A cultural critique of community psychiatry in India

Jain, S & Jadhav, S (2008): A Cultural Critique of Community Psychiatry in India International Journal of Health Services, Volume 38, no. 3 (in press).

Author’s Biographical Sketch Mr. Sumeet Jain, B.A., M.S.W. is pursuing doctoral research at the Centre for Behavioural and Social Sciences in Medicine, University College London. Trained in Development Studies at the University of Toronto and in Social Work at McGill University, his research examines the cultural appropriateness of community mental health services in India. He has recently conducted a clinical ethnography of a community psychiatry team and the rural population they serve, in the State of Uttar Pradesh, North India. Dr. Sushrut Jadhav, M.B.B.S., M.D., MRCPsych., Ph.D., is Senior Lecturer in Cross-cultural Psychiatry at University College London; Honorary Consultant Psychiatrist, Homeless In-patient Services, Camden and Islington Community Health and Social Care Trust. He is Founding Editor, Anthropology and Medicine journal. His current interests include the deployment of cultural formulation approach to engage with acutely unwell psychiatric patients, mental health and marginality with a focus on South Asia, and the cultural premise of western Psychiatry. He is also Co-Director (with S.Dien and R. Littlewood) of University College London Masters in Culture and Health.


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Abstract

This paper is the first comprehensive cultural critique of India's official community

mental health policy and programme. Data is based on a literature review of published

papers, conference proceedings, analysis of official policy and popular media,

interviews with key Indian mental health professionals, together with field work in

Kanpur district, Uttar Pradesh, India (2004-2006). The paper demonstrates how three

influences have shaped community psychiatry in India: a culture asymmetry between

health professionals and the wider society; psychiatry's search for both professional and

social legitimacy; and WHO policies that have provided the overall direction to the

development of services. Taken together the consequences have been that rural

community voices have been edited out. The paper hypothesizes that community

psychiatry in India is a bureaucratic and culturally incongruent endeavour that increases

the divide between psychiatry and local rural communities. Such a claim requires

sustained ethnographic field work to reveal the dynamics of the gap between

community and professional experiences. The development of culturally sensitive

psychiatric theory and clinical services is essential to improve the mental health of rural

citizens who place their trust in India's biomedical network.


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A cultural critique of community psychiatry in India

Mr. Sumeet Jain Dr. Sushrut Jadhav

Centre for Behavioural and Social Sciences in Medicine, University College London

London W1W 7EJ

Submitted to:

International Journal of Health Services

Correspondence: Dr. Sushrut Jadhav Centre for Behavioural and Social Sciences in Medicine, University College London Charles Bell House, 67-73 Riding House Street London W1W 7EJ Tel: +44-207-679 9292/9478 Fax: +44-207-679 9028 Email: [email protected]


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A. Introduction

India has been considered a pioneer of both policy development and service

provision of community mental health in low-income countries (1). The national

strategy of integrating mental health with existing primary care services addresses scant

resources and challenges of servicing a dispersed remote population of a large and

diverse country. Whilst not disputing that the country’s mental health programmes were

initiated with bold and well-meaning objectives, numerous problems continue to thwart

implementation of these programmes. Several of the logistical and administrative

difficulties have been detailed in public health and psychiatric publications (2-4).

Significantly, a historical and cultural analysis of major forces that have shaped the

discipline is conspicuously absent in the published literature.

This paper therefore is both a brief cultural history of community psychiatry in

India and a critique of its policies and implementation. Analysis of policy documents,

published literature, and interviews with Indian mental health professionals form the

major source of data. Preliminary observations from field work by the first author in a

northern Indian village (2004-2006) and its community mental health team complement

the observations. The paper argues that community psychiatry is primarily a top-down

endeavour driven by policy makers at the centre that has edited out the community’s

voice from official programmes and policies. As a result, current mental health policies

and clinical services are incongruent with local experience of suffering. Paradoxically it

is this bureaucratization and cultural divide that provide legitimacy within international

mental health.

The argument is outlined in three parts: First, routine challenges to the practice

of this discipline illustrated through three brief critical clinical vignettes derived from


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ethnographic field work. These vignettes illustrate the nature of problems confronting

theory and practice of mental health in rural India. Second, a review and analysis of

significant influences shaping the development of both policy and services derived from

analysis of official health documents. The paper concludes with a consideration of vital

issues and exploration of future directions.

B. What Ail’s Community Psychiatry in India: Three illustrative vignettes

The vignettes that follow embody challenges to policy, service delivery and

utilization.

(1) India’s mental health bureaucracy

‘We have the model; all they have to do is photocopy it’

[Remark by middle-ranking community psychiatrist in India]

This comment is illustrative of the general approach and strategy adopted by

official mental health agencies in implementing the nation’s mental health programme.

The ‘model’ in this quote refers to India’s community mental health programme. ‘We’

refers to the mental health professional and institutions driving the country’s policy.

‘They’ refers to clinic staffing health care centres throughout the country. Although the

literature cites the development and testing of models for delivering mental health

services as one of India’s biomedical strengths, in practice this translates into testing a

singular approach (1). The thrust of this strategy is to integrate mental health with

existing primary care services. Alternatives to this approach have neither been

considered nor tested; and illustrate a dogmatism in pushing a particular approach. To

date, the programme is restricted to a limited coverage across the country and currently

functional in 100 of 593 districts (5).


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Field observation of micro-level implementation of a rural mental health

programme revealed that this process of ‘photo-copying’ was not working. In other

words, clinical practice did not maintain fidelity to the proposed model. For example,

whilst the policy prescribed mental health training for health workers, the programme

was operating satellite clinics at a number of peripheral rural health centres in parallel

with a core clinic at the local district hospital. This modified programme was confirmed

by a government medical officer who stated “the main efforts will be focussed on

district hospitals and not on training health staff at rural peripheral centres.”

