Features Saturday, March 21, 2015 - 05:30
Chitra Subramaniam | The News Minute | November 28, 2014 | 01:19 pm IST Dr. Sanjeev Jain is the kind of doctor that hospitals would move heaven and earth to find and retain. Passionate about the public provision of healthcare, his engagement in his discipline (psychiatry) ranges from Molecular Genetics to History of Psychiatry. From his office at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, where he is Professor, Molecular Genetics Laboratory, Department of Psychiatry, Dr. Jain attends to his Indian patients and gets calls from all around the world asking for a second opinion, a document review or demystification of medical jargon. He is one of India’s most respected public health persons, a coat he wears lightly, when he does. Dr. Jain shares his views with Chitra Subramaniam, Editor-in-Chief of The News Minute (TNM), on mental health and stigma, research, the need to rationalize health policies in India, WTO and patents, the essential drugs list and health care. Excerpts: The Nobel Prize in Physiology (or medicine) this year* is expected to play a large role in destigmatising mental health. Do you agree? Yes. This is a tangible, and easily understandable, set of experiments that show how maps and memory of places combine to produce what we call geographical orientation. By extrapolating from this, perhaps many other ‘mental’ processes will become better understood and this, in turn, would help us understand how changes in cognition and behavior, that underlie mental illness, occur. Psychiatry has long been called the ‘last island of medical ignorance’; and the stigma engendered by this ignorance is a very big problem. Improved knowledge of the disease process in other conditions; from tuberculosis and leprosy to epilepsy, has successfully reduced stigma for these. Whether these explanations from experimental neuroscience would be valid for the relatively concrete experiences (space/geography/perceptions etc), or be applicable to the more abstract psychological experiences (social constructs, altruism, violence etc.) needs to be seen. Disturbances of these are often the early symptoms in mental illness, and understanding their origins may still be a long way away, if at all feasible. This work is very encouraging, as it lights a small spark, in what has hitherto been a very dark tunnel! India’s mental health regulations were revised recently and you were involved in the process. What are the salient features? The new regulations emphasize access to mental health care being an inalienable right, at par with access to other health care. This is an important first step, and allows integration of psychiatric services at every medical service provider. It simplifies the registration procedure for provisioning this care, but still requires documentation (necessary due to possibilities of misuse of psychiatric hospitalization). There are certain clauses like advance directives, or establishments for long-term care being run by non-medically trained specialists that may be difficult to operationalize effectively. Certain intervention guidelines, disallowing procedures like non-modified convulsive therapies are necessary, but may not be welcome by the profession! It admits the need for increased provision of care for the chronically ill (as India has one of the lowest number of beds for psychiatry, in proportion to its population), and suggests increased involvement of the NGO and non-formal sectors in this. Whether this would suffice is unlikely, and increased provision by the State /public provision would be necessary. How does stigma manifest itself against people with mental conditions in India? There is the obvious social stigma (exclusion from marriage/many other expected roles) as well as neglect (those affected often become non-persons). ‘Family’ stigma too persists, so that families go a long way to ‘hide’ mental illness. Systemic stigma occurs at many levels: access to insurance for psychiatric care not provided by most companies; patients are not allowed to open bank accounts; vote etc. In public spaces it’s the most evident, so that at many levels of civic discourse, accusation of mental illness is used as a particularly galling insult or in a derisive manner (politicians calling each other mad, ‘recommending’ psychiatric evaluation for their adversaries; or media stories highlighting gory or disruptive behaviours) with little concern, or even understanding, that it as an illness. The ‘trickle-down’ effect of this contempt is thus spread widely across all segments of our society. Are there different patterns in the country – south not the same as the north, for example or is that only an impression? There are no such differences of any significance, at least not very much. This has been a subject of scrutiny for at least 200 years, ever since psychiatric services began in India. Many such impressions have been made from time to time, but none have stood up to accurate research. Places where services are relatively better run (Bangalore and many places in southern India) have better utilization of mental health services than other areas. The illnesses do not differ, but social responses and medical services do. Non Communicable Diseases (NCDs) kill more Indians today than anywhere in the world. Mental health is part of this problem. Is the government aware of