“If only I knew, I would have talked him out of it. He did not look normal and we hardly had any communication for days before he died,” says a farm widow in a remote village in Maharashtra’s Amaravati district. Her husband committed suicide some time back as he was unable to repay the debt that he had taken. The money he borrowed kept multiplying over the years. He was under lot of stress but did not share it with anyone, not even his wife or children. And one day, he just killed himself.
This is not a lone incident of its kind. It is the story of thousands of farm widows in Vidarbha region — now known more for farmer suicides than the fine quality cotton it grows.
Suicide and mental disorders are major public health problems in India. According to the National Crimes Records Bureau, 125,017 people committed suicide in 2008 and at least 1,000 farmers ended their lives every year in the Vidarbha region since 2001 though several experts dispute the figure for being low than the actual cases which do not even get reported. Similarly, the causes of suicide are multi-factorial like gender disadvantage, caste discrimination and debt.
However, the most important individual level determinant is mental disorder. By far, the most common mental disorders which contribute to this risk are depressive disorder and alcohol use disorders. In addition to mental disorders being a determinant for suicide, they are also a consequence; thus, family members, including children, often experience severe emotional difficulties and frank mental disorder in the aftermath of a suicide.
When farmers commit suicide, the burden of supporting the families shifts on women who also have to come to terms with domestic violence, if husband takes on to alcoholism due to stress and depression. Unable to deal with such situations, women and children are automatically pushed into the high risk group.
It is this population that Project VISHRAM has been silently aiming to target since the past two years. Vidarbha Stress and Health Programme (VISHRAM) is a four-year community-based programme for the promotion of mental health and prevention and management of psycho-social distress and mental disorders in agricultural communities in the Vidarbha region — Amaravati and Wardha districts. While in Amaravati, it is being implemented by Prakriti, in Wardha, it is being run by Watershed Organisation Trust with technical support from Sangath.
“We chose Vidarbha because there was considerable local concern among diverse stakeholders, including our partner organisations in the region, about mental health issues, particularly in relation to suicide. Among the most important mental health factors related to suicide are depression and alcohol abuse, and both of these are priority conditions for Sangth's programme,” says Vikram Patel of Sangath who is a Professor of International Mental Health at the Clinical Science Centre for Global Mental Health, London School of Hygiene and Tropical Medicine.
Studies have shown that rural communities are widely recognised as a high risk group for suicides as compared with most other occupations; moreover farmers have been reported to have high prevalence of common mental health problems and there is a large treatment gap for mental disorders. Vidarbha, in particular, has been badly affected by agrarian crisis which have been linked to farmer suicides.
“Unfortunately, people do not understand basic things like stress and depression until it is too late. In India, insanity is the only word that describes mental disorders of all kinds,” explains Suvarna Damle of Prakriti. “It is extremely difficult to convince people that mental disorders are curable. The only response we get when we talk of mental health is that there are no insane people around,” she says. In any case, faith healing is the first line of treatment that people adopt. When the patients are brought for medical help, the situation is generally out of hands.
Suicide is an extreme step but it begins with a very common and innocuous thing like stress or depression that can be a result of a range of social and health factors, especially in rural communities. For example, the greater insecurity of income, lack of access to credit, poorer access to appropriate health care and easier access to lethal methods for suicides like pesticides.
VISHRAM’s goal is to implement and evaluate a comprehensive, population-based intervention programme to reduce psycho-social distress and the risk of suicide through targeted interventions. “Agriculture is falling out of favour as an occupation in rural communities. One study found that about 40 per cent of farmers would like to quit agriculture. We spoke to 70 such children who do not want to take up agriculture as they do not find it prosperous any more and would rather sell off their land. Personal tragedies and alcohol abuse just add to this serious situation,” Ms. Damle points out.
Prakriti covers 16 villages of Amaravati and The Watershed Organisation Trust (WOTR) eight villages in Wardha. In each village, one person has been identified as a community health worker who acts as the first point of contact and helps to identify people with symptoms of mental disorders, even if it is just stress or depression. Of the 16 community health workers that Prakriti has, six are Accredited Social Health Activists (ASHAs) who are trained to detect such people and persuade them to visit the outreach clinics run by the organisations in collaboration with either district hospitals or private hospitals who send psychiatrists for these clinics. In the case of ASHAs, it is easy to link patients with the District Mental Health Programme (DMHP) being run in government hospitals.
“VISHRAM aims to be a community-based programme to promote mental health literacy and awareness and deliver basic mental health care services by trained counsellors in community settings in addition to providing specialised mental health care services through a collaborative partnership with public and private health care providers,” explains Bhupali Mhaskar of WOTR. Its ultimate goal is to integrate mental health with regular health care needs.
During the past two years, WOTR has mobilised self help groups and village leaders for early detection of mental disorders with focus on home-based care. Mental health awareness programmes include distribution of IEC material, street plays and informal interactions with women’s groups and free distribution of medicines. The next target now is to involve schools in identifying children with such symptoms by training teachers.
“The issue of mental health is so sensitive that it takes lot of time and persuasion to make people talk about it. Most people do not even relate to it,”' explains Arti Khangar, a counsellor with WOTR. Initially when they were told the meeting would discuss mental health, the villagers would say it is a meeting meant only for “insane people”.
However, things seem to be moving in a positive direction now with villagers providing information about families under stress due to economic or social distress, alcoholism and domestic violence in the neighbourhood or even about someone in need of medical aid. The WOTR has identified between 90-96 patients with severe mental illness like schizophrenia who were referred to Datta Meghe Institute of Medical Sciences and Hospital for treatment, while in Amaravati this number was 64. A large number of patients are being treated at the outreach clinics also.
Three mentally retarded children were also detected in Choramba village. However, it was their mother who needed counselling because she kept worrying all the time about the future of her children after she dies. She complained of acute body pain which was because of mental stress but she could not relate the two. Baby Tihile’s husband is an alcoholic and had reportedly beaten her up when she was pregnant which, probably resulted in the condition of her children. An anganwadi sevika, Baby Tihile had even sent her children to a specialised residential school but pulled them out because of the pathetic conditions of the mental home.
“Four years down the line, we want to hand over the project to the public health system. There would be enough demand generated by then and enough trained people at the primary health centre level or community health centres to deal with such cases,”' Ms. Damle says. VISHRAM's focus is on treating mental disorders and addiction at the community level and within home settings, and at an affordable cost.
However, there is a huge drop-out rate as patients resist coming to clinics for the fear of stigma and even stop taking medicines once they show signs of improvement. This continues to be a huge challenge.