This ethnographic observation highlights an important problem that impacts

upon the delivery of mental health care in India. It appears to be an administrative,

state-driven endeavour involving implementation of top-down models conceived and

written at the Centre, marginalizing communities for which services are to be made

available. The evidence to support this proposition will be discussed at length in Section

C of this paper.

(2) ‘Going to the community...’

[A repeatedly overheard rhetoric amongst urban community mental health professionals

staffing rural clinics]

A crucial finding from rural ethnographic observation revealed a clear

disjuncture between the notion of the term ‘community’ as constructed by the villagers

and that defined and operationalized within the country’s mental health policy. Urban

based mental health professionals responsible for running rural clinics would often refer

to their ‘field visits’ as ‘going to the community’i.

Indeed from the perspective of an urban professional, the rural health centres

that they periodically staffed were a site where they interacted with the ‘community’.


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These health centres provided them with both a physical and conceptual means of

accessing the inaccessible village. Hence, the use of the short form ‘going to the

community’ is an accurate reflection of how urban health professionals conceptualize

the term ‘community’ and their relationship with rural people. Community in this

context is a physically defined ‘space’ existing ‘out there’. Its relationship with

providers of mental health care is defined through the lens of ‘cases’ and viewed as a

site of ‘disease’ and ‘pathology’.

These professional views of ‘community’ are in striking contrast with the views

held by villagers themselves. The village was viewed by the latter as an important

source of identity with its ‘name’ linked to history, a combination of zamindars (land

owners) and prominent public figures. Thus, for example there was the popular

association with a well known neurologist and a former Member of Parliament both of

whom hailed from this village. Prominent caste (Katiyars, a dominant Other Backward

Caste) and community figures together with political affiliations also provided an

important reference point to outsiders and villagers themselves. For the villagers,

identity was also conceptualized and expressed through their history including ancestors

and ghosts. Gods, Goddesses, local Hindu and Muslim spirits comprise rich

cosmologies that defined both physical and supernatural boundaries of the village. Thus

Ghost stories frequently inter-digitated with everyday narratives of suffering. A

significant proportion of time was spent in appeasing supernatural agents that were

considered aetiological to a range of misfortunes. Caste based affiliations played a vital

role in the social stratification of the community and its loyalties.

Consequently, there are important gaps between the clinical objective view of

mental health professionals and the more nuanced, somewhat indefinable everyday


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experience of the local community. This highlights a conceptual incompatibility. On the

one hand professionally derived constructs of community frame it as a locale outside

their world, a remote site to be visited. This contrasts with the ways that every day life

is experienced. The implication of this incongruity will be further examined in Sections

C and D of this paper.

(3) ‘The Local Health Centre: So Near Yet So Far’

[Field notes of the first author]

The Ibrahim Sayeed Dargah, a Sufi Muslim shrine, is a serene place that enjoys

popularity among both Hindus and Muslims as a place of healing. The deceased Nau

gaja Pir Baba’s (nine-foot saint) grave is in the inner sanctum of this shrine. Entering

the Dargah compound, the intense activity and interactions are striking– people

cooking, someone sweeping, groups of people sitting on mats talking and exchanging

food. There are a number of people lying down near the inner sanctum covered by a

sheet. They are undergoing ‘surgery’ which Baba performs to cure a range of physical

diseases including tumours and gastro-intestinal problems.

Several aspects seem to facilitate healing and distinguish it from the local

government health centre only a few kilometres away. These came to the fore in

interactions with a young Muslim man, Rizwan, who was brought from a long distance

because he was disturbed by a shaitan (an evil spirit). Rizwan would stay with his

parents for several months at a time in the Dargah and return home when he was a bit

better. When unwell, he would be seen wandering around the Dargah, unkempt, talking

to the sky. Others related that when he was first brought, he was in chains because he

would run around hitting people. He would speak in mumbled tones jumping from topic

to topic and rarely make sense. On other occasions, Rizwan would give the impression


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of being a clean, bright, and well spoken young man, helping out with activities in the

Dargah.

Rizwan’s family did not view his problem in bio-medical terms. Rather they saw

it as a result of shaitans placed on him by unspecified relatives. Difficulties had started

whilst walking to school when he was relayed the untrue news of his mother’s death.

Although he wrote his exam, it was at this point that he became unwell (‘Mind out

hogaya’; Transliteration: The mind had stopped working). He dropped out of school

and could not work. Additional difficulties included his mother’s uterine cancer and the

murder of Rizwan’s married sister by her husband’s family.

The family found strength and meaning to cope with these major life events

through their association with the Dargah and its local community. No other institution

– be it the cancer doctors in Kanpur, the local health centre or the police who refused to

register a case against the sister’s murderers – could respond in the same fashion. The

Dargah provided spiritual strength, a healing space in which they could find the support

and friendship of others, and an overall framework to reconcile a range of psychological

and social tensions.

Rizwan’s help-seeking illustrates challenges to local mental health services.

Only a few kilometres away from the Dargah, a monthly psychiatric clinic operates at

the government health centre. Yet Rizwan and his family preferred attendance at the

Dargah. Similarly, interactions with other respondents at the shrine revealed their

problems were expressed through physical idioms that included a set of supernatural

causes relating to shaitans. This vignette suggests that poor utilization of the local

psychiatric clinic is not necessarily related to physical inaccessibility, including time


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and costs towards travel (6). The cultural distance between clinic staff and the local

villagers is a crucial barrier.

