His speech is of mortgaged bedding,
On his kine he borrows yet,
At his heart is his daughter’s wedding,
In his eye foreknowledged of debt.
He eats and hath indigestion,
He toils and he may not stop;
His life is a long-drawn question
Between a crop and a crop.

— Rudyard Kipling, The Masque of Plenty

Large swathes of cotton farms in central India have been the epicentre of a debt crisis that has gripped the rural population. For years now it has driven thousands of farmers to commit suicide. These suicides are not merely the loss of human lives, they are debilitating scars on a nation’s development canvas. While debates continue to rage on reforming the agricultural sector to improve the economic conditions of the farmer, there has not been any attempt to focus on the possible psychological problems arising out of economic stress that could lead to suicides.

Farm suicides are a reflection of an ailing rural economy. It also shows a state of hopelessness among farmers, which make them emotionally vulnerable enough that they are taking their own lives. A field-based research study in the prestigious medical journal The Lancet (by Pandit et al) concludes, “Most Indians do not have community or support services for the prevention of suicide and have restricted access to care for mental illnesses associated with suicide, especially access to treatment for depression, which has been shown to reduce suicidal behaviours. Reduction in binge alcohol drinking through regulations, higher alcohol taxation, or brief interventions in primary care might also reduce suicide cases.”

The abysmal state of mental health care in the country has made matters worse. Most government-run hospitals lack proper infrastructure, and visiting a private counsellor and sustaining the treatment—usually a long drawn out affair—is an expensive proposition for most families. The ignorance and the callous attitude towards psychiatric ailments, coupled with social stigma, dissuades most from seeking help.

But there are silver linings on what most see as a cloud of despair. There are several selfless professionals who are using their talent and ingenuity to address some of our toughest problems. One such is Vidarbha Stress and Health Programme, or VISHRAM. Designed by Dr Vikram Patel, a professor at the Public Health Foundation of India, VISHRAM was implemented in the Vidarbha region over a period of 18 months – from September 2014 to October 2015. He had, in 2015, figured in the Time magazine’s 100 Most Influential list, and was dubbed the “Well-being Warrior” by the magazine.

“He provides hope that mental illness and trauma make us neither weak nor unworthy of love and respect,” they wrote.

The programme is designed to address the mental health risk factors for suicide (ie, depression and alcohol use disorders) in a predominantly rural population of 100,555 people in 30 villages in the Amravati district of the Vidarbha region, the epicentre of farmer suicides. The programme was executed with help from a cadre of trained grassroots community health workers armed with mental health first-aid kits, some of them, with no background in mental health care.

Surveys were done at the start and at the end of the programme. The researchers interviewed 1,887 subjects on mental health indices.

The evaluation 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 percent to 2.5 per cent.
  • a range of mental health literacy indicators showed significant improvement.

    This in itself highlights the success of the programme in spreading awareness and raising mental health literacy. As depression is one of the leading causes of suicide, this could explain the sharp dip in suicide numbers as well.

    Patel uses community volunteers and trains them as mental health workers for his project. He runs focus groups to gauge community acceptance and conducts trial sessions to train new counsellors who impart enhanced care. This includes diagnosis by a doctor or a health worker at a primary health centre, medication if necessary, and sympathy from the staff. Counseling has a great role to play in alleviating stress and helping depressed people improve their self-esteem and their ability to cope with despair.

    Janrao Haware is one of the locals trained as a psychopathic counsellor. He was assigned the care of Shubham Kitukale, a farmer living in Marlod village in Amravati district. Kitukale had attempted suicide when the debilitating debt on his farm grew out of control. Through a series of counselling sessions, Haware and Kitukale were able to pin down the causes of despair and the aggravating factors that led to the attempted suicide. Through simple sessions of empathetic counselling by Harare and by sharing and ventilating his anxiety, Kitukale was returned to full health. The young farmer recently got married and is now expecting a baby. He says that when things get tough, he no longer considers suicide as a way out.

    According to Patel, mental health support workers can be trained at a low cost. In countries like India, where there is a shortage of trained doctors—especially in the field of psychiatry—community treatment through these workers can prove to be a successful alternative support system.

    “We need to enhance the skills of doctors working in primary care units to detect and treat mental health problems,” Patel says.

