How many deaths will it take ‘til he knows
That too many people have died
The answer, my friend, is blowin’ in the wind,
The answer is blowin’ in the wind.
–Bob Dylan, Nobel Laureate
India’s economy may be soaring, but agriculture remains its Achilles’ heel, the source of livelihood for hundreds of millions of people but a fraction of the nation’s total economy and a symbol of its abiding difficulties.
Farmer suicides are a wrenching affliction that is as tragic as it is complex and is a serious threat to India’s most critical economic sector. A new report has very distressing news on the farm front. Despite satisfactory rainfall last monsoon, Maharashtra, India’s most populous State, registered a paltry fall of 5% in farmer suicides to 3,063 in 2016 from 3,228 in 2015. Shockingly, the number of suicides in the last six months after the 2016 monsoon set in was as high as in 2014 and 2015 for the same period. Farmer suicides rose by 42% between 2014 and 2015, according to “Accidental Deaths and Suicides in India 2015” a report released this January by the National Crime Records Bureau (NCRB). It recorded 5,650 suicides by farmers and cultivators in 2014. The figure rose to 8,007 in the latest data. In the fluid world of statistics, numbers may not always tell a true story. But it does show us where rural India is headed as a society.
Currently, the government does little more than grant compensation to the families of farmers who take their lives, which many consider an incentive. The cash compensation does help them tide over the immediate problem of feeding the family. But there is politics here also. The compensation can be denied if ownership of the land is disputed or if the death is not judged to be linked to indebtedness of the farm crisis.
For many bereaved families, receiving compensation remains out of bounds. The agricultural department does not accept all suicides as compensation worthy. Its officials say: “If a farmer is unable to clear loans taken for agriculture from authorised banks or financiers, it is considered a farmer suicide by the government. Loans taken for other purposes, or even agricultural loans taken from unauthorised financial institutions, are not accepted as causing farmer suicides.”
After receiving the money, a widow often has to fend off claims from her husband’s family and creditors. Widows forced to repay loans can be caught in a vicious cycle of debt bondage. The abysmal state of mental health care in the country made matters worse.
Most government-run hospitals do not have psychiatric drugs, and visiting a private shrink and sustaining the treatment — usually a long drawn out affair — is an expensive proposition for most families. The ignorance and callous attitude towards psychiatric ailments, coupled with social stigma, dissuades most from seeking help. Counseling centres are purely urban phenomena.
There may be some light at the bottom of this abyss, an intensive 18-month grassroots mental health programme in rural Vidarbha, in Central Inida, called VISHRAM (the Vidarbha Stress and Health Program), has improved the mental health profile of the farm community. Launched in 2001, it is designed to establish a sustainable rural mental health support to address issues relating to stress and tension that abet suicides alcohol abuse and depression in the farm community.
This intervention has seen an effective reduction in suicidal behaviour besides encouraging more and more people to seek professional help on depression, according to an evaluation study of the VISHRAM programme by the Public Health Foundation of India (PHFI). The study was published in Lancet Psychiatry.
VISHRAM was designed to address the mental health risk factors for suicide (i.e., depression and alcohol use disorders) in a predominantly rural population of 1,00,555 people in 30 villages in the Amravati district of Vidarbha region, the epicentre of farmer suicides. While in Amaravati was implemented by Prakriti in Wardha. It is run by Watershed Organisation Trust with technical support from Sangath. The programme is built around a cadre of trained grassroots community health workers – armed with mental health first-aid kits, some with no background in mental health care.
Surveys were done at the start and the end of the programme. The evaluation at the end found that:
–the proportion of people with depression who sought care rose from 4.3 per cent to 27.2 per cent;
–the prevalence of depression fell from 14.6 per cent to 11.3 per cent;
–the prevalence of suicidal thoughts in the previous 12 months fell from 5.2 per cent to 2.5 per cent; and
–a range of mental health literacy indicators showed significant improvement.
Patel, who is also a professor at the London School of Hygiene and Tropical Medicine and co-founder of Goa-based mental health research nonprofit Sangath is the architect of this programme.
Patel wants suicide to be seen as a public health issue. “In India we haven’t done good research on farmers’ suicides and in terms of mental health, this has always been seen as a social issue. But if you look around the world at least 50% of farmers, and adults who kill themselves would have had a depressive disorder or an alcohol use disorder, these two being the main mental health conditions,” he says.