Taken together, the three vignettes suggest that both national policy and its

service operationalisation neither match nor engage with local experiences. This

conceptual asymmetry between official policies and common concerns of the wider

population begs the question: How and why has this come about? Addressing this

question requires a nuanced analysis of the cultural history of community psychiatry in

India. This history is detailed in four phases: an early period based on innovation by

pioneering Indian psychiatrists; a second phase shaped by WHO policies; a third phase

involving two major Indian experiments; a fourth phase in which the experiments were

translated into policies; and a fifth phase of routinization and consolidation of mental

health services.

C. Brief Cultural History of Community Psychiatry in India

(1) The Early Period: innovations by pioneering Indian psychiatrists

Indian psychiatry’s own re-telling of the history of community psychiatry

usually begins with the work of Dr. Vidya Sagar, the Medical Superintendent at the

Amritsar Mental Asylum during the 1950s. Several of the senior psychiatrists

interviewed in this research, together with the published literature on community

psychiatry in India refer to Dr. Vidya Sagar’s pioneering initiatives. It is therefore

appropriate to denote it as a principal parent myth that has both shaped and structured

community mental health in India. Faced with an over-crowded hospital, Vidya Sagar

experimented by involving families in the care of their relative. Families were allowed

to stay on the hospital grounds and received education on mental health and illness. His

experiment was viewed as innovative, an approach that broke down the barriers of the


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asylum. In an era dominated by custodial style institutions this was an important and

practical step (7). Vidya Sagar’s effort was considered a model of care to be enshrined

and idealized by professional colleagues over generations. A crucial characteristic of the

re-telling relates to the reification of this innovative parent myth that then legitimised

the rationale for subsequent programmes and policies. The literature refers to Vidya

Sagar’s strategy of inter-mixing religious and spiritual idioms with an emphasis on

increased public awareness of psychiatry and the role of Amritsar Mental Hospital as an

important place for psychiatric care (8). Community engagement was based on a

psycho-educational model, with information flowing from professionals to the

community (8).

Interestingly, little is known on the public shaping of psychiatric practice at the

time. The overwhelming focus in published literature is on Vidya Sagar’s labour at

engaging with the public. This may be simply an artefact of accounts written many

years later, mainly mental health professionals with well-meaning, important objectives

of reaching the community. The absence of the popular voices and local experiences

from accounts of this important early innovation illustrates a continuing challenge for

the discipline.

The absence of public influence is in part a colonial legacy. It was only in the

latter part of the colonial period that local communities began to accept mental asylums

as places of treatment. Prior to this, asylums interacted with the general public through

the legal system. Most patients were brought in by the police not by family or

community members (9;10). Colonial psychiatry had little legitimacy and credibility

with the popular Indian community. This theme frequently emerged in the early annual

conference speeches delivered by Presidents of the Indian Psychiatric Society (IPS).


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Alluding to the low status of psychiatry within medicine, one of the Presidents stated:

“More than prejudices against psychiatry among the lay public we have often to

contend against prejudices to profession itself.” (11:103). The task of seeking

credibility from both public and medical colleagues appeared to pre-occupy the

discipline during the early post-independence period.

Consequently, initial service delivery reflected these challenges. With increasing

over-crowding, researchers at the then All Indian Institute of Mental Health (AIIMH),

Bangalore, reported that more than one-third of inpatients could return to their families.

However, the main obstacles to this were “…..the unkind attitude of the community at

large and family in particular towards the mental illness…”. Patients were perceived as

a burden. In one group of patients studied, 62% received no regular visits from family

members (12). The psychiatric profession was constrained by prolonged

institutionalization resulting in limited interaction with communities and understanding

of their needs. Communities too, may have come to view admission to mental hospitals

as a final resort for difficult to care family members (9).

A related aspect of this post-colonial interaction between psychiatry and the

general public concerns the integration of Indian cultural traditions within mental

health. An Ayurvedic Research Institute was set up in 1959 at the AIIMH, Bangalore,

and aimed at assessing the efficacy of Ayurvedic treatments (13). Similarly there were

attempts to develop an ‘Indian psychology and psychiatry’ by uncovering mental health

concepts within indigenous texts and traditions (14-16) including the development of an

Ayurvedic Mental Status Examination (17). This linking of ‘modern’ psychiatry to

‘traditional’ Indian knowledge systems reflected then post-independence ideas of

development and official attempts to legitimize indigenous Hindu traditions.


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Consequently many senior Indian psychiatrists privileged classical indigenous medical

systems and Hindu texts over folk healing traditions. In relation to the classical

traditions, the focus was less on contextualizing their role in relation to local challenges.

Rather they sought to demonstrate a goodness of fit between classical texts and western

psychiatry in order to legitimize the former (14-16;18-20).

This isolation of psychiatry both within medicine and society underwent a shift

in the 1960s. The development of general hospital psychiatry units (GHPUs) brought

about a closer interaction between the public and mental health professionals. There

was a steady proliferation of such units and by 1970 more than 90 existed {Behere &

Behere, 2001}. Anecdotal evidence suggested they reduced the stigma of mental

disorder due to shorter periods of hospitalization and the involvement of family

members (4;21). It was following this period that community mental health services in

India were shaped by international forces. This requires a fuller analysis.

