In a 2016 Lancet Global Health study, suicide was found to be the leading cause of deaths among young people in India. In the following year, India enacted the National Mental Healthcare Act, “to provide for mental healthcare and services for persons with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental healthcare and services.”
Yet, India’s mental health crisis is still rife, and it is time for a change.
Mariwala Health Initiative (MHI) is a mental health advocacy and funding agency which aims at making mental health accessible to marginalised groups in India. Their motivation is to create a “big picture of mental health”, away from narrow medicalised views, and towards “more inclusive, holistic, and empathetic practices”.
Its director is Raj Mariwala, board advisor for BluePrint Group – a global joint advocacy and learning coalition on mental health, as well as for Lancet Commission on Stigma and Discrimination. Moreover, she is a board member of Parcham – a nonprofit serving adolescent girls through sports.
In this interview, Mariwala shares with me the story and influences behind MHI, and gives her views on the mental health situation in India as it stands, and how she sees it evolving.
What was the journey like that led you to working on this initiative?
As a family, we had already discussed that disproportionate accumulation of wealth and assets was problematic, and so the question of how to do philanthropy. I suggested mental health since I have been interested, passionate about and been able to access mental health for myself.
We knew physical health received much attention but mental health was invisible in these conversations. So, it was one of the areas under consideration, and our initial research was insight-gaining exercises with stakeholders such as psychologists, counsellors, and mental health service users.
So, we identified that mental health that was underrepresented, under-funded, and underserved. As mental health faces the issue of accessibility and this is anywhere in the world – whether it’s a developed country or a LMIC – we decided to focus on mental health for marginalised communities and groups. My co-author and I detail this process in MHI’s journal ReFrame: Funding Mental Health.
Your slogan is ‘Crucial Conversations, Important Interventions’. What do you think are the most crucial conversations, and the most important interventions, we need to be having?
Dominant narratives around mental health are expert-led, biomedical and rooted in Western discourse and practise. The emphasis tends to be on individual cure and recovery. In our view, a paradigm shift in the conversation is called for: from prescriptive and paternalistic to perspective-oriented and intersectional. To work towards mental health for all, we need to talk beyond the treatment gap or anti-stigma. Anti-discrimination, human rights and socio-political contexts are important. Additionally, it is critical to widen the scope for participation in these crucial conversations to not just the binary of expert/user-survivor but to persons who have lived realities of marginalisation.
We also believe that social justice is inherently connected to mental health. In terms of interventions, access to mental health is an issue everywhere – even in the places that have the highest number of psychiatrists in the world (USA). Thus, the treatment gap, or the focus of interventions needs to be looked at carefully – do we need more highly trained experts? Or do we need better systems of care? Our emphasis on interventions is that when we build interventions for the margins – we can work towards everyone being covered. If you build interventions for the people who are most likely and easily able to access them, you will take a long time to reach the margins.
In a 2016 Lancet Global Health study, suicide was found to be the leading cause of deaths among young people in India. What is your take on this? How has the situation evolved since then?
The positive news is that suicide was decriminalised when the National Mental Healthcare Act was passed in 201. There is no national suicide prevention policy as mandated by MHCA 2017, nor is there any consistent data on suicide in India. For example, young persons from farming families dying by suicide so that their parents are relieved of economic pressure.
However, the discrimination and stigma around suicide have not changed. Young persons in India are likely to face a lack of agency and choice over their lives, hostile education systems and entrance examinations, as well as an incredibly disproportionate focus on academic achievement.
There is also a lack of access to material around sexual health and reproductive health. Young persons from a marginalised caste, religion, gender or sexuality face overt institutional and peer violence as well. Young women are a group particularly affected by suicide due to early arranged marriages, domestic violence, young motherhood and forced economic dependence.
During COVID, there has been a definite worsening of the situation, with young people dying by suicide as they have been unable to access education due to the digital divide, or for example, students dying by suicide due to concerns around a highly competitive entrance examination for medical college being held during COVID. Whether for young people, or marginalised groups, addressing suicide must go beyond the ambit of mental health; it is an intersectoral issue that requires work in the arenas of education, justice, livelihood, food security, housing and mental health.
In 2017, India enacted the National Mental Healthcare Act “to provide for mental healthcare and services for persons with mental illness and to protect, promote and fulfil the rights of such persons during delivery of mental healthcare and services.” – How effectively do you feel this act has been adhered to?
Having the MHCA means that access to mental health care is an enactable right – free and good quality of mental health care to ALL citizens, with or without below-poverty-line proof. It also mentions making psychiatric medication available for free state-run facilities. There are some important provisions that are critical, such as state mental health authorities and mental health review boards that remain to be set up.
The MHCA mandates a national suicide prevention policy as well, which remains uninitiated. There are some provisions which I am personally excited by, such as Advance Directives and the right to a Nominated Representative. However, policies do not work if they remain unimplemented, which is the current state of affairs.
MHI fully funds a program by the Centre for Mental Health Law and Policy which provides training to stakeholders like lawyers, mental health professionals, social workers and the judiciary on the MHCA. For some states like Chhattisgarh and Gujarat, they have been open to and thus received training on the MHCA for multiple arms of government and judiciary. The most recent development is an #MHCA e-Legal Support Unit in Chhattisgarh, in collaboration with Directorate of Health Service to provide remote guidance & support to stakeholders for legal queries on the implementation of the Mental Healthcare Act.
According to the WHO, the economic loss to the Indian economy caused by a mental health crisis was estimated more than $1 trillion between 2012 and 2030. Why do you think government officials still only spend a very small proportion of their healthcare budget in this area?
I think it is not just the government – mental health is underfunded by CSR, by philanthropy. Mental health hasn’t received coverage like physical health has and also doesn’t lend itself to ‘bright photo-ops’ that may be beneficial to political careers. Further, it is not just the Indian government – Mental illness contributes to 31% of the impact of global diseases but receives 1% or less funding from national health budgets worldwide.
In 2019, we attempted a campaign called Bridge The Care Gap that called upon citizens to say that government action on mental health mattered to their vote. Suffice to say, we have not managed to garner the political will to take action on mental health in an intersectoral, rights-based manner, nor to fully implement the MHCA 2017 in letter and spirit.
If you were able to give Prime Minister Narendra Modi any advice for how to better tackle mental health issues in India, what might you suggest?
He has his work cut out, and a blueprint for action readily available in MHCA 2017 as well as the National Mental Health Plan (NMHP). By law, the government is accountable to provide access to mental health, so starting to fulfil these responsibilities would be some excellent initial steps.
Despite the availability of these laws and policies, to make mental health invisible is to be complicit in the structural oppression that affects mental health. Finally, any steps on mental health taken by the government should be guided by the credo – nothing about us, without us and not take any steps without consultations with persons with mental illness and marginalised communities.
What is the mental health situation like in your country? How have you seen it evolving over time? Leave a comment below or send me a message