its magnitude? Increasingly, yes. The inclusion of mental health as a component of NCD was in a sense spearheaded by India. Depression is a risk factor for cardiac disease and diabetes, while chronic medical disease shortens the life-span of those with mental illness by almost two decades. What this implies at the clinical and bedside level remains unclear, as the services for these NCD’s (hypertension and diabetes, depression and psychoses) have developed along divergent trajectories, and there is little planning at the moment as to how this synergy will be developed. Can the government solve this alone? Renaissance, reform and progress over the past 300 years have relied on this basic fact: the health of the people is the responsibility of the Government, and almost the sole source of its legitimacy. The government that is of, by and for the people, and does not see itself as an adversarial and managerial class, of the rulers vs the ruled/administered, will not have any objection to proclaiming that it can address this need, and if necessary, alone. This was most vehemently asserted by Virchow, as the famous truism that “Medicine is a social science, and politics nothing but medicine at a larger scale.” As a society, and a polity, we have to decide whether we see medical care as a business opportunity, or as a public, common good. The increasing participation of the private sector is critical, as it allows some economy of scale and efficiency. In most parts of the world, healthcare is one of the most closely supervised and regulated sectors; and the private sector does conform to these rules. These rules have evolved over a few centuries, on a background of social transformation. Third World countries (as India now finds itself labeled as) seldom have such a history, and access and regulation can thus be quite disorganized. It is often suggested that competition is necessary for growth. This adage may be difficult to envisage in medicine: lives and illnesses cannot be subject to competitive methods, but rather benefit from equal methods. Also, competition requires a level playing field. State investment in health care delivery has remained static over decades, and many public Institutions have been allowed to be run to the ground. Whether they provide competition to the private sector, or a walk-over, is thus debatable. Unfortunately, health care is now often being considered as a business and a tourism sector. Medical education has been effectively privatized, as has most critical, as well as long term care. Access to care is constrained by paying capacity, and medical expenses are a major cause for indebtedness in the poor. The whole pattern seems to follow the misanthropic slogan “from each (patient) according to their capacity; to each (component of medical care) according to their greed”. What is the role of the pharmaceutical industry in India in mental health – partners or predators? Can we even frame it like that? This is a complex issue. Pharma is essential for delivering health care.The knowledge base on which this is based is incremental, but basically derived from a backdrop of the ‘knowledge commons’. Indian chemical industry established itself in the early part of the 20th century, when assertion of scientific and industrial self-reliance was strongly encouraged. Relying on the early success, India developed a strong base in chemical manufacturing. The lack of integrated R&D and industry, and the asymmetry of knowledge and opportunities in the post-colonial systems, has meant that many skilled processes are never transferred to the Third World. India could achieve relative self-reliance in this field. Over the last few decades, however, the shutting down of almost all public sector pharmaceutical units (IDPL declared a ‘sick company’, Hindustan Organics almost the same, shutdown of most government vaccine production labs) and dismantling of controls, has resulted in a re-emergence of dependence. Global trends in manufacturing make other sources, China, for example, provide even cheaper basic drugs while the drugs emerging from new research, especially for NCD, are now very expensive. The recent price control order has kept business interests in mind, and costs will rise. Surprisingly, almost none of the drugs used in psychiatric care are part of the essential drug list. So it is not just the pharma ‘industry’ but the whole process of planning for health care. Drug manufacturer and pricing is regulated by the petroleum and chemicals industry, taxes and dumping issues by commerce ministry/industry while use is by health ministry. Little effort is made to co-ordinate or plan for a systemic response, including innovation and manufacture, to current and projected needs for various pharmaceuticals. What level of research is being done in India in the pharma sector ? I am not very sure. There are pharma research labs in the industries, but these seem more as a visible adherence to the letter (of the rules), rather than in spirit. Academic research does go on. But historically there has been a gap in India between the bench and the work-floor as well as bench to bedside, and the situation persists. For example Astra, which was one of the few companies that had a research lab for infectious diseases in India, just shut shop. MNCs are buying up many companies, but whether they will invest in research here