(2) The World Health Organisation Expert Committee Report and Community

Psychiatry in India

In 1975, the WHO published a seminal report entitled ‘Organizing Mental

Health Services in Developing Countries’ (22). Major recommendations by the WHO

included the integration of mental health services with primary health care and

decentralization to the local level. These developments were in keeping with the

WHO’s emphasis on basic health services (22).ii This Report defined the community’s

‘need’ at the outset, as the gap between the numbers of people needing help and the

availability of services. Strategies of integration and decentralization were proposed to

deal with this unmet need. Integration of mental health services “…means that the

mental health component should be incorporated into the work of the primary health


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worker, the community health centre, district and regional health centres and

hospitals.” (pp.32). Decentralization referred to the transfer of skills and delegating

tasks. This was to be achieved through training of health workers.

The relationship with the community was mediated through the institution of the

health centre and through administrative strategies of planning and training.

Communityiii thus, was framed as an object of intervention, a place in which disease

could be located, detected and treated; and a site for delivering services. A dynamic

view of community that considered its different components, voices, interactions and

world-views did not emerge.

The report emerged in the context of a number of experiments in India and some

African countries during the late 1960s and early 1970s that sought to evolve new

approaches to mental health service delivery (28-30). Such experiments demonstrated

more humane and cost-effective ways of caring for patients. This period was also

characterized by several international, national conferences and country workshops that

debated these problems. These were sponsored by the World Health Organization, the

World Federation for Mental Health, the National Institute of Health, and the

Commonwealth Foundation (31), (32), (33), (34), (35), (36). Despite extensive formal

discussions, no clear consensus on the development of mental health services emerged.

For example, two polarized views were evident in a 1973 international workshop held in

Indiaiv: reliance on mental hospitals and training of primary health personnel (34). Over

time, the latter view dominated subsequent policy.

It is in this environment of debate that the WHO report assumed importance. It

provided legitimacy to a coherent agenda for mental health services. Coherence

stemmed from the detailed plans and recommendations. Legitimacy was related to


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WHO’s endorsement of the report and to the report committee’s membership which

included prominent mental health professionals from both low and high income

countries. The report had a strong influence on Indian mental health services which

uncritically accepted its recommendations. A senior Indian psychiatrist actively

involved in events of the period commented: “It was the WHO report and WHO

influence is huge.” (Professor of Psychiatryv).

The WHO’s symbolic power was evident:

“See they [WHO] are a very powerful organization and people like to hang on because you know we are a very poor country and even to travel abroad, we need support. So people went on for that direction, which is alright……………….they would end up influencing WHO policy, it will become a WHO policy. So that would have in fact influenced the governments to …I think that was another way of influence and it was not a wrong way … because WHO can influence the governments and ultimately did. And that’s …that’s why they were more into to the WHO model.” (Professor of Psychiatry).

This view is endorsed by several Indian psychiatrists who made important contributions

to community psychiatry. They noted the dilemma of Indian mental health professionals

struggling to build mental health infrastructure in the 1960s and 70s while such

structures were being dismantled in Western:

“Indian professional thus had to cope with the ambivalence of building an infrastructure and stay abreast with global trends of breaking down structures. A reflection of these difficulties can be seen in premature entry, without adequate preparation of the child guidance movement, general hospital psychiatry and in more recent times, the community mental health movement. We would argue that as a as a nation we were ‘pushed’ into these programmes.” (37).

(3) Indian experiments in community psychiatry

In a 1977 paper on the development of India’s mental health programmes, two

senior psychiatrists, Professors Wig and Murthy assessed the state of services. They

concluded that “the present situation is like attaining something and then becoming


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painfully more aware of the needs for the future” (38:60). While listing the

achievements of Indian psychiatry since 1947 including indigenous training institutes,

research output and public awareness, the authors concluded that “…no meaningful

service is available for 450 million rural population.” (ibid:60). It was this challenge of

providing accessible services to rural populations that gave impetus to service

developments in that period. This problem was addressed through two pioneering

initiatives that introduced differing approaches to community mental health: the

Community Psychiatry Unit and Sakalwara project at the National Institute for Mental

Health and Neurosciences (NIMHANS), Bangalore and the Raipur Rani project at the

Post-Graduate Institute of Medicine, Chandigarh.

Community Psychiatry Unit and Sakalwara project at NIMHANS

The Community Psychiatry Unit was established in 1975 at NIMHANS.vi It was

locally initiated and supported by senior politicians, including the minister of health:

“He [Karan Singh] supported us, he helped … gave us money to do this work, he gave us but moral support, which is very important. He would speak about us in various places. He was also interested in bringing in the Indian traditions in the treatment of mental illness. The whole issue of yoga and all that, he was interested in that. So we started putting that in also.”(Professor of Psychiatry)

Thus from its very inception, the NIMHANS unit benefited from domestic political

support to pursue objectives of developing and evaluating models of mental health care

delivery in rural areas “…through the existing health care channels….” (39).

A rural health centre, established in 1976 at Sakalwara village, 15 kilometres

from NIMHANS was central to the clinical academic activities of the Unit.vii The

Centre provided both physical and mental health services and served as a site for

training and research activities. Initial activities of the Sakalwara projectviii focussed on

experimenting with simple methods of identifying cases and conducting mental health


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education delivered through training manuals. Primary health workers were found to

successfully identify and care for patients with psychiatric problems after fifteen days of

training (3).

Raipur Rani Project

Shortly after the commencement of the Sakalwara project, another initiative

addressing rural mental health, the Raipur Rani project, commenced at the Post-

graduate Institute of Medicine, Chandigarh in northern India. This project was part of an

international study initiated in 1975 (40) as a direct response to the WHO Expert

Committee Report (22). The study sought to test whether “…it is possible to extend

mental health care in developing countries” (41), and entailed research on the efficacy

of health workers in the identification and treatment of priority conditions.