    “There should also be a direct link between the specialists teaching or practising in medical schools and district hospitals with basic medical facilities. This is the same model of care used for chronic diseases. 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.”

    VISHRAM mobilised self-help groups and village leaders for early detection of mental disorders with a focus on affordable, home-based care. More than 1,000 small group meetings were held over 18 months. First aid for mental health was provided to 1,441 individuals with psychosocial 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. Psychiatrists from the government’s District Mental Health Programme and the private sector provided medication for serious mental disorders.

    Existing front-line workers such as the Accredited Social Health Activists, or ASHAs, worked at the community level to raise mental health literacy. They were provided with psychological first aid and treatment in community and primary health centres. Frontline workers interact directly with the people, talking about the “tension” they are experiencing and raising awareness about the stress episodes and ways to cope with them. For many farmers, sharing and ventilating their toxic and morbid thoughts was cathartic. Moreover, since healthcare workers are drawn from the same community, they are familiar with the environment and are able to empathise with the farmers.

    According to Patel, mental health support workers can be trained at a modest cost. In countries like India where there are significant doctor shortages, these mental workers can be a successful alternative. Even family elders are sometimes the best counsellors. With training in basic psychological skills, they can play a very useful role in curbing suicidal tendencies.

    The idea sprang from something Patel saw in Zimbabwe, where he worked as a psychiatrist in the mid-1990s at the 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 are very few psychiatrists and where the local culture harboured very different views about mental problems. The situation is not very different in India. The ratio between psychiatrists and the population is worsening and so is the stigma of mental illnesses.”

    Patel wants suicide to be seen as a public health issue. “In India, we haven’t done good research on farmers’ suicides in terms of mental health. This has always been seen as a social issue. But if you look around the world, at least 50 per cent of farmers and adults who kill themselves would have had a depressive disorder or an alcohol use disorder–the two main mental health conditions,” he says.

    Patel and others are seeking to scale up the programme, spreading it to other states of the country. VISHRAM is a cost effective and efficient model that can be scaled up or implemented in different parts of the country, but it needs government help. Scaling up has challenges. One of them is to retain the efficiency factor that a smaller and more closely monitored programme has.

    “We’re no longer asking if we could use community workers, we’re asking how we deploy them,” says Patel.

    A much larger project is being launched by Punjab Agricultural University (PAU) which has now teamed up with its counterparts in Telangana and Maharashtra, and also the psychology department of the Punjabi University at Patiala, to create a “stress index” (SI) for farmers and prepare a training module for village-level volunteers to counsel those on the verge of committing suicide.

    The exercise is part of a research project, for which the Indian Council of Agricultural Research has released Rs 13.5 million. It will focus on the “psychological and behavioural aspects” behind farmer suicides. The target is to survey 1,000 “vulnerable” farmer households at both baseline (before counselling) and endline (after counselling) stages, while also training 200 “peer support volunteers (PSVs) in Punjab and 100 each in the other two states. They would identify distressed farmers within their areas and provide about six months of counselling to prevent them from taking any extreme steps. The PSVs would be trained to provide sociological and psychological inputs and motivate farmers to follow a “positive path” and practice austerity and a simple lifestyle.

    The study has two major components – stress index (SI) and psychological resource index (PRI). Stress index of the farmers will be measured on the basis of eight tools, including depression, suicidal tendencies, resilience, and hopelessness among others. It will be a qualitative as well as a quantitative study as apart from interviews. Typically, distressed farmers would show a high SI index and a low PRI – these two together would measure their mental strength and readiness to cope up with stress. A high PRI would indicate resilience – which should reflect after six months of counselling.

    How will stress index work?

    Step 1. The survey will be conducted on 1,000 ‘vulnerable’ farmer households

    Step 2. The data collected from these farmers will be used to measure their stress levels and whether they are mentally strong enough to handle it.

    Step 3. Distressed farmers would typically exhibit high SI and low PSI, a measure of their mental strength and resilience to cope up with stress.

    Step 4. Around 200 ‘peer support volunteers (PSVs)’ in Punjab and 100 each in Telangana and Maharashtra will identify distressed farmers within their areas and provide about six months of counselling to prevent them from taking any extreme steps.

    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. 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.

    Moin Qaziis the author of Village Diary of a Heretic Banker. He has spent more than three decades in the development sector.

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