen, former LSE associate director and senior programme adviser, LSE Enterprise, said: "It also speaks volumes about how mobilising civil society groups, academics, medical experts and journalists can be so productive especially in such a situation. That was indeed unique and is a distinct and hopefully lasting contribution to policymaking in India which takes us beyond the usual interests and forces that drive most decisions."

Mala Rao, United Kingdom-based professor of public health, commended Desiraju after his lecture on “Issues in Public Health in India”, at Somerville College in 2019: “A true champion of better health and wellbeing and one who has hugely benefited global and national public health strategy through his advocacy.”

Desiraju’s concern about the state of public health infrastructure in India was evident in his last major interview to this correspondent, soon after the first wave of the COVID-19 pandemic caught the world unawares (Frontline, May 8, 2020): “Our systems on the ground are flimsy, despite massive investments since 2005, under NRHM, later NHM. Investment in public health is not a one-shot operation as some donors and some CSR [corporate social responsibility] activities would have us believe. Unless there is continuous and systematic investment in building both human and physical infrastructure, we will not have a public health system which has the ability to respond quickly and effectively to a crisis.”

The psychiatrist Soumitra Pathare, a friend of Desiraju, wrote in National Herald on September 5: “He brought that something elusive to the health sector—hope of good governance. The angry articles on his abrupt and unceremonious transfer from the Health Ministry in 2014 after just 11 months in the post for his unwillingness to compromise on public health issues is another example of the health sector’s high regard for him.”

In 2014, at a farewell organised by public health professionals when Desiraju was transferred from the Health Ministry, Srinath Reddy, who headed the Public Health Foundation of India, described Desiraju as “Health Secretary Emeritus”. “The world of public health, and health overall, considered him a true friend and a champion of health equity.... He contributed tremendously to tobacco control, and was… very keen on health policy and systems research. He took his official designation lightly but took his official responsibilities with unswerving commitment.”

It is because of his active engagement with public health issues that Desiraju was on the board of several health-focussed organisations after his retirement. This included the Population Foundation of India (he chaired its governing body), The Banyan Academy of Leadership in Mental Health, Schizophrenia Research Foundation and the Cancer Institute (all based in Chennai), the Pallium India Foundation (Thiruvananthapuram), the Centre for Disease Dynamics, Economics and Policy (Washington D.C., and Delhi) and the Centre for Policy Research and the Centre for Equity Research (both in Delhi).

At the time of his passing, he and other members of the governing body of the Cancer Institute were working on reworking the institute’s systems and processes following the demise of its chairperson, Dr V. Shanta. Dr Shanta had expanded the scope and reach of the institute severalfold, catering to patients across many geographies.

Early years

Desiraju, who opted for the Uttarakhand cadre after the bifurcation of Uttar Pradesh (“because it is easier to effect policy changes working with a new set of people’s representatives who are chosen as Ministers for the first time”), had introduced the ‘108’ emergency ambulance service and helped strengthen the health system in the State.

Despite having a “network” of fellow officers and civil society representatives and being identified in most circles as former President S. Radhakrishnan’s grandson, Desiraju refused the ‘perks’ that came with the trappings of reflected glory. (He once told this correspondent that when he introduced himself to former Samajwadi Party chief Mulayam Singh Yadav, the latter told him that he knew who he was, including the fact that he was Radhakrishnan’s grandson). After each stint with the Union government, Desiraju went back to his parent cadre during the “cooling off” period. This was at a time when it was routine to seek favours from ruling party politicians to remain in Delhi or manage a posting abroad.

Through a long and distinguished career that spanned over three decades, Desiraju left his impression on most of the sectors he dealt with, particularly health, where he spent his longest time. Prabha Chandra, a doctor at NIMHANS, tweeted: “Keshav Desiraju was the main driver for NIMHANS to become an institute of national importance. He will be remembered for many pathbreaking initiatives in health, including guidelines for sensitive handling of sexual assault. We have lost a great visionary.”

