The Abandoned and the Abused – 1. In Hospitals

(This is the first part of an article I wrote along with Sundar in 2008-09. We failed in getting it published.)

On 8^th March, 2008, which incidentally was the International Women’s Day, a daughter visiting her mother at the Pavlov Mental Hospital, Kolkata, was shocked to see everybody in the female ward naked. The reason, apparently, was that the patients have only three sets of dress each and the washerman comes only once in a fortnight. The question remains why the patients do not have more dresses, and why the washerman does not come more frequently. When Anjali, the Kolkata based NGO, and the West Bengal media raised hue and cry, the government ordered an inquiry. The inquiry may come up with answers and the government may initiate some remedial measures. This would soon be forgotten and another Inquiry Committee would be constituted to look into the next blatant human rights violation reported.

This incident is only the tip of the proverbial iceberg. Three years ago, a sweeper of another Kolkata hospital kissed a woman patient and the hospital staff refused to perceive this as sexual harassment. Beating the patients who ‘act difficult’ or ‘refuse to be medicated’ was also perceived to be ‘normal’. Government mental hospitals in India are often run in an irresponsible manner, violating many of the rules stipulated by the government itself, as report after report has shown. Hospitals lack sufficient infrastructure, are under-resourced and overcrowded. Patients are abused, bullied, molested, harassed and physically assaulted and their rights, ignored.

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Dehumanising

In most mental hospitals, you would not be allowed inside, unless you are a prospective 'inmate'. No visits to the wards even if you are a journalist; especially if you are a journalist. The hospital authorities apparently want no interference from outside. They apparently don't want the public to know what is happening inside. Every one of us has the right to know what exactly is happening inside hospitals, any kind of hospitals. Not only because they are spending public money, the money we pay as taxes. In the case of mental hospitals, it is also because they are supposed to take care of one of the most vulnerable sections of society. And, we as citizens have a right to know what is happening there. Especially because tomorrow one of us also could be a patient there.

The authorities may say that everything is fine inside. But when someone found that the female patients in the Pavlov Mental Hospital, Kolkata, had no clothes on, they cried foul. Not because the patients had no clothes ("what is wrong in that?" said the nurses), but because someone discovered it! What happens inside the closely guarded gates, apparently, is purely the business of the "authorities".

A hospital with 800 patients may have 400 beds and even fewer mattresses. This may be the situation in most public hospitals. But mental patients are people without voice because no one takes them seriously. So, we have to speak for them. The food is often of low quality. The amount ear-marked for a meal might have been based on an estimate made a decade back, and not revised. There does not appear to be a system for regular revision and adjustment for inflation. The mentally ill are, anyway, it is perceived, not going to know what they are eating. Even if they know, who is going to listen to their complaints? We need to change this notion. Most mental patients do understand what is going on around them. All mental patients are not totally devoid of consciousness or feelings. And they too are humans and have their rights.

The patients are never taken out. Once inside, it is almost forever. Even prison officials at times refuse to take back the prisoners admitted to mental hospitals for treatment. Very few are lucky enough to be discharged and accepted back by society, and there seems to be no reliable data on the number of persons who have been cured but still languishing in the hospitals. Sometimes, the hospital refuses to discharge a patient who has been cured if his/her family is not willing to come and receive him/her. This could mean hospitalization for life. If a person has recovered, (s)he should be discharged voluntarily, on her/his own responsibility. Being mentally ill doesn't mean that they cease to be human beings or that they could be deprived of their human rights. "Few dispute that mental hospitals have long since been dehumanized through neglect, and had failed to meet patients' needs" write Philip Bean and Patricia Mounser (Discharged from Mental Hospitals, Macmillan in association with Mind Publications, 1993). Though written in a somewhat different context, this is valid even today in our country.

Most mental hospitals lack the infrastructure needed to handle the number of patients they get. And they lack the manpower too. Even the employees who are there are often posted as ‘punishment transfers’, says the report Quality Assurance in Mental Health by the National Human Rights Commission, 1999. Electro-Convulsive Therapy (ECT) is used routinely, though it is a controversial treatment and adverse effects have been reported (http://www.issuesinmedicalethics.org/154oa157.html). As per law, ECT can be given only with the consent of the patient, and that too, only under anaesthesia. And it has to be modified ECT, where the so-called peripheral seizure (the epilepsy-like effect that is often frightening) is suppressed using a drug. Most hospitals do not even have an anaesthetist. Patients are hardly consulted. And ECT without anaesthesia is most often used instead of modified ECT, according to the 1999 report of the NHRC.

