By Glenn C. Kharkongor
“In 2019, 1 in 8 people, or 970 million people worldwide, lived with a mental disorder, with anxiety and depressive disorders being the most common. The prevalence of mental illness is highest in the 25-34 age group and suicides are highest among 15-29 year olds.
Many health workers, including doctors, are concerned about mental health. They would prefer to focus on physical and physiological medicine, leaving mental illness outside the discipline. Of course, there are admirable people and organizations that are directly involved with mental illness. The initiative to forge a mental health policy by the state government health department is highly recommended.
One can comment on the process and content of the draft and some of that will be covered in this article. But health professionals and civil society must offer a constructive and positive approach. The health department is one of the few well-functioning departments in the state. It is run by trained officers, who steered the state through the covid pandemic efficiently and effectively, despite inherent obstacles and pockets of resistance.
The Covid crisis in mental illness
Even before Covid, the burden of mental health outweighed all other illnesses. In 2019, 1 in 8 people, or 970 million people worldwide, were living with a mental disorder, with anxiety and depression disorders being the most common. The prevalence of mental illness is highest in the 25-34 year old age group and suicides are highest among 15-29 year olds. Nearly 200 million Indians (14%) suffer from a mental disorder. A DALY (Disability Adjusted Life Year) represents the loss of one year’s worth of full health. India has one of the highest DALY rates for mental illness in the world.
The number of people living with anxiety disorders and depression has increased significantly due to the COVID-19 pandemic. Initial estimates show an increase in depression by 40-60% and a 28% increase in anxiety. There has been an increase in mental illness among vulnerable groups such as youth, people with disabilities, healthcare workers, and LGBTQIA+. Domestic and child abuse has increased. According to the WHO, “the world is failing in our duty to care for mental illness and the well-being of health workers.”
Focus on necessary mental health
Unfortunately, the Mental Health Act of 2017 only has a definition of mental illness, but does not contain a definition of mental health. Thus, a focus on illness is maintained and provisions are activated only after a mental illness occurs. A higher priority is ensuring mental health and well-being.
The WHO has a comprehensive definition of mental health that says “it is of vital importance to everyone, everywhere, and goes beyond the mere absence of a mental health condition. It is an integral part of wellness, as it enables people to develop their full potential, show resilience in the face of adversity, be productive in the diverse settings of daily life, form meaningful relationships, and contribute to their communities. Interrelated physical, psychological, social, cultural, spiritual and other factors contribute to mental health, and there are inseparable links between mental and physical health. The promotion and protection of mental health is also essential for the proper functioning of a society. It fosters social capital and solidarity, which are essential in times of crisis”.
culture and mental illness
The WHO definition of health focuses on physical, mental and social well-being, and its definition of mental health includes cultural factors, stating that culture is inseparable from mental health. Current health systems focus primarily on physical health. Mental health is not given the importance it deserves and social health is almost never mentioned. Along the way, the role of culture in social and mental health has been neglected.
The word “culture” is mentioned 84 times in the draft policy. The word is often shortened to a buzzword or to give a modern veneer to an academic or government narrative. There are no details in the draft policy, just vague ideas. Outside of the arts and culture department, the word is not on the radar. Even in the health sciences, culture is rarely studied as a significant factor in health.
The International Classification of Diseases (ICD) issued by the WHO in 2016 includes a section titled “culture-specific disorders” and has recommended that mental health professionals include a separate category for cultural syndromes. The ICD has already included 20 such diseases from around the world in an annex, one of which is a disease from India called ‘dhatu’.
The Diagnostic Statistical Manual (DSM) is the official manual of psychiatric disorders published in 2013 by the American Psychiatric Association (APA). Includes a table of more than eighty mental disorders with cultural issues. The APA recommends that a culture-related interview be included, relating the context and the patient’s social and cultural history, to arrive at a correct diagnosis. The DSM describes the entities of “culture-bound syndromes”, “popular diseases” and “culture-specific disorders”.
All tribes and even other ethnic groups have cultural diseases. Examples of these among the Khasi-Jaintian tribes are “thlen”, “taro” and “niangsohpet”. These illnesses are based on belief systems, which may have spiritual dimensions, and discussion of these illnesses should be treated with sensitivity. The fact is that these diseases are prevalent in our society and have physical and mental symptoms, and as such they need to be included in the health discourse.
The WHO recommends the inclusion of traditional healers in a pluralistic health strategy. The report on Tribal Health in India, 2018, issued jointly by the Ministry of Health and the Ministry of Tribal Affairs, recommended the study, documentation of health traditions and traditional medicines of different tribes. Another important recommendation is to integrate tribal doctors into primary health care.
Traditional Khasi and Garo medicine is used by most of the tribal population and is believed to be effective. It is also accessible and affordable. Unfortunately, the ten thousand healers in our state have no official status and their services are not supported by policies or schemes. They can be integrated into the health system to provide both traditional and modern health services.
The Khasi Traditional Medicine Protection and Promotion Act was passed by the KHADC in 2011 and signed by the Governor. It has four main features: the registration of traditional healers, the establishment of a training institute, the establishment of medicinal plant sanctuaries, and the protection of intellectual property rights. Unfortunately, there has been little progress in implementation.
Research
Mental health policy must contemplate specific areas of research. There are two major focus areas. The first is to investigate the beliefs, attitudes, and behaviors associated with the high birth rate, low contraceptive use, low vaccination rates, and high prevalence of oral cancer seen in Meghalaya. The second area of study would look at cultural factors and cultural illnesses.
In anthropology, the term liminality literally means the ambiguity or disorientation that occurs in the middle stage of rituals. In a broader sense, it indicates the transition stage of a tribe that is on the threshold between its previous way of structuring its identity, beliefs and traditions, and the new way of thinking, values and behaviors. Our tribes in Meghalaya are at that crossroads in their ongoing evolution and our restless engagement with traditional cultural beliefs is an example of this liminality. In this transition we have to reevaluate these things, without losing our roots.
One final review
I suggest that the draft policy be reviewed by a committee of experts from various stakeholder groups, especially those with cultural backgrounds, which outsiders will not be able to understand. The implementation plan should include specific contributions from various stakeholders, especially those from civil society and educational institutions. There should be annual reports and reviews by stakeholders.
Mental health must be integrated into general health. Continuing to focus separately on mental illness or even mental health invokes stigma. We have moved away from words like “crazy,” “hysteria,” and “lunatic,” and we must continue the attitudinal journey to see mental health in the holistic context of health and wellness. Those of us who may consider ourselves to be on the front lines of liberated thought still have to lead our fellow tribesmen, with all due respect to traditional beliefs. Especially since these are not unrelated beliefs, but have implications for physical, mental and social health.
“The word “culture” is mentioned 84 times in the draft policy. The word is often shortened to a buzzword or to give a modern veneer to an academic or government narrative. There are no details in the draft policy, just vague ideas. Outside of the arts and culture department, the word is not on the radar.”