Baseline studies at the Raipur Rani project established that health workers did

have a “…desire and willingness…” to participate in training and provide mental health

care but had difficulties identifying mental disorder (42). An important finding was a

limited scope for adding to the health workers existing work load. However:

“it was noted that the amount of curative work was limited though occupying high prestige position in their own evaluation. This offers an avenue for possible inclusion of ‘curative’ components of mental need for developing priorities and training methods suited to the background of the health personnel.” (42:278-279)

There were significant differences in genesis and subsequent development

between the Raipur Rani and Sakalwara projects. The Sakalwara project was primarily a

domestic, government driven initiative with an overt focus on developing services and

models. In contrast, the Raipur Rani project was WHO driven, and followed the

approach of testing and evaluating models to be expanded to other areas. These


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differences shaped the sustainability of both projects. Activities at Sakalwara Health

Centre have continued to date because it is a permanent service delivery component of

NIMHANS. In contrast, the Raipur Rani project was a time bound externally funded

venture that ended in the late 1980s. Both Sakalwara and Raipur Rani however remain

entrenched in the professional imagination as models to be replicated.

A major flaw with both projects was the ways in which the term ‘community’

was constructed. Framed as peripheral and under-developed and in need of services and

education, villages were represented in highly factual and asocial terms (42). Although

there is justified emphasis on the population, roads, occupation, water supply, location

and other infrastructural aspects, a social description of the village was missing.ix No

information on caste, gender, political set-up, kinship or other social aspects of village

life was presented.x It was almost as if the villagers themselves did not exist. Instead,

they are glossed over as an homogenous entity. For example, in research reports,

community health volunteers (CHVs), are described as ‘….local persons selected by the

villagers.’ (42:277). Such a description obscures the immediate politics and social

processes which shape both selection of the CHVs and functioning of the health system.

As one senior social scientist commented:

“Participation – for example, in the selection of village health workers – rarely gained any meaning in practice. Village health committees – supposed to oversee the work of the Community Health Worker and to carry out environmental improvements – are seen as part of normal political activity, and dominated by factionalism; they primarily serve as a means of increasing the assistance the village receives from government services.” (43:283-284)

This analysis amplifies the salient issues highlighted in the second vignette.

Although the Raipur Rani project included community consultations, these mainly

consisted of key informant interviews focussing on community leaders and opinion


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makers. The ‘community’ was viewed as a place to deliver services – a locale in which

activities, programmes and projects were carried out. In descriptions of these initiatives,

references to the ‘community’ are primarily focussed on the health centre.

Related to this was the singular focus on ‘case-finding’, a vital component in

both initiatives. This reflected an epidemiological view of the community. Early papers

from both projects dealt with comparing efficacy of different methods of case detection

to establish quick and inexpensive means of identifying potential patients (44;45).

However by deploying instruments aimed at identifying psychiatric disorders, a case

detection approach made prior assumptions about the nature of problems in the

communityxi. As the initial steps in developing community mental health programmes,

the focus on ‘cases’ and the ‘priority disorders’ of psychosis and epilepsy helped reify,

in subsequent policies, a notion of the ‘community’ as a reservoir of disease.

(4) Experiments to Policies: the National Mental Health Programme

The creation of the National Mental Health Programme (NMHP) in 1982

established as an important indigenous reference point for community psychiatry in

India. Drawing on the WHO report and experiments at Raipur Rani and Sakalwara, the

programme had three main objectives:

1. “To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and under-privileged sections of population.” (48:9)

2. “To encourage application of mental health knowledge in general health

care and in social development.” (48:9)

3. “To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community” (48:9)

Its chief focus included extending the reach of mental health services through, training

of health personnel and involvement of the community.


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The development of the NMHP originated with an expert group that held

consultations with “…many of the important person concerned with mental health in

the country as well as the Director, Division of Mental Health, W.H.O.; Geneva.” (48).

These deliberations culminated in a crucial meeting at Lucknow, Uttar Pradesh where a

‘drafting’ committee comprising eminent psychiatrists, the WHO representative in India

and the Director General of Health Services “…spent two nights, three days writing the

draft.” (Professor of Psychiatry). In the final stages of approval, the draft document was

presented at two workshops in 1981 and 1982. The July 1981 workshop addressed

mental health experts,xii and led to some revisions. A year later, the programme was

presented at a second workshop to experts from psychiatry, medicine, education,

administration, law and social welfarexiii. The latter meeting did not seem to influence

the final draft which was submitted in the same month for government approval (48).

Although espousing principles of community participation and involvement of

non-professionals, the process of developing the NMHP did not involve any meaningful

public participation in practice. It was a document crafted by professionals and health

bureaucrats rooted within a WHO agenda (22;42;49). Indeed, it seemed to lack support

among the country’s mental health professionals (3).

In the early years of its implementation the National Mental Health Programme

came up against several barriers and very little was achieved in practice. The first

problem was in obtaining funding (50). As the programme was adopted in the middle of

the nation’s sixth five-year plan (1981-85), the budget was only allocated in the seventh

five-year plan (1985-90). This was a mere 10 million rupees, 0.04% of the total national

health budget (51).


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Related to these fiscal problems was the lack of clear objectives. The central

government set a series of targetsxiv described in subsequent assessments as

‘ambitious’(50) and ‘unrealistic’ (3). Although these were revised in 1985,xv an

appropriate budget was not allocated and “…hence it was not possible to initiate and

activate various activities as envisaged in the 7th Plan document.” (51:11). One critic,

commenting implementation of the NMHP during the 7th fifth year plan (1985-1990)

stated: “What happened during the subsequent five years is a sad story, with hardly any

target met except the holding of meetings, seminars and workshops.” (3:95). A

Ministry of Health progress report on the programme is riddled with opacity and policy

jargon. Although recognizing the failures, it attributes them to lack of funding and

“...lack of clear-cut models to be adopted” (51:23). The major achievements cited by the

progress report were the “....sensitisation of various organizations…” and obtaining

baseline data for the next five-year plan (51:23).

