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By Lalitha Sridhar The Banyan model of care for the mentally ill incorporates support, vocational training, rehabilitation and permanent care. NIMHANS, the nodal institution for mental health in India, recommends that the 10-year-old and very successful Banyan model be replicated in other parts of the state
A recent evaluation report of the nodal National Institute of Mental Health and Neurological Sciences (NIMHANS) Bangalore recommends that the example set by The Banyan, an NGO working with wandering mentally ill women in Chennai, be replicated in every district of Tamil Nadu within the next five years. Dr Kishore Kumar of NIMHANS, co-author of the unique study, says: “The Banyan experience proves that caring for the homeless mentally ill is fruitful. With adequate care, 50% show improvement and return to live in society.” Meanwhile, Benedetto Saraceno from the department of mental health and substance dependence, World Health Organisation, wrote: “One of the very important recommendations of the WHO has been to develop community mental healthcare, appropriate both from the point of view of human rights of the mentally ill (in line with the UN declaration of 1991) as well as for developing countries that do not have a very big infrastructure of institutions. The Banyan is a remarkable example.” These commendations come as The Banyan celebrates its 10th anniversary this year. Set up as a voluntary organisation providing shelter to wandering mentally ill women, ‘The Banyan Model' has become a vertically-integrated case study that incorporates support, vocational training, rehabilitation and permanent care of the mentally ill. About 2-5% of India's population suffers some form of mental or behavioural disorder. Around 1% has a serious form of mental disorder requiring urgent care at any one point of time. No less than 10-15% of those attending general health facilities have a common mental disorder. But while ophthalmology, paediatrics, orthopaedics etc are all studied as separate subjects under medicine, mental health is not accorded much attention in the undergraduate syllabus. Primary health officers, who have only studied up to the graduate level of MBBS, often do not know how to identify and treat mental illness. There are around 400,000 wandering mentally ill persons in India. They are often seen, in various states of mental distress and physical abuse, around railway stations, bus stands, pilgrim centres and on street corners. They are the ‘invisible people', separated from and/or neglected by their families. The wandering mentally ill belong mainly to economically backward and socially marginalised families. Nine out of 10 have diagnosable and treatable mental disorders; four out of five have significant co-morbid physical health problems. The stigma and economic burden of mental illness are the main reasons why it is so poorly treated. Says Dr Ponnudurai, nodal officer for the state mental health programme, who also heads the government-run apex Institute of Mental Health that houses 1,800 inmates: “At our hospital, we have people who are ready to be discharged but they have nowhere to go because their families do not want them.” Though epidemiological figures show the enormous burden of illness resulting from psychiatric and behavioural disorders, this burden is grossly underrepresented by conventional public health statistics. The focus has always remained on mortality rather than morbidity or disability. The Banyan currently has infrastructure to accommodate and provide psychiatric care to about 200 residents. It looks after almost twice this number. Over 400 of the 800 wandering mentally ill women who took shelter here have been rehabilitated with their families. Follow-up medicines are sent to them by post. Residents who have recovered but are rejected by their families are ‘mainstreamed' in groups of three and four, equipped with skills to survive independently. A protected ‘village' is to be built outside the city for those who need lifelong care. Says Vandana Gopikumar, founder-trustee of The Banyan: “We did not start with any comprehensive plan in mind. We have learnt according to the needs of our residents. The wandering mentally ill lack basic physical care. They are vulnerable to all kinds of abuse, including sexual (abuse). They suffer from serious health complications such as tuberculosis and AIDS. Finally, nobody wants to deal with them. They are the ‘untouchables' of urban society.” Inmates invariably arrive with festering wounds (sometimes stones are thrown at them). Many have been sexually abused; they are covered in soot and grime, wear filthy clothes and have matted maggot-infested hair. They are mentally unstable and physically unfit. Their condition is more a comment on how ‘mad' the world can be. Meanwhile, India marked the third anniversary of the horrific Erwadi-Ramanathapuram fire that broke out in August 2001. The event, in which 27 mentally ill inmates of a facility in Erwadi in Tamil Nadu were burnt to death as they were chained to their beds, brought into critical focus the need for reform in the mental health sector. To introduce regulation, the courts ordered that any potential resident of a mental healthcare institution would have to be produced before a magistrate and obtain reception orders. Given the state of the victim's mind, this is not only a cumbersome procedure but also a destabilising one. Paperwork and court appearances call for at least four hours of controlled behaviour. The Banyan has worked towards making the courts more proactive. Says Gopikumar: “Just as there are lok adalats for labour or pensions, we have one on our premises to meet the needs of the mentally ill. We are grateful for this unprecedented support from the judicial system. We would like to see this happening in other places too.” Last year, thanks to this NGO's advocacy efforts, the chief justice of the Madras High Court, B Subhashan Reddy, inaugurated the world's first permanent and continuous lok adalat for mentally challenged persons at The Banyan. C K Gariyali, secretary for health and family welfare in Tamil Nadu says: “Tamil Nadu has the maximum number of mental health institutions. But the population is so vast and communities so diverse, with rural and tribal areas, that anywhere you go it is the same story -- getting funds is a problem. Certainly, we'll do our bit but you (NGOs) must do yours too.” Says Ponnudurai: “There is no shortage of beds for the mentally ill in Tamil Nadu. There are 10 beds allocated in all district hospitals and 10 beds in all medical college hospitals. But the National Mental Health Programme was too gargantuan to have any significant impact at the grassroots (level). The District Mental Health Programme is operational only in three districts of Tamil Nadu.” Ponnudurai adds that the system of indenting drugs before stocking them results in a shortage of medicines. “There is the pressing need for better healthcare in rural rather than urban areas,” he stresses. “Taluka and village-level programmes are necessary.” According to Gariyali, the mentally ill and disabled should be included in the existing network of Self Help Groups (SHGs). “Every panchayat in Tamil Nadu has an SHG,” and therefore “SHGs (have) proved that the poor are bankable, so why not the disabled? Even if only one mentally ill or disabled person is included in each of them, 136,000 (the total number of SHGs in the state) of them would benefit in the first year itself.” SHGs consisting of disabled individuals already exist in Coimbatore, Villupuram and Madurai. The mentally ill, however, have witnessed no such progress. A number of support systems exist on paper only. The People with Disabilities Act 1985 provides for the disbursement of loans, but nationalised banks insist on significant, therefore impossible, collateral. The National Handicapped Development Corporation (NHDC) is more credit-friendly, but “the procedures are very centralised”. Says Gariyali: “You can imagine remote villages sending applications to Delhi. We have been taking this up. Collateral is a big problem. We have been telling them (the NHDC) to leave the money with us (the state) for disbursement.” There are three ailments that come with the baggage of stigma attached -- HIV/AIDS, mental illness and leprosy. Great strides have been made in eradicating leprosy, while the problem of HIV/AIDS generates enough attention. Mental illness, however, remains orphaned. Dr Vijay Nagaswami, noted author and psychiatrist, says: “Disabilities inside the mind are difficult to sympathise with.” InfoChange News & Features, October 2003
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