"The study shows that all relatives signed consents; many reported that the details of ECT were discussed with them and alternative treatments offered and they were happy with the outcome. Yet many relatives also perceived that they were forced to provide their consent. Even the minority of patients who signed the consent form could not recall the details of the procedure. Many patients also reported coercion." report A.P. Rajkumar, B. Saravanan and K.S. Jacob (Indian Journal of Medical Ethics, Oct-Dec 2007). "After much brutal experimentation and research, the developed world banned direct ECT in the early 1960s. Many European countries have phased out even modified ECT, while in the US its usage has come down drastically after the 1980s, following class action." ECT was apparently abandoned after it was found that up to 20% patients suffered vertebral fractures and many of them suffered from terror and trauma. In this respect, India remains a primitive country where 52 per cent of institutions still use ECT without anaesthesia and only eight institutions have facilities for routine electroencephalography monitoring. (Voices of people who have received ECT, by A.P. Rajkumar, B. Saravanan and K.S. Jacob)

Perhaps the overall Indian experience of institutionalized care is far from civilized. "The findings reveal that there are predominantly two types of hospitals," the report by the National Human Rights Commission (cited earlier) evaluates. "The first type does not deserve to be called 'hospitals' or mental health centres. They are 'dumping grounds' for families to abandon their mentally ill member, for either economic reasons or a lack of understanding and awareness of mental illness. The living conditions in many of these settings are deplorable and violate an individual's right to be treated humanely and live a life of dignity. Despite all advances in treatment, the mentally ill in these hospitals are forced to live a life of incarceration."

"The second type of 'hospitals,” the NHRC report continues, "are those that provide basic living amenities. Their role is predominantly custodial and they provide adequate food and shelter. Medical treatment is used to keep patients manageable and very little effort is made to preserve or enhance their daily living skills. These hospitals are violating the rights of the mentally ill persons to appropriate treatment and rehabilitation and a right to community and family life".

Not that there aren't well-run mental hospitals in the country, but they are too few and too far apart. One such is the National Institute of Mental Health and Neuro Surgery in Bangalore. Another is the Institute of Human Behaviour and Allied Sciences (IBHAS) in New Delhi, the only mental hospital where the public can enter and take a look around, like most other ordinary hospitals. So, not that it is impossible. Mental hospitals can be run just like any other hospital, and maintained clean. If only there is a will.

There have been changes in some of the hospitals in the country after the report came out, which have been discussed in the updated 2008 publication Mental Health Care and Human Rights from NHRC and NIMHANS. There are some positive changes in some hospitals, but a tremendous lot remains to be done.

"It resembles like a jail (sic). There are two closed wards. The rest are barracks and cells." says the NHRC report about the hospital in Varanasi. "Surprisingly, there is not a single nurse posted in the hospital, or nurse's post." says the report about the Bareilly hospital. "The attenders use long lathis to control the patients (who) often get beaten up." This is about the Agra Manasik Arogyasala. According to the report, the nurse-patient ratio here is 1:225, instead of the stipulated ratio of 1:3!

The updated report of 2008 says: “Insufficient seating, no drinking water or toilet facilities for out patients and their families. There is no proper facility for registration and recording of out patients. No separate MRD. … No managing committee to oversee day to day management of the hospital and to take decisions. No PSWs, Clinical Psychologists, Psychiatric Nurses.” The report doesn't say whether more nurses have been appointed, or whether the patients are still locked up in cells.

Remember the Erwadi incident where mental patients chained to their beds died in a fire not long ago (see Box 1)? Some action was taken at that time, but matters seem to be becoming as bad as before. As in any other, in the case of mental hospitals also, we need to keep a constant vigil.