Thus, the implementation of the nation’s mental health programme turned into a

bureaucratic and professionalized endeavour, one that lacked in public participation and

popularity. The focus was on administration and logistics rather than an examination of

serious clinical and theoretical concerns relating to a cultural incongruence between

providers and users.

(5) From Centre to Periphery: the District Mental Health Programme

Although, mental health had become enshrined within the nation’s official

health policy, it lacked an operational blueprint. Operationalization of the NMHP began

with the piloting of a community mental health programme at Bellary district,

Karnataka state in 1984. This pilot, termed as the District Mental Health Programme


22

(DMHP) provided a ‘tested’ model that was ‘rolled-out’ to other parts of the countries

in the 1990s (3).

The premise of this initiative lay in ‘scaling-up’ strategies from previous

projectsxvi to the unit of a district. A district was chosen because it was already an

important administrative denominator for implementing other government programmes

(52). The ‘Bellary pilot’, however, faced problems similar to those at Raipur Rani and

Sakalwara. First, community awareness and participation activities focussed primarily

on improving clinic attendance. There was no public involvement in the formulation

and operation of the programme. Second, there were serious difficulties in

accomplishing local health staff take over tasks and activities. Low numbers of patients

were identified by health staffxvii and only a small proportion of cases were referred by

health workers (52). This would suggest inadequate training of these workers and

limited public acceptability. Third, clinical outcomes and adherence were poorxviii.

Finally, difficulties emerged in ensuring coverage of services across the district, with a

larger proportion of care centred in the district clinicxix.

Taken together this would suggest that the attempt to integrate with the local

health system was not a success. Indeed, the pilot depended on centralized professional

inputs to sustain itself. The service ceased functioning when the Programme Officer was

transferred from post (3). Despite these difficulties, the DMHP, known as the ‘Bellary

Model’, became the central activity of the National Mental Health Programme. By the

end of the 1990s, this model had been extended to 25 districts across the country (53).

However, these district programmes did not maintain ‘fidelity’ to the model. A senior

Psychiatrist noted:

“The community care models developed have not been adequately evaluated, especially the DMHP. Its implementation between 1995 and 2000 continues to


23

be one of extension services by professionals rather than true integration of mental health with primary healthcare.” (50)

In spite of these apparent failures, the DMHP continued to hold symbolic value

within professional and policy circles. Thus, an important restructuring of the national

mental health policy in 2002 invoked the ‘Bellary Model’. This ‘re-strategized’ National

Health Program followed a recognition that previous efforts to implement the Program

had met with limited success (3;4;54) A major architect of this ‘re-strategized’ National

Mental Health Program stated:

“The Bellary model ……. is unevaluated. It has become a holy cow which no one dares questions and there were major problems in that.......there were major dysfunctional aspects…and because it became a holy cow so we could not question it, we adopted it lock, stock and barrel and this is responsible for many of the problems we are facing now.

We have [now] modified it without specifying or saying it in so many words because it’s a holy cow you can't touch it. So what we have done is that we have put it aside because no one really knows what is the Bellary model so.…we are on safe ground. So whatever we do we can say it conforms to that model.”

The mental health reforms sought to re-balance activities away from a singular

focus on the DMHP and included investment in hospitals, public education, training and

research. The impetus for the reforms emerged in the context of several international

developments in the field, including the publication of two influential reports that

underscored the global burden of mental disorders (55;56). The program attained

legitimacy, and received funding by highlighting scientific evidence about the

‘treatability’ of mental illness and citing favorable treatment outcomes in developing

countries (57). The new policy emphasized provision and distribution of psychotropic

medication, and was supported by a steep budgetary increase of Indian Rupees 16.2

billion (US$345 million). The earlier cited architect of the new policy explained:


24

“This [budget increase] involved advocacy but the methods, which I adopted, were unorthodox….I worked out the cost of treating psychiatric conditions using the retail prices in Delhi…I was somehow able to convince the top people then that mental health interventions...”

In a policy environment emphasizing outcomes, ‘the pill’ had the requisite appeal to

garner funding:

“I was only referring to pharmacological interventions because you see as far as the health care system is concerned it is only drugs and treatment you see there’s no question of psychotherapy and treatment of psychosocial....because if you get involved in that those things they may be scientifically correct but...... So I said you cannot have a cheaper public health intervention and the results are phenomenal…so this...some how appealed to them...”

Thus, this new version of the NMHP continued earlier trends of defining problems from

above and seeking solutions within the health bureaucracy. In an interesting twist, this

‘re-strategized’ program has been recently declared a ‘failure’ by the current Union

Health Minister, Dr. A. Ramadoss:

"What's more worrying is that our previous national mental health programme has failed to perform. We will start implementing the new programme very soon. It will cover 400 districts in the next three years and all the districts within five years. At present, the programme only caters to 100 districts. Treatment of acute patients through counselling and medication will start in a few weeks," (58)

D. Critical Issues and Future directions

(1) Understanding Communities

A central issue emanating throughout the analysis relates to the

conceptualizations of community within policies and programmes. Firstly, the

community is conceived in epidemiological terms as a reservoir of disease that needs

quantification through case detection and official diagnostic categories. This limits


25

service delivery to bio-medical models. Secondly, the community is understood through

the ‘health-centre’xx. Viewing the community through the prism of the clinic is

problematic. It circumscribes mental suffering within the boundaries of biomedical

conceptions of health, and refracts local patterns of distress into discrete clinical

symptoms. This results in an editing out of social and cultural context that are germane

to conceptualising local suffering and distress.

