As many as 66.1% of those worst affected in India during the Spanish Flu belonged to oppressed classes and suffered the consequences of multidimensional poverty . Similar trends persist today. The inability to adhere to public health protocols that prescribe distancing and use of hygienic products, the absence of private toilets and basic amenities, and the lack of adequate nutrition are all realities in lower- and middle-income countries. Amongst those most affected are homeless persons and the ultra-poor, many of whom are employed in the informal sector. They are exposed to greater adversity against the backdrop of intergenerational social disadvantage and lack of social security.
Health shocks could precipitate a downward spiral into a state of not just homelessness, but also hopelessness. Globally, unpreparedness to handle the pandemic and near collapse of the health systems denudedour ability to focus on health. Many countries have attempted to make amends for the unjustifiable perpetuation of structural barriers and inequities. However, are we awakened to the needs of our poor only during a disaster? The pandemic has made a sound case for increased investments in the health and social sectors. States must also re-examine the role of social determinants of health in perpetuating unjust structures that normalise deprivation. A person’s social context and health intersect to help achieve a better quality of life. Relative poverty and its co-relation to stress, mental health and well-being have been evidenced. While distress cannot always be pathologised, data suggest that deaths by suicide and common mental disorders have also been on the rise during the pandemic.
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Distinctly deprived
Within this context, distinctly deprived are homeless persons living with a mental illness. They are at risk of violent victimisation, assault and long-term incarceration. In India, close to two million individuals sleep rough; 35% of them live with one or the other mental health concern.
The presence of homeless persons with mental illness elicits a range of responses from a desire to help, triggered by evocation of pity or sympathy, to wilfully wishing them away or shunning them from mainstream society. Historically, in a limited context of religiosity associated with renunciation and hearing voices (considered unique to the saint), a few were deified; however, the majority were feared, found to be repulsive and often treated as objects of ridicule. This has resulted in their occupying a lowly place in society’s hierarchical structure even today.
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Pathways into homelessness include abject poverty, conflict, natural or man-made disasters, lack of access to health and mental health care, social hardships, disruptions in care-giving and domestic violence. In India, homeless persons with mental illness are also the largest number of long-stay patients in State mental hospitals. Besides a few exceptions, services for this under-served group are scarce globally. As they are susceptible to physical co-morbidities and co-occurring substance misuse, and unshielded against the consequences of homelessness, malnutrition, sexual violation, loss of support networks and kinship, homeless persons find their longevity impacted. Further, their experience of loneliness and hyper-segregation contributes to their low sense of self-worth and shrunken group identity, weakening their collective ability to influence change. Additionally, we unfortunately inherited a legacy of name-calling and large and unwieldy lunatic asylums and poor houses from the colonial era which got off to an altruistic start but were later ridden with inadequacies and often deployed as punitive measures to initiate ‘reform’. Inadequate care staff resulted in a grossly underwhelming caregiving climate. Fortunately, strong resistance has been built against parochial practices which are giving way to newer dimensions of therapeutic and social care. However, much remains to be done.
Also read | A better life, a healthier mind
A person-centric action plan
UN Secretary General Antonio Guterres’s call to “step up for the vulnerable” cannot be more timely. The UN set up a fund of $2 billion to alleviate the distress of the ultra-vulnerable, including those living with disability or chronic illness. Along similar lines, the Tamil Nadu government, taking cognisance of the mental health needs of homeless persons, will take to scale Emergency Care and Recovery Centres (ECRC) that will support the treatment and community inclusion of this vulnerable section in 10 districts (in addition to the five districts where ECRCs were set up in 2018). The Department of Health, the National Health Mission, the Institute of Mental Health in Chennai, and The Banyan, a mental health care establishment, in partnership with multi-sectoral service providers, will together pursue the goal of improving mental health access and mitigating social and opportunity losses.
Three hundred bed spaces will be earmarked for homeless persons in psychosocial distress, with a capacity to service more than 1,000 people a year, in smaller and integrated care units in district hospitals and/ or social care centres. Early enrolment into care may result in reduction of exposure to harm, injury and starvation, and better prognosis. An integrated approach may also help address stigma associated with this group. Additionally, facilitation of social needs care and livelihoods may reduce the recurrence of episodic homelessness, critical to sustaining and enhancing well-being gains. Three sectors — the government, development and corporate sectors — will partner to ensure that the lives of those who live on the fringes matter. The mental health team that anchors the Centre may also lend further support to the District Mental Health Programme, and offer counselling support to address mental health issues in the context of the pandemic.
Comment | Inclusive ecosystems for mental health
However, we must remember that issues of homelessness and mental ill health even independently present intractable problems; in combination, one may confront ethical dilemmas and emerging constraints and challenges. We realise that the ECRCs are not a panacea to all distress undergone by homeless individuals, and that we cannot frame the problem within a restrictive and normative orientation. Incorporation of heterogeneity of experiences and multi-nodal approaches to care, which are embedded in values of accountability and integrity and take into account variegated distress markers, maybe critical for the evolution of newer meaning-making around social and psychiatric phenomenology. More importantly, these care paradigms have to be informed by the long overdue voice of the ‘subject in distress’. While this is a powerful start to acknowledge the need to focus on minority mental health, we also hope to benefit from feedback to further build on care plans and mental health systems for the vulnerable.
Vandana Gopikumar is Co-founder, The Banyan and The Banyan Academy of Leadership in Mental Health, and J. Radhakrishnan is Principal Secretary, Department of Health and Family Welfare, Government of Tamil Nadu