By Moin Qazi*
How many deaths will it take ‘til he knows
That too many people have died
The answer, my friend, is blowin’ in the wind,
The answer is blowin’ in the wind.
–Bob Dylan, Nobel Laureate
Large swathes of cotton farms in central India have been the epicentre of the debt crisis that has gripped the rural population. For years now, it has driven thousands of farmers to commit suicide. These suicides are not merely a loss of human lives; they are debilitating scars on a nation’s development canvas.
A study suggests India will see more such tragedies as climate change brings hotter temperatures that damage crops and exacerbate drought. For every 1 degree Celsius (1.8 degrees Fahrenheit) of warming above 20 degrees C (68 degrees F) during the growing season in India, there are 67 more suicides on average, according to the findings published in the Proceedings of the National Academy of Sciences, or PNAS.
While debates continue to rage on reforming the agricultural sector to improve the economic conditions of farmer, there has till now recently been no attempt to focus on the likely mental problems arising out of economic stress that may be leading to suicides. Farm suicides are a reflection of the economic plight of an ailing rural economy but demonstrate the utter state of mental hopelessness and weak resilience of farmers who have become emotionally so fragile that they are meekly taking their own lives.
A field-based research study in prestigious medical journal “The Lancet” (by Pandit et al) concludes, “Most Indians do not have community or support services for the prevention of suicide and have restricted access to care for mental illnesses associated with suicide, especially access to treatment for depression, which has been shown to reduce suicidal behaviours. Reductions in binge alcohol drinking through regulations, higher alcohol taxation, or brief interventions in primary care might also reduce suicide deaths.”
The abysmal state of mental health care in the country has made matters worse. Most government-run hospitals do not have psychiatric drugs, and visiting a private counsellor and sustaining the treatment — usually a long drawn out affair — is an expensive proposition for most families. The ignorance and callous attitude towards psychiatric ailments, coupled with social stigma, dissuades most from seeking help. Counseling centres are purely urban phenomena.
But there are several silver linings on what most seem to see a landscape of despair. There are several selfless professionals who are using their talent and ingenuity to address some of our toughest problems. Making money or earning a name is not their first objective. Their first objective is to make a contribution.
An intensive eighteen-month programme in the affected region of Vidarbha, Maharashtra, has seen an effective reduction in suicidal behaviour while encouraging those affected to seek professional help for depression. The programme deployed health workers from within the community
Conceived as VISHRAM (Vidarbha Stress and Health Programme), it was implemented over 18 months from September 2014 to October 2015. It has been designed by Dr Vikram Patel, a Professor at the Public Health Foundation of India who figured in Time magazine’s 100 Most Influential list for 2015. The magazine dubbed him as “Well-being Warrior” and wrote, “He provides hope that mental illness and trauma make us neither weak nor unworthy of love and respect.”
The programme was designed to address the mental health risk factors for suicide (i.e., depression and alcohol use disorders) in a predominantly rural population of 1,00,555 people in 30 villages in the Amravati district of Vidarbha region, the epicentre of farmer suicides. The programme is built around a cadre of trained grassroots community health workers – armed with mental health first-aid kits, some with no background in mental health care.
Surveys were done at the start and the end of the programme. The researchers interviewed 1,887 subjects on mental health indices .The evaluation at the end found that:
- the proportion of people with depression who sought care rose from 4.3 per cent to 27.2 per cent;
- the prevalence of depression fell from 14.6 per cent to 11.3 per cent;
- the prevalence of suicidal thoughts in the previous 12 months fell from 5.2 per cent to 2.5 per cent; and
- a range of mental health literacy indicators showed significant improvement.
This in itself highlights the success of the programme in spreading awareness and raising mental health literacy. As depression is one of the leading causes of suicide, this could explain the sharp dip in suicide numbers as well.
Patel uses community volunteers and trains them as mental health workers for his project. He runs focus groups to gauge community acceptance and conducts trial sessions to train new counsellors who impart enhanced traditional care. This includes diagnosis by a doctor or health worker at a primary health centre, medication if necessary, and sympathy from the staff.
Counseling has a great role to play in alleviating stress and helping depressed people improve their self esteem and improve their ability to cope with despair. What is needed for a good counselor is empathy and good communication skills. As Stephen Covey says:” When the trust account is high, communication is easy, instant, and effective.” A good counselor is able to patiently figure out the emotional map of the patient and then gently engage him in ways that can unravel the internal tangles. He must skillfully and gently work through inner feelings and inner conflict respecting the patient’s values and privacy.
VISHRAM has mobilised self-help groups and village leaders for early detection of mental disorders with a focus on affordable, home-based care. More than 1,000 small group meetings were held over the 18 months. First aid for mental health was provided to 1,441 individuals with psycho-social distress. More than half of these people (793) were referred to counsellors, while patients with severe mental illnesses like schizophrenia were referred to the local medical hospitals.
With trained counsellors working at a grassroots level, Patel and others are seeking to scale up the programme, spreading it to other states of the country; the government could integrate such programmes into its National Mental Health Policy.
Today, Patel says, the challenges are figuring out how to scale up the programme, and how to make sure that a larger-scale programme will produce adequately trained counselors. Scaling up has challenges and one of them is to retain the efficiency factor that a smaller and more closely monitored programme has. “We’re no longer asking can we use community workers, we’re asking how do we deploy them,” says Patel.
A lot of good programmes got their start when one individual looked at a familiar landscape in a fresh way. These creative and passionate individuals saw possibilities where others saw only hopelessness, and imagined a way forward when others saw none. What they did was to change the fundamental approach to solving problems, and the outcomes have been truly transformative.
*Author of “Village Diary of a Heretic Banker”, with the development sector for more than three decades