Thirdly the community is constructed as ignorant and in need of psycho-

education. This view is demonstrated in the service delivery efforts which inevitably

include a component of ‘community awareness’. This implies an assumption that the

community is ignorant, and that doctors have true knowledge whilst patients merely

have beliefs (60). This singular uni-directional approach undermines efforts to bridge

professional and popular knowledge (61).xxi Consequently, mental health theory

remains uninformed by the community, its values and priorities. In other words, it is

rendered culturally invalid.

Finally, the community is viewed as a geographical unit. In brief, such a

homogenised view obscures the diverse identities in communities and various

trajectories of both social relationships and suffering. Operationalizing different

understandings of community within service delivery models remains a challenge for

future research and service delivery.

(2) From cultural incongruity to cultural negotiation

Planners of public mental health service delivery remain rooted within a

centralised academic and administrative system that adopts a top down vertical

approach. It would be pertinent to ask - why has there not been a challenge to this

singular approach? Why are local values and concerns not embodied within such


26

programmes? From the review detailed so far and published literature in the field (63-

65), it could be hypothesized that these structures have been historically shaped by a

dominant westernised Indian elite trained and socialized predominantly through western

biomedical theory that is considered universal. Furthermore, the ideology of such an

alienated Indian middlexxii class professional body of mental health professionals is

legitimised by a historical patriarchal template that shapes the teacher-student bond in

India. The literature refers to this as the Guru-Chela paradigm (66;67). This

authoritarian pedagogic relationship frequently impairs alternative and creative modes

of thinking and acting, including the crucial and often cited value of locally embodied

forms of knowledge. The relationship is rooted in a skewed interpretation of pre-

colonial Indian cultural pedagogy and re-enforced by alienated teachers (Gurus) of

Indian psychiatry who in turn, have successfully internalised European psychiatric

wisdom. As a consequence, local psychiatry including its theory and practice is

culturally invalid. An oppressive and stagnant dynamic between contemporary Indian

teachers and their students, further perpetuates the alienated connection between doctors

and their patients; urban health planners and their rural recipients; and between public

mental health service providers and users. Thus, academic and administrative ‘Gurus’

(senior mental health professionals-educators and health administrators) demand their

Chelas (student)xxiii loyalty. The social consequences for students challenging ‘senior’

Gurus and their dominant official theory and policy is too grave for both professional

and personal identity of the former (compare Primary Health Care doctors and rural

health workers), who might well seek development of unorthodox but more effective

ideas, theory and policy that embody local cultural values and concerns (68).


27

Overcoming these difficulties requires a fundamental change in both education

and training. In brief, this includes providing health professionals with: 1. Awareness of

how their own social cultural background shape their professional training, identity and

interactions; 2. Recognition that current psychiatric theory and policy is culturally

invalid; 3. Knowledge and relevance of a culturally embodied health and illness

paradigm (69); and 4. Skills to negotiate such cultural differences, commencing in

clinical practice that would then be embodied into policy (64;70).

(3) From a bureaucratic model to a multiplicity of models

A major challenge for community psychiatry in India includes balancing

government support, both financial and logistical with the administrative nature of

governmental health programmes. Financially and logistically, it makes sound sense to

utilize existing government health infrastructure in order to deliver mental health

services for a geographically dispersed population. The pitfall of this, however, has

been that mental health service delivery is only as good as the overall health delivery,

and in certain States, such as Uttar Pradesh and Bihar, the rural health system face

serious operational issues. Mental health policy has ‘adjusted’ to these issues by shifting

strategies from decentralization and integration to operating specialized satellite clinics

in selected health centres. It is difficult for a single mental health team to cover a whole

district.xxiv

There is thus a need to evolve multiple channels of delivery and flexible

approaches. The largely singular strategy based on primary health care does not allow

an engagement with issues of poverty, social inequity and the cultural dilemmas of

globalization that face the country.


28

Many Indian mental health professionals would argue that a more pragmatic

approach should focus on providing quality clinical services to as much of the

population as is feasible, and thus would support the current ‘satellite clinic’ orientation

of the DMHP. The authors of this paper do not argue against the centrality of clinical

services in mental health policy. Rather, it is suggested that consideration be given to

continuing critiques, alternative modelsxxv, and evaluation of efficacy of such clinical

services. These challenges require serious re-consideration of several inter-digitating

themes. They include a detailed historical analysis of forces that have shaped psychiatry

in contemporary India together with continuing critiques of policies and interventions.

More crucially, facilitating the involvement of a multiplicity of strategies and actors is

vital for both the peoples and professionals particularly in rural settings.

V. Conclusion

This cultural critique of community psychiatry in India raises issues that are

germane to the future of the discipline. The paper demonstrates how three influences

have shaped community psychiatry: the culture asymmetry between health professionals

and the wider society; psychiatry's search for both professional and social legitimacy;

and WHO policies that have provided the overall direction to the development of

services. As well intentioned as practitioners and policy makers may have been, taken

together the consequences have been that community voices and activists who could be

allies have been edited out.

The paper hypothesizes that community mental health in India is a culturally

incongruent endeavour that increases the divide between psychiatry and local

communities. Such a provocative claim requires sustained ethnographic field work to

reveal the dynamics of the deep gap between community and professional experiences.


