The last man standing: Policy solutions to help the mentally ill destitute

A wandered, mentally ill person provides a mirror to the lacunae that exist in the increasingly sophisticated world of urban psychiatry, reminding us that there are still many regions and communities in India which do not have the basic facilities of psychiatric health care.

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NO one in this world would want to conclude the death of their loved one, who had been missing for a long while. Section 108 of the Indian Evidence Act, for all its practical and legal purposes, defines a stretched-into-infinity never-ending period of seven years of a person being missing, along with attempts at being able to find their missing family member, including a missing police complaint first information report ('FIR'), advertisements, contacting relatives and friends, among other things, having come to naught, to presume that person's death.

Shraddha Rehabilitation Foundation deals with the neglected and shunned elements of human existence – the wandering, mentally ill roadside destitute. And the common scenario which we as psychiatrists at Shraddha face while reuniting the recovered destitute with their families in their 'mufassil' hometowns is that many a times the relatives of the wandered, mentally ill have exhausted all their resources in terms of time, money and reserves of energy to search for their lost relative, and have ended up presuming that they are no more, believing that their loved ones must have succumbed to a natural calamity (an accident or starvation or, as in recent times, the pandemic and the lockdown).

Going beyond this alive-or-dead scenario and adding further dimensions to the picture, many a times the spouses of the missing person have remarried, wills have been made and executed, and assets have been exchanged, merely on the presumption that the missing person is possibly no more.

Completing the complicated grief picture is the all-important emotional aspect of having to believe that their loved one is no more, despite not having clear and certain evidence towards their non-existence, or the presence of a dead body or any witness. This brings us (commenting as professional psychiatrists) to the vexing psychological question as to when does a family stop waiting for the arrival of a loved-but-disappeared, possibly deceased relative, and when does it move on to an actual emotional closure.

All in all, one single disappearance, under the influence of mental illness, of a human being leads to the emotional scarring of the family, the neighbourhood, and often of the entire community, intertwined as communities are, in rural India.

Also read: A Mental Health Crisis As Is: A Fall-Back Plan

Heartrending story or Sanjay Kumar

Against this backdrop was the story of Mr. Sanjay Kumar. He was a B. Sc. final year drop out by education, a native of Patna in Bihar, a husband, a father of two children, a son to elderly parents, and afflicted by a mental illness called schizophrenia. He remained under-treated for eight long years, before tragically and finally wandering away from home under the influence of the illness. This was in 2018.

Although missing for four years, as per his family, Kumar was only rescued from the streets of Kerala on July 17 this year as a dishevelled and disorganised, wandering, mentally ill person, and was shifted to Shraddha in Karjat, Maharashtra on August 8 for further management and rehabilitation. The paradox of human existence being what it is, no one knows where and how he lived for the four years since 2018, including the tumultuous, agonising two years of the COVID pandemic, until Snehalaya, an NGO in Kasargod, Kerala dealing with the roadside destitute, rescued him from a nearby street this year and subsequently, three weeks later, transferred him to our NGO Shraddha, based in Karjat.

Meanwhile, in a parallel universe, in his hometown in Bihar, on June 9, 2020, during the COVID-induced lockdown, local police identified a dead body and suggested to the family of Kumar (which was already psychologically disturbed by his absence) that it could be Sanjay's dead body, basing the claim on some rumours created by some neighbours, that Sanjay had been seen wandering around the place where the body was found. Unaware of the intricacies of law, unable to verify the dead body, and buried and almost defeated by the weight of their own emotional plight and sense of loss, the family succumbed to the presumption that it was indeed his dead body and Kumar was no more. In a grieving state, the innocent family members completed the last rites and even hung a photo of their beloved Sanjay with a respectful traditional garland over it.

This, when the harsh, gut-wrenching truth all along was that Kumar was alive in his own parallel universe created by his own wandering, in a different, unknown region altogether – unnamed, unseen and unheard by anyone. Such is the reality of life for the wandering, mentally ill, roadside destitute on the streets of India.

When Ajay Ransure, a social worker of Shraddha, travelled with Kumar all the way from Mumbai to Bihar, on the auspicious day of Chhath Puja, it was an event of shock and utter miracle for the entire family, who coincidentally had just returned from the religious rituals of the Chhath Puja from the banks of the nearby pond, to see a presumably dead relative alive in full flesh and blood, and in a recovered state, as compared to how he had been when he had wandered away.

Kumar may have been lucky in having a loving and caring father, and non-greedy siblings who did not exploit his rights. The fact remains that the certificates issued by the authorities despite adequate verification could have been misused at any level.

Such are the travesties of justice in terms of basic constitutional human rights.

Also read: Using Empathy to Shatter the Stigma of Mental Illness

 Legislative guarantees

The Mental Healthcare Act, 2017 states that persons with mental illness who are destitute/homeless/living below the poverty line ('BPL') (whether or not in possession of a BPL card) – criteria which each and every wandering, mentally ill roadside destitute fulfils – shall be entitled to mental health services free of charge at all mental health establishments ('MHEs') run or funded by the appropriate government and at other MHEs designated by it. The appropriate government shall ensure that the right to access shall mean that the mental health services are of affordable cost, of good quality (equal to other general health services), available in sufficient quantity, accessible geographically and without discrimination on the basis of gender, sex, religion, culture, caste, class, social or political beliefs, disability or any other basis. 

The same Mental Healthcare Act further states that every person with mental illness shall have a right to live in, be part of and not be segregated from society, and have the right to live with dignity.