Many civil servants and retired officials recall him as an affectionate but firm Deputy Director of the Lal Bahadur Shastri National Academy of Administration (LBSNAA). He was Deputy Director of the Academy from 1984-88. Anup Wadhwan (1985 batch, Uttar Pradesh and later Uttarakhand), who retired as Union Commerce Secretary a few months ago, recalled at a virtual condolence meeting recently: “There were 160 of us in my batch. He knew each of us by name. He was our role model…. We instinctively look down upon people who are socially inferior to us such as our driver, domestic worker, etc. He never did…. Many of us are in his debt because he could always help us figure out the right way forward.” Wadhwan underlined the “intimidation of senior officers” when interacting with juniors and with the common man—this was par for the course—and said that in Desiraju, there was not even a “trace of intimidation”.

Amitabha Bhattacharya (1975, Andhra Pradesh), whose tenure on the faculty at LBSNAA coincided partly with Desiraju’s, noted in an article in The Statesman: “He worked towards integrating the role of non-governmental, grass-root organisations into the training framework…. Aware of the deficiencies of ‘sarkari’ processes, he strove to expand the boundaries of government action to accomplish what really constitutes public service.”

In the view of his colleagues and seniors, he never broke a rule, but “interpreted it to help people”. In one instance, as Joint Secretary, Union Department of Personnel and Training, he declined a women IAS officer’s request to alter her date of birth to gain a few years of service. In another, he saved the career of an IAS officer by bringing to a close a false complaint against an officer who was set to graduate from the Academy. The officer is now making a significant contribution to governance.

Book on M.S. Subbulakshmi

Even before his retirement, Desiraju had begun working on a book on the celebrated Carnatic vocalist M.S. Subbalakshmi, because he felt that there was a major gap in understanding the person and her environment. He rubbished ill-informed criticism that she rose to stardom because she was pretty and because she had a pushy and influential husband. Placing her life and career in context with a critically acclaimed book, Of Gifted Voice: The Life and Art of M.S. Subbulakshmi, Desiraju made a valuable addition to the world of classical Carnatic music.

Former Union Minister Jairam Ramesh said in a message on social media: Keshav has written the definitive biography of M.S. Subbalaksmi. K. Vijay Raghavan, Principal Scientific Adviser, Government of India, noted on Twitter: “A man of many facets with whom discussions were always collegial no matter how strongly opinions differed. A scholar, whose recent biography of M.S. Subbulakshmi is analytical, insightful.”

Amitabh Kant (IAS, 1980, Kerala) former NITI Aayog Chief Executive Officer), tweeted: “A remarkable human being, a professional civil servant, a progressive intellectual & an author of a wonderful book on M.S. Subbulakshmi.”

The social activist and former civil servant Aruna Roy, who reviewed Of Gifted Voice for The Book Review, commented that the book was "a fascinating story not only of music but also of politics of a woman who struggled to get somewhere in the world of performance. Yet, it is a book about a musical genius embedded in cultural politics".

At the Jaipur Literary Festival, held virtually in March 2021, author Samanth Subramanian asked Desiraju why he chose to write on the musician. “You have obviously identified some kind of gap in the public knowledge of MS—whether it is in the literature that surrounds her or in just what people think of her. What was the gap that you thought you could bring this book into?”

Desiraju answered: “There is a great deal of MS that we don’t know…. I really wanted to write about MS the musician…. She was portrayed as many things. She was many people in her own life. But she was first and foremost, a classical musician of the first rank. And that is the image I wanted to capture.”

Desiraju wanted to put two more lives in perspective— that of Dr Muthulakshmi Reddy and Carnatic music composer Tyagaraja. A mutual friend informed him that V.R. Devika, author and art critic, was working on a book on Muthulakshmi Reddy, and wanted him to edit the book. The last fortnight of his life was dedicated to completing the editing work. “Keshav wanted a clarification or had caught on to a proofing problem every few lines…. I didn’t know him. But he spent so much time on my book,” Devika said. Desiraju completed the editing work, and sent the last few chapters to Devika just past midnight on September 4.  

