Ruefully there is also an element of apathy in my own medical profession. While the issue is primarily psychiatric, I very strongly believe it is a matter that should invite concern of the entire medical profession.
Dear Mr Prime Minister,
I am taking the very unusual step of writing an open letter to you in the hope that it would somehow be drawn to your attention and the very disconcerting issue that I raise would merit your kind consideration.
I am a psychiatrist with over 40 years of experience in 11 different countries across the globe as an academic psychiatrist plus a medical relief worker in different settings. Midway through my academic career, I decided to train as a barrister and hold a Masters from Harvard Law School in Mental Health Legislation and Human Rights and a doctorate in philosophy. I relocated back to India after nearly three decades and work on a charitable basis.
I had left India in the mid 70’s and my first impression on returning was while there was a massive overall change, somehow the needs and aspirations of the weakest section of the society continue to be ignored the same way they were when I had departed.
I mean, of course, the mentally ill. They are unquestionably the most disadvantaged section in the society – much-much more than the identified disadvantaged who draw political attention. It is easy to understand why they have not been catered to; they do not constitute any vote bank and consequently have remained voiceless just as much now as they used to be 40 years ago. This is indeed most unfortunate, as public awareness of mental illnesses within the society has increased with times. People do understand most parameters of mental illnesses and at least in the urban areas shun witch-doctors who have caused the society so much harm.
My distress is over the fact that while the magnitude of the problem has become all too obvious, there is no urgency on part of any of the agencies who are responsible for the well-being of the mentally ill, either directly or indirectly.
You have in your numerous addresses given an undertaking that the weakest section of the society which has lost out in the process of development would be given their due. And I also seem to remember you saying that you would work to ensure that through active inclusion of the marginalized, you would ensure that India would gain its primacy in ensuring justice through egalitarianism.
Sadly that has not happened with the mentally ill — perhaps the most marginalized section of our society. You just have to visit my mofussil town (Gorakhpur in Uttar Pradesh) where you would find at least 50 people with florid mental illnesses living a life of vagrancy with no real hope of procuring treatment and leading a life of dignity, which surely is their due. And from my peregrinations throughout the country, I have convinced myself that my mofussil town is not alone in this regard. Heaping not just apathy but undeserved humiliation on this section of infirmed individuals is the norm rather than an exception throughout the country. We must really hang our heads in shame!
The provisions of facilities for the mentally ill are shockingly scarce and leave a lot to be desired. There are occasional lofty pronouncements by different sections which are never really acted upon. We have enacted a modified Mental Health Act. Having had an opportunity to study Mental Health Acts internationally (when I was asked to help towards drafting Mental Health Acts in three countries), I can confidently state that the Indian Mental Health Act is probably one of the most advanced mental health acts in the world. But it has not resulted in enhancement of the quality of mental health care in the country.
We have an abysmal psychiatrist-population ratio of any established democracy. The knee jerk reaction would be to increase the number of seats available for training psychiatrists. That clearly would be the wrong approach. While the enhanced numbers would make some difference in terms of availability, it would simply not work. As clinical psychiatrists, effective provision of mental health services in my view would require suitably trained mental health nurses, clinical psychologists, occupational therapists and psychiatric social workers. No other discipline in medicine relies as heavily on paramedical support as we do. Unless these needs are factored in, any initiative, no matter how well intentioned would be doomed. When we look at the number of facilities in the country that train psychiatric nurses, the picture becomes self-evident.
There is also an ancillary issue that cannot be ignored. Excellence in mental health service provision cannot be looked in isolation. The family practitioners, who would ultimately be entrusted for the follow-up care, are virtually non-existent in the country. When we look at the best mental health services in the world i.e. in Cuba, Switzerland, Norway, Denmark and Sweden, we find that family practitioners play a very key role. Dr Raman Kumar is making very commendable effort in this direction by attempting to change our mind-sets — but until such time as we do have excellence in family medicine, we cannot expect fundamental changes in the way we look at the mentally ill.