And to add teeth to its stature, the same Mental Healthcare Act goes on to add that every officer in-charge of a police station shall have a duty:

(a) To take under protection any person found wandering at large within the limits of the police station whom the officer has reason to believe has mental illness and is incapable of taking care of himself;

(b) Every person taken into protection under the above sub-section shall be taken to the nearest public health establishment not later than 24 hours from the time of being taken into protection, for assessment of the person's healthcare needs; and

(c) In case of a person with mental illness who is homeless or found wandering in the community, an FIR of a missing person shall be lodged at the concerned police station, and the station house officer shall have a duty to trace the family of such person and inform the family about the whereabouts of the person.While appropriate laws are in place, the million-dollar question arises – where are the actual ground-zero shelter homes, where are the actual ground-zero police human resources, and where are the actual ground-zero MHEs? Fellow citizens within our beloved country cry for the facilities, paradoxically already promised and laid down by law. 

Also read: Mental Healthcare Act: issues of intersectionality and stigma need to be addressed 

Actual ground reality

And what is the actual load that we are looking at in our beloved country? In India, there are an estimated 1.8 million homeless individuals. With 50-60 per cent of the homeless being afflicted with mental illness, this works out to about ten lakh. This corroborates with the official statistics from the National Institute of Mental Health and Neuro Sciences, Bengaluru. Whether homelessness causes mental illness or whether mental illness causes the person to wander out from their home are moot, unaddressed questions, but the hard reality remains that ten lakh Indians on the roads have mental illness. Kumar was just one of them.

There must be the remaining 9,99,999 Indians whose families must be in emotional limbo as to when to stop waiting for the arrival of a loved-but-disappeared and possibly deceased relative, and when to move on to an actual, true emotional closure. Add to these their neighbourhoods, their entire village communities and one gets an idea of the emotional holocaust unseen, unheard, unexpressed, un-ventilated and unnamed that exists, associated with this plight of the wandering mentally ill in India. There is no catharsis and there is no closure.

Since individuals with mental illness often do not have a say or a voice even otherwise, and are not considered part of a supposedly healthy and responsible society, events such as wandering out of home and hearth add to the layers of injustice and exploitation of the mentally ill. 

Out of a total health budget for the whole of India of 73,932 crore rupees for the year 2022, a paltry 41.8 crore rupees was allotted to the National Mental Health Program and 555 crore rupees to the two centrally-funded Institutions of Psychiatry. With the government spending 0.81 % of its total health budget on mental health, mental illness in India has been considerably under-invested in, and huge swathes of populations with major mental illness do not have access to psychiatric treatment and may/will eventually wander out of their homes.

Also read: Madness in the State: The PIL addressing Delhi's mental health freefall

The roadmap ahead

Rehabilitation of the wandered, mentally ill roadside destitute is no rocket science, but not a piece of cake either. A system of Rescue – Treat – Recover – Trace – Reunite – Outreach forms a simple roadmap, of reaching the origins of reflection of what is lacking and what needs to be done.

A wandered, mentally ill person provides a mirror to the lacunae that exist in the increasingly sophisticated world of urban psychiatry, reminding us that there are still many regions and communities in India which do not have the basic facilities of psychiatric health care; even if there are, they have a very poor outreach.

When we at Shraddha reunite such recovered wandering mentally-ill patients with their original communities, instead of allowing them to remain unattended on the roads, we reach out to the community, bringing along hope for them that mental illness is a treatable entity and people with mental illness can live a normal life, breaking the shackles of stigma and unawareness.

Had there been better government systems in place, or many more NGOs such as Shraddha and Snehalaya, maybe Kumar could have been rescued, recovered and reunited faster, and the family would not have had to go through such psychological trauma and despair.

To conclude, what is needed are not just laws (which on paper already exist even now); what is needed is a huge awakening of civil society, be it at the government's financial inputs level, be it at the government's physical infrastructural levels, be it at the human resources level (in terms of more psychiatrists, psychiatric social workers, nurses, and trained community volunteers). Each one of us can do a lot.

The private sector can contribute at its own micro, individualistic level, the corporate sector can make mega-contributions, NGOs can do their often selective but effective coordination and outreach to the interiors of India, the pharmaceutical sector can do its bit by giving medicines at low costs, funding agencies can chip in, local executive authorities can do their bit by easing rules to meet priorities, psychiatrists can do a lot (either through admitting the roadside destitute into their nursing homes or by giving free, regular visits to NGOs sheltering the destitute), nursing colleges can do their bit, social work institutes can pitch in by providing socially-minded manpower, youth organisations can add their own infectious, optimistic joie-de-vivre, the news media and social media can spread morale and awareness, international agencies add their might, religious organisations can add their salvation balms, advertising agencies can provide outreach programs, HR development experts their professionalism, corporate social responsibility funders can reach out vide either the NGO branches of individual corporates or vide other ground-zero NGOs, tax exemption schemes can drive contribution incentives, educational institutes can help through consolidation of social foundations, vocational guidance organisations can provide counselling, and employment bureaus can re-direct appropriately suitable applicants.

A huge awakening is required in civil society.

There has to be an ethereal, spiritually-humane Gandhian desire to touch the last man standing, in our individual and collective decision-making processes.

And the last man standing in this case, Kumar truly was, until Shraddha reached out to him and reunited him with his loved ones in Bihar, and which 9,99,999 wandering mentally-ill roadside destitutes are, and remain, until you, me – all of us – reach out and rescue them out of their unnamed, unspoken, unheard non-existence.