is not known at present. What impact does adherenceto World Trade organization (WTO) patent laws have on costs of health care also needs to be kept in mind. India has insisted on specific safeguards, and the Supreme Court stepped in to fix prices a few years to insist (to the effect) that if patents have been granted, the drug HAS to be manufactured failing which the patent would lapse. More pertinently, it is increasingly recognized that a large proportion of leads for new drugs actually emerge from public-funded research in the ‘academic’ sector. And the almost extortionate cost of medical formulations is unsustainable. What are the first signs that a person may be in need of mental care? There are many symptoms that point to this. In general, feeling or behaving differently from one’s usual pattern; changes in sleep, appetite, weight for no apparent reason for more than a few days or weeks; or a subjective sense of anxiety, depression, irritability, difficulty in concentration are some of the early symptoms. Individuals may appear pre-occupied, develop unusual behaviours (talking or gesticulating when alone, repeating words or actions over and over, being suspicious or hostile for no reason, inexplicable mood swings etc. ) and in general, appear transformed from their usual selves. In addition to this, self-control and awareness of use and abuse of various things (from nicotine to alcohol and drugs; internet; gambling; etc) needs to be kept in mind. In special populations (children/elderly), a more careful watchfulness by people around them, for similar symptoms as mentioned above, may be necessary, as they may not be able to communicate their symptoms as well. How can families cope with denial that one of them may need assistance? Denial of the illness itself is occasionally a protective reflex to prevent explicit awareness, which would come with the baggage of stigma, and also powerlessness (as the family may not have the resources to treat). Or denial of the causes (as often happens with chronic stress leading to depression; or acute trauma giving rise to symptoms). Basically, they need encouragement, and acceptance. And assurance that help is available. Most families are comfortable once the initial hesitation has been overcome, especially when they realize that treatments work. What percentage of the Indian population is in need of some form of assistance in mental health? This is a complex issue. The ones most in need are those with severe mental illness. These illnesses begin early in life, and quite often require prolonged drug treatment and social interventions. Over a lifetime, these are the most expensive, both in monetary and social consequences. Since treatment for these rests on drug treatment, ensuring availability of treatment, monitoring its effectiveness and timely assistances for periods of crisis is essential. These disorders (psychoses/severe mood disorders) will be experienced by almost 2% of the population in their lifetime, so in India we can expect about 20 million patients. A significant proportion (upto a third) may require several months, or even years in protected living arrangements, as they may not be able to be independent. There are other disorders such as addiction/depression, anxiety and related syndromes; childhood disorders such as learning disability, autism etc; and increasingly issues with the elderly such as dementia or depression that may occur, independently or related to other NCD. Combining all this, about 6-8% of the population may need some kind of help. Is community health the way forward? All health care is community health. Hospitals, research laboratories, specialist Institutes are as much part of the community and civic life as are Asha workers and PHC’s. Creating a sharp division between these services is illogical and disruptive. Health care has to be tiered keeping both disease parameters, and social conditions in mind. There is no one-size- fits-all approach. We thus need to develop services that extend from brick-and-mortar institutions to social welfare and human interaction based institutions. Whatever it is, it needs to be institutionalized and made predictable, reliable, accessible and affordable. So that people know that if they have a problem, they will get all the necessary help in an equitable way. This is achieved in other parts of the world by continuous training, supervision, participatory audits and public awareness. Community health models need to be strongly encouraged, and provided with institutional support. By itself, as a standalone, it may not be enough. In essence, this depends on the social matrix under which care is being provided. Under the capitalist/competitive and health as a business models as in the USA there is no role for the social community in the provision of health care (as Margaret Thatcher commented: there is no such thing as society). If medicine as seen as a social good and a democratic right: then all medicine is community medicine. This is thus a political choice, and not a ‘technical’ medical decision. Too often, specialists, either in the clinic, or experts in community health, who are specialists in their own way, decide on this. But both are equally distant from health care that is both participatory and democratically owned. *Read about the Nobel Prize here

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