After he completed the book on Subbalakshmi, an effort that took nearly a decade, he began preliminary work on Tyagaraja. He soon realised that unless he read the original manuscripts, he would not be able to do justice to a book on the composer of Carnatic music. So he started taking Telugu lessons in August 2020.

All through his life, Desiraju had looked up to former Governor Gopalkrishna Gandhi, and had a very close friend in the historian Ramachandra Guha. Vandana Gopikumar and her husband and director of Qube Cinema, Senthil Kumar, were added to that special list later.

Says Vandana: “The principles that he lived by were inspired by a sense of equality, a sense of justice and a sense of ensuring that every individual had a right to a life of dignity…. There are several lessons that we [Senthil and I] have taken away. The most important being that every achievement should sit lightly on us, that there should certainly be a sense of community and fellowship and that music of whatever sort and rythmn and cadence is a very integral part of our life.”

Ramachandra Guha described Desiraju as an “exemplary Indian” in an interview to The Wire. “No civil servant in recent memory has got this kind of spontaneous appreciation and tributes after he died.” Guha wrote in Scroll: “He sought [as Union Health Secretary], heroically, to take on the corrupt cabal that ran the Medical Council of India, which had many influential politicians in its pocket. This campaign, as well as his opposition to the tobacco lobby, led to this remarkable officer being shifted away from the Health Ministry by the United Progressive Alliance government then in power. For a general election was around the corner and an upright secretary was an impediment to the collection of funds via illegal means.”

Guha shared an interest in music with Gopalkrishna Gandhi and Desiraju. On a trip to Tiruvannamalai (Tamil Nadu) ahead of Gopalkrishna Gandhi’s posting in South Africa in 1996, Gopalkrishna Gandhi told Guha to write an article on why M.S. Subbulakshmi should get the Bharat Ratna because of her body of work, and the many new facets that Desiraju had dug up over the years. “It was the only ghost-written article in my career. Gopal told me how to write it and wanted it published in India Today because it was a mass circulated magazine at that time. About a year and half later, we heard the news that she had received the Bharat Ratna…. So even at that time Desiraju was working on this…. He would work through the week, and the weekends were devoted to researching MS. His enquiry focussed on what MS was singing at different points of time.”

Asked how he was he different, as a human being, bureaucrat and a writer, Gopalkrishna Gandhi told Frontline: “I cannot say, because I did not look for that different-ness in him. He was true. He was real. He did not pretend to be something he was not. He did not try to impress. He did not seek admiration. He valued love. He cherished friends. He was generous in appreciation.

“Shabash! was a favourite word of his. Said in Tamil, not Hindi. He exclaimed that for a fine sentence spoken, a fine phrase sung. And a fine example of cooking. He enjoyed what he enjoyed to the brim.

"When he enjoyed a line he read or heard, he let it sink in, and internalised immediately, enjoying its sound sense and taste. Yes, he could taste language. When he enjoyed a phrase in music he embraced it in his mind, for its tone, pitch and timbre. And a lyric for its depth, its craft.

“When he ate with his hands, south Indian food, he would eat to the last particle of the meal, leaving nothing on the thattu, not a grain of rice, not a sprig of coriander, not a single mustard seed. And sliding his palm on the thattu's rim, would wipe the last drop of the flowing gravy with his index finger and finish the meal with that final flourish.

“He loved looking at beauty. Human good looks entranced him. And when looks were accompanied by a matching sensibility, Keshav was simply captivated. But, and this is important, he was utterly non-possessive about the objects of his entranced admiration. He did not ever want to own or possess them physically, except of course his Ravi Varma paintings, his music and his books.

“What he loved, and he loved a great deal, he loved to the lees. There was one thing he loved above all his loves. And that was his own quiet time when no one and nothing intruded, when he was by himself, his thoughts, his memories. And strange as it may seem, that ‘quiet time’, an inanimate thing, loved him for it found in him an undemanding unconditional unceasing lover.

“Love has lost a lover.

“Quiet has lost a partner

“We are of course quite used to corporate lobbies and special interests shaping policies, but here is an example of an altogether more interesting process that actually strengthens democracy and accountability while also serving a vital social purpose.”

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