Thursday, 3 December 2015

A Transcendental Indian Adventure (4) Mental Health Action with the forest tribes of Kerala

Until seven years ago, Dr Manoj Kumar was a consultant liaison psychiatrist setting up oncology services in Leeds, in the NHS. Now he leads an NGO based at Kozhikode (Calicut) in Kerala which runs 43 mental health clinics for the poorest people in the surrounding areas, and two Masters-level training programmes for psychologists and social workers: Mental Health Action Trust (MHAT) - click for website.

We visited two very different clinics in rural villages outside Kozhikode, and held a seminar with the psychology students at the MHAT training base in the city. Interestingly, Kozhikode has just been voted the second best city to live in India.

Talking to Manoj, he explained several hallmarks of MHAT that make it unique:
·        Volunteers are used to provide extensive psychosocial input, including home visits and day care centres.
·        There are many more volunteers than paid staff (who are qualified clinicians)
·        Nearly all the clinic administration is undertaken by volunteers
·        The volunteers in the village projects have support from Manoj who is available by phone to discuss medication issues etc
·        People are screened to ensure they are very poor. For example, having a mobile phone would probably exclude somebody. 
·        Supporting compliance with medication is often important, but it is also part of the psychiatric philosophy to ensure people are on as little medication as possible.
·        They engage with the family and head of the local communities.
·        The normal state service for those who can’t pay is entirely hospital inpatient-based, and best avoided.
·        People who can pay a little more would generally see a private psychiatrist and get little care apart from a prescription.
·        Unlike most of the rest of his career, he get up on a Monday morning excited and enthusiastic about going to work!

Manoj himself was very open and honest about how he can see mental health from three angles, and uses them all in his clinical conversations: as well as being a psychiatrist, he described how he had experience as a patient with a depressive disorder needing medication, and as a carer when his elderly father was dying with dementia. I got the sense that this sort of candour is even more unusual in India than it is in the UK - but what a powerful anti-stigma statement it is.

This way to the MHAT clinic!
The first clinic we visited, at Karakunnu, was a mature project which had an experienced team and was well-integrated into the village, here: . The things that seemed to stand out were how similar to good community mental health care, as we know it in the UK, it was - but predominantly run and staffed by volunteers rather than professional paid staff, and all in very basic premises. Apparently, he occasionally gets criticised for delegating responsibility that others think should be the sole province of professionals, but when the alternative is no care, for very deprived people indeed, it strikes me as what they call a no-brainer. Similarly, the means testing has been criticised on behalf of the 'slightly wealthier', but it is clear that they would be overwhelmed by demand if they drew the boundaries any wider. 
The day centre


Staff and volunteers - including two friends from Penukonda LLE

The volunteers proudly showed us the work they were doing it and how they documented it all (in utterly incoimprehensible Malayalam script, plus books of photos and artwork). Perhaps, and most noticeable of all, was the sense of espirit de corps and team cohesion: sadly not always the case in British services. A joyous bunch of mental health workers who clearly really enjoy their work, and are very proud to be doing it.

The clinic base - and mobile pharmacy - for the forest colony
On the second day we went to a new project, just a few months old, way up the Western Ghat mountains where they look after people in Wayanad tribal colony: If the people Karakunnu were poor and lived in very basic circumstances, the people here were even more poor, and made the community services at  Karakunnu look fairly familiar to western eyes. These tribal people were in some ways even lower than 'the lowest of the low' in the Hindu caste system - they had even less social status than those who were once called the 'untouchables'.

The children wonder who we are...
The forest tribes, of which there are dozens or hundreds in this part of Kerala, each comprise of about fifty people who have previously been living off the land, in thatched self-built dwellings, without contact with the commercial world of employment and money. In the name of progress and with government 'development' policies they had been relocated to 'better' areas where there was at least a possibility that they could receive education and health care (and so help India score better as a developed nation); the one where we visited two families with the MHAT volunteers was amidst scattered luxury Keralan houses for the affluent - which looked like the Indian equivalent of holiday homes. But the tragedy we saw was how the tribespeople who had been displaced here had lost their sense of meaning and purpose in being relocated, and many took to a life of total intertia and continuous intoxication with home-brewed alcohol. I won't presume to understand what was going on in the two consultations we saw - but the individuals we saw were in a very poor state to look at, as we were eagerly surrounded by numerous inquisitive and lively children.

Across the Western Ghats
Teaching session in Kozhikode
After the spectacular drive back down the nine hairpin bends on the road off the Western Ghats into town, we had an impromptu seminar with the Masters students about therapeutic communities and greencare - which seemed to be well received. Interestingly, one of the key staff at the teaching centre, Malika, is a Tavistock-trained psychosynamic psychotherapist - and the compassionate, boundaried and therapeutic understanding shone through in the students. Then (yet another) lovely Indian dinner,this time at Malika's home - and many passionate conversations with Manoj, Malika and her psychiatrist husband Ajay over a bottle of scotch...

And so to bed - before our return to Bengaluru and Sunday afternoon Christmas shopping with Anando's mother (surprising successful and enjoyable for one like me who generally hates shopping!)

Then up at 0245 for a drive through strangely deserted streets to catch BA118, the daily shuttle plane to Heathrow.


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