29

The development of culturally sensitive psychiatric theory and clinical services is

essential to improve the mental health of citizens who place their trust in India's

biomedical network. Finally, the authors posit that the discipline of community

psychiatry in India offers real potential for decolonizing psychiatry both in India and

other countries that have shared a similar history, and offers a fertile ground for

generating culturally valid theory and practices in the field of mental health.

Acknowledgements: We gratefully acknowledge support from the Department of Psychiatry, Chhatrapati

Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh; Officers of the District

Mental Health Programme, Kanpur, Uttar Pradesh; Mr. Kailash Katiyar and family;

residents of Bilhaur Tehsil, Kanpur District; and Late Mrs. R.D. Jain and family.

Financial support for this research was provided by the Shastri Indo-Canadian Institute;

Central Research Fund, University of London; Graduate School, University College

London; The Chadwick Trust, London; and The Sir Richard Stapley Educational Trust,

United Kingdom.


30

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i These field visits took place two days each week (Tuesdays and Thursdays) and involved seven visits each month to health centres that were up to sixty kilometres from the District Hospital where the team was based. These journeys often involved travelling in challenging conditions of heat, dust, road jams and punctured tires among other difficulties. ii This culminated in the Alma Ata Declaration of 1978 in which primary health care was declared the dominant strategy for developing health services (23). In this period, development policy shifted from a focus on growth to concerns with the ‘basic’ needs of the poor, poverty alleviation, employment, and income distribution (24). There was recognition that despite the 1948 WHO constitution which made health a responsibility of national governments, significant improvements in health status in low-income nations had not been achieved (25). And the health policy environment previously dominated by physicians and technical solutions was shifting to include social scientists and account for the social,

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cultural and economic determinants of health (26). Alongside this there were reports of innovative health care delivery initiatives, including the bare-foot doctors in China (27). iii The Report uses the term ‘populations’. This may have been related to the political context of the WHO where the term community may be considered incompatible with its nation-state based membership. Additionally it also reflects the epidemiological roots of the Report. iv Jointly sponsored by the World Federation for Mental Health and the Indian Psychiatric Society. v Various Professors of Psychiatry were interviewed between 2004 and 2006. Their anonymity is preserved. vi NIMHANS was created out of a merger of the All India Institute of Mental Health and the Karnataka Government Mental Hospital. vii In addition, the Unit undertook four other programmes on an experimental basis (3): an urban mental health programme, a school mental health programme, a home care programme for psychiatric patients, and psychiatric camps. viii A key component of the Community Psychiatry Unit was the rural health and training centre at Sakalwara village. The term ‘Sakalwara Project’ will be used in the rest of this paper to denote the activities of the Community Psychiatry Unit. ix Field work interviews with key informants involved in Raipur Rani and Sakalwara reveal a different picture with informants reminiscing about interactions with community members and living in the community. Much of these personal anecdotes and subjective experiences appear to be edited out of publications reporting on the projects. x Given the number of village oriented studies conducted by social scientists in the 1960s it is surprising there had been little crossover of methods from the social sciences. xi An important exception was the work of Dr. Ravi Kapur and colleagues in developing the Indian Psychiatric Interview Schedule (IPIS) and the Indian Psychiatric Survey Schedule (IPSS) (8;46;47). The IPIS and its modified version, the IPSS were developed to reflect symptoms relevant in the Indian context and based on field work conducted in southern India. xii From the list of 68 participants, it would appear that most were psychiatrists. xiiiEighteen out of 30 participants were psychiatrists. xiv Within its first five years, the program targets included providing two weeks of training to 5000 non-medical professionals on mental health care, training 20% of all PHC physicians and creating a post of psychiatrist in 50% of all districts. xv Revisions by the Planning Commission included the training of “at least” one doctor at every district hospital, mental health services at 10% of all primary health centres (PHC), and provision of essential psychotropic drugs at the PHC level xviFor example, Raipur Rani, Sakalwara and the Collaborative Study on Severe Mental Morbidity (1987). The Indian Medical Research Council-Department of Science and Technology: New Delhi. xvii The overall rate of identification of cases and registration was about 4 per thousand (Isaac, 1988). xviii Among patients with epilepsy, about 54% were regular patients and were classified as symptom free or with reduced symptoms. Among patients with psychosis, this group was only 42%. Among psychosis and epilepsy patients about 45% were classified as irregular (52)


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xix Of the total number of cases of psychoses (1202), 52% were seen in the district clinic and 23% in the primary health centres (PHUs). For epilepsy cases, the corresponding figures are 17% and 42 %. Thus a greater proportion of epilepsy cases were treated in the PHCs, perhaps a reflection of the higher level of knowledge about this illness among doctors and other health staff (52) xx Some have suggested replacing the term ‘community psychiatry’ with primary care psychiatry as the former does not accurately reflect the reality of strategies in low-income countries (59). xxi Important exceptions to this are the psycho-educational materials written in the Kannada and English languages by Dr. C.R. Chandreshekar a senior community psychiatrist in India (62).. xxiii Chela is a pejorative term that can be loosely translated as ‘side-kick’. xxiv Kanpur Nagar District has a total rural population of 1, 370,488. There are thirty primary health centers. The multi-disciplinary mental health team visits 7 of these centers each month. xxv For example, the women’s homeless mental illness program developed by a non-governmental organization, The Banyan at Chennai (http://thebanyan.org/); Eco-Psychiatry in the Sunderban (71); the Asha Gram Project in Madhya Pradesh (72-75), mental health reforms in the state of Gujarat (Government of Gujarat, 2003); and Bapu Trust in Pune (http://www.camhindia.org).

A cultural critique of community psychiatry in India

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