By Glenn C. Kharkongor
“In 2019, 1 in every 8 people, or 970 million people around the world were living with a mental disorder, with anxiety and depressive disorders the most common. The prevalence of mental illness is highest in age group 25-34 years and suicides are highest among those aged 15-29 years.”
Many health workers, doctors included, pussyfoot around mental health. They would prefer to focus on physical and physiological medicine, leaving mental illness on the fringe of the discipline. Of course, there are admirable individuals and organizations who engage head on with mental illness. The initiative to forge a mental health policy by the health department of the state government is to be highly commended.
One can comment on the process and content of the draft and some of that will be covered in this article. But health professionals and civil society must proffer a constructive and positive approach. The health department is one of the few well-functioning departments in the state. It is led by able officers, who steered the state through the Covid pandemic in an efficient and effective manner, in spite of inherent hurdles and pockets of resistance.
The Covid crisis in mental illness
Even before Covid, the burden of mental health outweighed all other diseases. In 2019, 1 in every 8 people, or 970 million people around the world were living with a mental disorder, with anxiety and depressive disorders the most common. The prevalence of mental illness is highest in age group 25-34 years and suicides are highest among those aged 15-29 years. About 200 million Indians (14%) suffer from a mental disorder. One DALY (disability-adjusted life year) represents the loss of the equivalent of one year of full health. India has one of the highest DALY rates for mental illness in the world.
The number of people living with anxiety and depressive disorders rose significantly because of the COVID-19 pandemic. Initial estimates show an increase in depression by 40-60%, and a 28% increase in anxiety. There has been an increase in mental illnesses among vulnerable groups such as youth, disabled persons, health workers, and LGBTQIA+. Domestic and child abuse has risen. According to the WHO, “the world is failing in our duty of care for mental illness and well-being of health workers”.
Focus on mental health needed
Unfortunately, The Mental Healthcare Act, 2017 has only a definition of mental illness, but does not contain a definition of mental health. A focus is thus maintained on illness and the provisions kick in only after a mental illness sets in. A more important priority is to ensure mental health and well-being.
The WHO has a comprehensive definition of mental health saying that “it is critically important for everyone, everywhere, and goes beyond the mere absence of a mental health condition. It is integral to well-being, enabling people to realize their full potential, show resilience amidst adversity, be productive across the various settings of daily life, form meaningful relationships and contribute to their communities. Physical, psychological, social, cultural, spiritual and other interrelated factors contribute to mental health, and there are inseparable links between mental and physical health. Promoting and protecting mental health is also critical to a well-functioning society. It fosters social capital and solidarity, which are essential during times of crisis.”
Culture and mental illness
The WHO definition of health focuses on physical, mental and social well-being, and its definition of mental health includes cultural factors, stating that culture is inseparable from mental health. Current health systems mostly focus on physical health. Mental health doesn’t receive the importance it deserves and social health is hardly ever mentioned. Along the way, the role of culture in social and mental health has been neglected.
The word “culture” is mentioned 84 times in the draft policy. The word is often diminished to a buzz word or to lend a trendy veneer to an academic or government narrative. There are no specifics in the draft policy, only vague ideas. Outside of the department of art and culture, the word is not on the radar. Even in health sciences, culture is hardly studied as a significant factor in health.
The International Classification of Diseases (ICD) issued by the WHO in 2016 includes a section titled “culture-specific disorders,” and has recommended that mental health practitioners include a separate category for cultural syndromes. The ICD has already included 20 such diseases from around the world in an annexure, one of which is a disease from India called ‘dhatu’.
The Diagnostic Statistical Manual, (DSM) is the official handbook of psychiatric disorders issued in 2013 by the American Psychiatric Association (APA). It includes a table of more than eighty mental disorders with cultural issues. The APA recommends that a culture-related interview, relating the patient’s social and cultural context and history, be included to arrive at a correct diagnosis. The DSM describes the entities of “culture-bound syndromes”, “folk illnesses” and “culture-specific disorders.”
All tribes and even other ethnic groups have cultural illnesses. Examples of these among the Khasi-Jaintia tribes are “thlen”, “taro” and “niangsohpet”. These illnesses are grounded in belief systems, which may have spiritual dimensions and discussion of these illnesses must dealt with sensitivity. The fact is that these illnesses are prevalent in our society and have physical and mental symptoms, and as such need to be included in the health discourse.
The inclusion of traditional healers in a pluralistic health strategy is recommended by the WHO. The report on Tribal Health in India, 2018, issued jointly by the Ministry of Health and Ministry of Tribal Affairs recommended the study, documentation of health traditions and traditional medicines of different tribes. Another important recommendation is to integrate tribal medical practitioners into primary health care.
Khasi and Garo traditional medicine are used by a majority of the tribal population and believed to be efficacious. It is also accessible and affordable. Unfortunately, the ten thousand healers in our state have no official status, and their services are not supported by policy or schemes. They can be integrated into the health system to deliver both traditional and modern health services.
The Protection and Promotion of Khasi Traditional Medicine Act was passed by the KHADC in 2011, and signed by the governor. It has four main features: the registration of traditional healers, the establishment of a training institute, the setting up of medicinal plant sanctuaries, and the protection of intellectual property rights. Sadly, there has been little progress in implementation.
Research
The mental health policy should provide for specified areas of research. Two areas are of important focus. The first is to investigate the beliefs, attitudes and behaviours that are associated with the high birth rate, low use of contraception, low vaccination rates, and high oral cancer prevalence seen in Meghalaya. The second area of study would look at cultural factors and cultural illnesses.
In anthropology, the term liminality literally means the ambiguity or disorientation that occurs in the middle stage of rituals. In a larger sense, it indicates the transition stage of a tribe standing at the threshold between their previous way of structuring their identity, beliefs, and traditions, and the new way of thought, values and behaviours. Our tribes in Meghalaya are at such a junction in their continuing evolution and our uneasy engagement with traditional cultural beliefs is an example of this liminality. In this transition we have to reassess these things, without being unhinged from our roots.
A final review
I suggest that the draft policy be reviewed by a committee of experts from various stakeholder groups, especially those with cultural experience, which outsiders will not be able to comprehend. The implementation plan should include specified contributions from various stakeholders, especially those in civil society and educational institutions. There should be annual reports and reviews by stakeholders.
Mental health should be integrated into general health. Continuing the focus separately on mental illness or even mental health invokes stigma. We have moved away from words like “mad”, “hysteria”, and “lunatic”, and we need to continue the attitudinal journey to looking at mental health in the holistic context of health and well-being. Those of us who may consider ourselves on the front lines of liberated thinking, still have to take our fellow tribals along, with due respect to traditional beliefs. Especially because these are not disjointed beliefs, but have implications for physical, mental and social health.
“The word “culture” is mentioned 84 times in the draft policy. The word is often diminished to a buzz word or to lend a trendy veneer to an academic or government narrative. There are no specifics in the draft policy, only vague ideas. Outside of the department of art and culture, the word is not on the radar.”