But that is not enough. “According to NIMHANS, there are over two crore persons in our country who are in need of treatment for serious mental disorder and about five crore people who are affected by common mental disorder. About 30 to 35 lakh persons need hospitalisation at any time for mental illness. In contrast, there are about 29,000 beds available.” says Sri Akhil Kumar Jain, IAS, Secretary General, NHRC, in his preface to the report Mental Health Care and Human Rights published by NHRC and NIMHANS in 2008. As per an estimate, around 12% of all patients in India are mental patients, yet only about 1% of the health budget is allocated for mental health. There is a ten-fold shortage of psychiatrists in India. There are only 3,000 psychiatrists in India as against a demand for over 32,000.This means that mental hospitals are under-staffed and lack sufficient infrastructure, reflecting our society's lack of concern for mental patients.

Mental patients, being what they are, are extremely susceptible to abuse and exploitation. A mental patient who is on the streets can deliver a child every ten months. Even women in a hospital may not be safe: they can be sold for a night, for a consideration, in cash or kind. Or be exploited by the hospital employees. There have been allegations of boys being sodomised. There were allegations that men were surreptitiously allowed into the women's ward in a government mental hospital at night. That was a quarter century ago. In 2003, a young schizophrenic in-patient at NIMHANS was raped by an out-patient while she was sitting outside. The rapist happened to be HIV positive. The hospital refused to take the responsibility for the incident. Recently, it was reported locally that a patient who asked for some more curry was beaten. Remember Oliver Twist?

There was a case in which a person was admitted to a mental hospital and given treatment for four years to make his sexual orientation "normal". "During counselling therapy sessions, the doctor explicitly told the patient that he needed to curb his homosexual fantasies, as well as start making women rather than men the objects of his desire. The doctor also administered drugs intended to change the sexual orientation of the patient, providing loose drugs from his stock rather than disclosing the identity of the drug through formal prescription. The patient reports experiencing serious emotional and psychological trauma and damage, as well as a feeling of personal violation, due to these actions. This form of psychiatric treatment, reflecting an understanding of homosexuality as a disease, represents a serious contravention of internationally recognized psychiatric guidelines and human rights standards." (see here) The case was raised before the NHRC in 2001.

Pathetic, to say the least, was the case of Machal Lalung of Mikir Chuburi in Morigaon district, arrested in 1951 for voluntarily causing grievous injuries. Since he was mentally unfit to stand trial, he was sent to the mental hospital. He remained there, as the case never came up for trial. His release in July 2005, after more than 50 years in prison, came after the National Human Rights Commission intervened.

In 2007, Mr. Deenadayalam, 54, was admitted to the Institute of Mental Health at Kilpauk in Chennai on an order by the Tambaram Judicial Magistrate, although he had no mental illness. He was illegally detained for 30 days. In this instance, the person could escape through a habeas corpus petition filed in the High Court. Else, the story itself would not have come out.

And, allegedly, at least some hospitals have become dumping grounds for aged people who are no longer needed by their families. And not just the elderly. It was not long ago that Tehelka exposed a doctor who was willing to certify a woman as mentally ill without even seeing her. The deal was settled for just Rs. 10,000, so that a journalist could get rid of his "undesirable wife". While this was only a story used by Tehelka to expose the racket, who knows how many women would have spent their "married" lives in the several mental hospitals in the country! Remember the story of Anjana Mishra!

The question naturally arises, "How come, if things are so bad, no one has been complaining?" The question, unfortunately, is based on a wrong premise that no one has complaints. Remember what a patient told one of the authors (Sundar) about the condition of their cell. Patients do have complaints. But who will listen to them? They are, after all, "mad". Their relatives, in most cases, are not bothered. They would like to somehow get rid of the “lunatic” in their family, delete them from their lives.

Box 1: The Erwadi incident

Mental patients are often locked up, chained and sometimes even beaten. They are treated like criminals. See what happened in a mental hospital in Erwadi. “The chain is blackened and the ring is horribly twisted but still fastened to the charred stump – of a leg. Mentally challenged and physically shackled he was, yet Murugaraj had desperately tried to free himself. Twenty seven more mentally ill people died with him in the early hours of August 6, 2001, when a fire engulfed the thatched roof of the Moideen Badhusha Mental Home at Erwadi, a fishing village 27 km south of Ramanathapuram town in southern Tamil Nadu in India. They were stripped of dignity when they lived - chained, confined and ill treated. The manner of their death was even worse.” wrote Asha Krishnakumar in Frontline (Vol. 18, Issue 17, Aug. 18-31, 2001) about the incident that suddenly brought the issues of the mentally ill into public conscience.