My other very major concern is even more disturbing. Through our apathy, many mentally ill have ended up being incarcerated in prisons; and this should be of the greatest concern to us. I have myself visited several prisons informally and noticed several floridly ill mental patients who have no business being there. Many had, from the records available, the illness before their conviction. Some others had developed mental illnesses while in prison — and most prisons do not have a psychiatrist readily available.
As a psychiatrist cum lawyer, I have been writing on this issue extensively in different portals since my relocation. Even a rookie lawyer would claim familiarity with the concept of insanity defence normally dictated by M’Naghten Rule which dictates in simple terms that a person cannot be held guilty of a crime if his/her reasoning was impaired to the extent that his/her comprehension of the act was rendered impossible. I have again written extensively on insanity defence (including an article on this portal) where I have conceded that while the parameters of insanity defence have still not been accorded international consensus, there is an overall agreement that a floridly psychotic patient cannot be held guilty of a criminal act. It is also an accepted principle that a person cannot be brought to a criminal trial if he/she does not have the capacity to instruct a counsel.
I am not sure of the present situation but not long ago, we did have a prisoner called Charanjit in Tihar whose plight was reported in the newspapers. He was abandoned by everyone and had to spend nearly 20 years in jail without being tried; he was floridly psychotic!
Clearly, these very fundamental principles are not being adhered to. Most lawyers I spoke to are blissfully ignorant of the M’Naghten rule as they claim it was never a part of their instruction. I spoke to some very senior lawyers who are usually very vocal in the media. Most displayed shocking ignorance and others were simply not bothered. Being a judge’s son, I also spoke to some retired judges. Most of them conceded that they had never been asked to adjudicate on a case of insanity defence by a defence counsel — in other words Mens Rea, the most fundamental of all principles, was never argued before them. Ruefully there is also an element of apathy in my own medical profession. While the issue is primarily psychiatric, I very strongly believe it is a matter that should invite concern of the entire medical profession.
Plus as this has such profound human rights implications that it befuddles me why this has not been taken up by a human rights campaigner and a public interest litigation (PIL) filed. I am always reminded of Fyodor Dostoevsky’s immortal words — The degree of compassion within a society can only be judged by visiting its prisons! Clearly we are on a very sticky wicket on that count.
I feel these matters are just too important not to be brought to the attention of the head of the government. Although health is a state issue, the problem is much too widespread with its tentacles in criminal justice system and human rights for it to be effectively tackled by state alone. I, as a concerned citizen, earnestly plead with you to give the matter very urgent attention.
Many democratic countries have appointed a Mental Health Ombudsman with statutory powers. I support such a move in India as well. But I also believe that a Mental Health Ombudsman would need to be both psychiatrically insightful with legal training, as both these dimensions would come into play more often than not. An effective Mental Health Ombudsman would go a long way towards amelioration of this most vexatious problem.
I might add that while we are falling behind on this score, apathy towards the rights of mentally ill is a truly international problem. My own interest was kindled when I witnessed a floridly ill patient being sent to prison because of public pressure despite a psychiatric report only to be released to a Special Hospital in the UK (We should have a provision of Special Hospitals like Rampton and Carstairs in the UK). I also witnessed how a colleague of mine, despite illness, was convicted wrongfully.
As an Indian, I would like my country to take a lead in recognizing and campaigning for the rights of mentally ill. As the human rights issues are so closely intertwined, I have often wondered whether it is apposite for the UN to consider appointing a Special Rapporteur for Mental Health. If you feel this suggestion has any merit, I personally would be happy to write a petition to the UN Secretary General and request my colleagues here and elsewhere for support.
The World Psychiatric Association has recognized the gravity of the problem of mentally ill in prisons all across the globe and the present President Professor Bhugra of London has constituted a Task Force to look into the matter and report to him. As a consultative member of this task force, I would like to be in a position to state that my country is taking this matter with utmost seriousness.
Having campaigned for the release of mentally ill from prisons across the world for decades, I, now a senior citizen, am beginning to see some light at the end of the tunnel. I would like to see the death of the cruel apathy towards the mentally ill before my own imminent demise. And Mr Prime Minister, you would have the undying gratitude of so many voiceless if your government takes strong steps in this regard.
Dr Ashoka Jahnavi Prasad