The idea sprang from something Patel saw in Zimbabwe, where he worked as a psychiatrist in the mid-1990s at university in Harare. “I learned so much in Zimbabwe, in particular about the need for humility in our ambition to extend mental health care in countries where there were very few psychiatrists and where the local culture harboured very different views about mental illness and healing. These experiences have profoundly influenced my thinking.”
At first, Patel and his colleagues thought they were starting from scratch. They ran focus groups to gauge community acceptance and conducted small trials and then larger trials comparing lay counselors to “enhanced traditional care” — basically, diagnosis by a doctor or health worker at a primary health center, medication if necessary, and sympathy from the staff, but not ongoing counseling.
Patel recalls being criticized at international meetings for advocating for substandard care. His standard reply: “We need to wake up.” Lay counselors are effective, he says, and they address the lack of mental health workers that is so common in poor parts of the world .The lay counselors come from the same community as their patients. They speak the same dialect, and they identify with their patients.
According to Patel, mental health support workers can be trained at modest cost, and in countries like India where there are significant doctor shortages, especially in a field such as psychiatry, community treatment by mental these workers can be a successful alternate support system.
According to Patel, “We need to build skills in the primary care doctor to detect and treat mental health problems. There should also be a robust linkage between the specialists in medical schools and district hospitals with primary care. “This is the same model of care used for all chronic diseases, not only for mental disorders. In fact, in the long term, the most sustainable way to improve access to mental health care is to see mental disorders as a chronic disease similar to diabetes”, he avers.
As a part of VISHRAM, existing front-line workers such as accredited social health activists (ASHAs) worked at the community level to raise mental health literacy and provide psychological first aid and lay counsellors provided psychological treatment in the community and at primary health centres. Psychiatrists from the government’s District Mental Health Programme and the private sector provided medication for serious mental disorders at the primary health centres and the rural hospitalFrontline workers interacted directly with the agrarian population, talking about the “tension” they were experiencing and by raising awareness about the stress episodes they were undergoing and ways to cope with the
For many farmers, sharing and ventilating their toxic thoughts was cathartic. Since they are drawn from the same community, the healthcare workers are familiar with the environment and therefore better able to empathize with these farmers .They combine their new cognitive skills with traditional wisdom for working out strategies to strengthen the resilience mechanism of these farmers.
Patel; feels that stigma is a major challenge and there is no simple solution here. What does work is disclosure: people coming out and talking about their experience of depression. Mental health is still looked upon as a rich man’s disease by many. It is assumed that, if you are poor, then the symptoms of depression are simply an expression of the misery of your life. However, this is not a natural consequence of poverty and those who are poor and depressed deserve, if anything, even more of our attention than the rich.
VISHRAM has mobilized self-help groups and village leaders for early detection of mental disorders with focus on affordable, home-based care. More than 1,000 small group meetings were held over the 18 months. First aid for mental health was provided to 1,441 individuals with psycho-social distress. More than half of these people (793) were referred to counsellors while patients with severe mental illnesses like schizophrenia were referred to the local medical hospitals.
The authors see it as a cost effective and efficient model that can be scaled up or implemented in different parts of the country, but it needs government help. It found that people seeking more access to care were evenly distributed across caste, class, gender, religion, even if their reasons for needing help were different.
Today, Patel says, the challenges are figuring out how to scale up the program, and how to make sure that a larger-scale program will produce adequately trained counselors. “We’re no longer asking can we use community workers, we’re asking how do we deploy them,” says Patel.
For every Indian farmer who takes his own life, a family is hounded by the debt he leaves behind, typically resulting in children dropping out of school to become farmhands,. The Indian government’s response to the crisis—largely in the form of limited debt relief and compensation programs has failed to address the magnitude of the problem or its underlying causes. If the government does not act, probably these women may also have to open the doors they have kept shut till now.
Farmers’ suicides have to be tackled on several fronts and addressing mental health problems is just one of them, but certainly a major part of the solution.
A lot of good programs got their start when one individual looked at a familiar landscape in a fresh way. These creative and passionate individuals saw possibilities where others saw only hopelessness, and imagined a way forward when others saw none. What they did was not something too revolutionary to supplant the whole system. They simply changed the fundamental approach to solving problems, and the outcomes have been truly revolutionary.
One inspiring step has a tendency to raise the sense of possibility in others. Passion is the secret ingredient of all great accomplishments. Better still it is a beautiful contagion that transforms everyone touched by it.
We increasingly have the tools; but we need to summon the will the way game changers like Patel are doing. People like him have shown there are solutions if we think out of the box. And don’t accept limits to how the world works.