As usual, the hullabaloo died out soon after and people forgot everything about it; perhaps they thought that everything would be taken care of. Yet, when the Punjab and Haryana governments submitted affidavits to the Supreme Court stating that no one in the state was kept chained, the Tribune showed that there were still persons with mental illness kept chained in various places, though may not be in hospitals. In 2007, NDTV visited a famous dargah in Hyderabad only to find that the mentally ill still continue to be chained in gross violation of human rights

The Erwadi incident did make a difference. Enquiries were conducted. The licences of mental hospitals in the private sector were examined and some were cancelled. But "violation of human rights is committed in hospitals where basic amenities and services are not provided, inhuman and degrading treatment is very common and patients are subjected to ill treatment and abuse." says a report.

Box 2: Hell on Earth

Conditions in mental hospitals have been intolerable always. “A total of 200 women. Some in dark cells. They have to piss and shit into a small pit…In front of a cell, a plate full of shit. There are no toilets in the cell. Everything has to be done into a pit. A woman might intelligently have done it in a dish and shoved it out of the grill and could have gone to sleep. Or else she would have to sleep on the floor. The stench is unbearable. No one will remove that plate. It would be the plate from which she eats…In one cell a man lay hugging another. ‘You should have come before 10 a.m. You won’t be able to stand anywhere. Shit will puddle everywhere. They will pour a bucket of water over it. Then it will have a unbearable stench!’, says a patient.’ This was what one of the authors (Sundar) saw in one of the hospitals that he visited in the mid 1980s. (Ee Bhraanthaalayathinu Naavundaayirunnenkil (Malayalam), Mathrubhumi Publications, Kozhikode, 2007).

Things did improve, certainly. But not necessarily everywhere, and never as much as it should have. "As one approaches the wards, a strange stench hits the nostrils. The sight is even more horrifying and nauseating. To the wooden railings of the long verandah are tied — actually tied with ropes — the patients diagnosed as violent, sitting on their own human waste. On either side of the verandah are located the two toilets – unusable and filthy. The toilets have absolutely no water, either running or stored." wrote Anjana Mishra in Manushi (No. 120) about the Central Institute of Psychiatry, Kanke, Ranchi, where she was forcibly admitted by her husband. "Fortunately, I came out of that hell alive but the nightmarish memories continue to torment me, constantly reminding me of other women, young and old, whom I have left behind, probably doomed for life, and whose desperate letters, pleading to be rescued, remain unanswered." she wrote. This was in late 1990s.

The way food is served to mental patients in hospitals leaves much to be desired. Look at what Anjana Mishra (real name) has to say: "The dining hall, situated a little away from the wards, constitutes the most unhygienic part of the entire establishment. Dirty wooden tables line the wall, with the remnants or leftovers of earlier meals, especially, rice and dal particles. Almost a dozen dogs loiter around. The afternoon meal consists of coarse, half-cooked rice, watery dal and a tasteless, odourless curry. All of this put together can kill the appetite of even the hungriest human being. Again, privileged patients, like myself, were entitled to a piece of fried fish, a little curd and a pappad. All the patients eat in a child-like fashion, hogging a mouthful and then taking a walk, then coming back for a second mouthful. The dogs happily lick the plates in this interval. ... Some of the very ill patients even put their food on the floor and have it along with the dogs, while the ayahs in charge exchange gossip." (Manushi, No. 120)

Recently, in a mental hospital in West Bengal, a woman who asked for an extra serving of curry was beaten with the ladle by a woman employee! The unionized militant employees of the hospital apparently believe they have every right to do that.

The names of all persons mentioned in the article are changed to protect their identity.

(This article is published under the Creative Commons Attribution Share Alike Licence India 2.5. The article may be reproduced in any media in its original or modified form provided this note is also included.)