It takes a villageRamesh Rajak was unknowingly acquainted with the night. The 33-year-old resident of Dhobighat would often wake up in the dead of the night and go out for ‘strolls’, disappearing for hours, or worse, days on end. When he was home, he would sit on his concrete terrace for hours, his eyes vacant and staring into the distance.
Ramesh Rajak was unknowingly acquainted with the night. The 33-year-old resident of Dhobighat would often wake up in the dead of the night and go out for ‘strolls’, disappearing for hours, or worse, days on end. When he was home, he would sit on his concrete terrace for hours, his eyes vacant and staring into the distance.
Like many other families in the country dealing with psychiatric illnesses, Rajak’s family, at first, did not immediately peg his odd behaviour to a mental problem. They instead decided to get him married, hoping the companionship would help him. Soon enough, however, his wife began taking note of Rajak’s erratic behaviour too. After one such episode, where her husband went missing yet again, she finally convinced him to go see a doctor. Rajak agreed, but not before being tricked into thinking he was going in to see a physician for a pain in his right hand and not a psychiatrist.
Rajak is currently under medication and rehabilitating at his home. In Nepal, where psychiatric illnesses still remain laden with stigma, his support system is a rare luxury not available to many.
“The debate of mental health [in Nepal] is all centred on a medical approach,” says Gael Robertson, an advisor at Chhahari Nepal—a Patan-based organisation working in the field of mental health. “Many mental problems stem from social issues and this should be dealt with accordingly. Instead of ostracising them, a shared bonding with family members and their reconnection with the society goes a long way. We have felt the difference.”
This might sound like a routine story that every person with a mental ailment goes through; but it is not. According to Robertson, her organisation does have to make concerted efforts to convince family members to take their loved ones back; and team members need to be deployed regularly to constantly interact with and counsel both the patients and their family. Family, she says, plays a crucial role in determining whether the patients are rehabilitated back into the society, or cast adrift forever.
Robertson, in one of her papers for the Institute of Development Studies published in May 2016, writes, that the neglect “is largely due to the stigma associated with mental illness perpetuated by inaccurate information that it is untreatable and the fear that individuals can be violent.” She writes that the afflicted are then forced to suffer in silence and experience daily discrimination and violation of their fundamental human rights, such as being kept in isolation and being mentally and physically abused.
Suresh Khadgi, 33, of Patan, is one of those abused. His long struggle with his mental illness began 15 years ago when he suddenly started hearing noises ringing in his ear—sometimes it would be a loud shriek, at other times just loud, indecipherable rumblings. Khadgi would run towards the noise but he couldn’t ever figure out its source, and would often get lost for days scouring the neighbourhood and the larger city. Disorienting and persistent as the noises were, he did not believe his family and peers when they said that he was the only one hearing them.
By the time doctors diagnosed him with schizophrenia, Khadgi had all but fallen through his many safety nets. If the community had once sympathised with the “boy who heard noises”, as Khadgi’s illness progressively worsened, he was often beaten up for causing a ruckus, while even small kids in the neighbourhood made up games where they would try and scare him by catching him off guard. At the time, even medications had failed to bring him back from the brink.
But, today, things are slowly changing, thanks to his mother who refused to give up on her son. Khadgi now lives with his parents and has constant follow ups with doctors. To add, officials from Chhahari meet up with his parents every week to discuss the various issues regarding Khadgi’s health and his progress. His mother, Keshari, drawing from her experience in dealing with her son, is now also an active advocate of caring the mentally ill patients through a two-pronged approach—where social rehabilitation supplements the administering of medicine.
Why is this approach important?
Dr Jaya Regmee, psychiatrist at Kanti Children’s Hospital, believes that a large part of mental illness stems from the patient’s social structure. “Three conditions—biological, psychological and environmental—amalgamate together and manifest into mental illness. So without adequate social support, it is hard to find a positive treatment outcome,” he said.
Dr Regmee added that the MoH is reviewing the mental health policy which will now prominently include social aspects while providing care for those suffering from mentally illnesses. Though no official data on the number of afflicted is currently available, Mental Hospital Nepal is planning a national mental health survey. Their initial estimates suggest a large section of the population is silently suffering from various degrees of ailments. Regardless, in Nepal, mental health remains a low-priority health issues. The stigma associated to the illness and people’s unwillingness to discuss the issue, particularly when a near and dear one is afflicted, is reflected in the Ministry of Health’s low prioritisation of mental health. Recently, the MoH has begun streamlining mental health issue in its policy and plans, at least on paper. Investments made so far, however, continue to pursue a medical model—which rely solely on medical treatment and care. Few professional counsellors are hired, and even fewer are involved in rehabilitating the patients back into their families and the society at large.
This is what the socio-medical model is attempting to change, not just in Nepal but internationally as well. Even veteran psychiatrists across the globe have been urging to focus more on the social conditions that contribute to or escalate mental ailments. In an article in the British Journal of Psychiatry in 2012, a group of 29 psychiatrists concluded that “psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine.”
It is a paradigm shift that has been a blessing for Suresh Khadgi and his family. After years of investing in purely medical treatments to Khadgi’s schizophrenia, without significant results, their involvement with Chhahari Nepal and a switch to a socio-medical approach, Keshari admits, has been a game changer. “Things are not normal, far from it,” says Keshari, “But Suresh has made such progress. If once many thought that he was a lost cause, today, we at least have reason to hope. Just that in itself is a big leap forward.”
Manish Gautam is health correspondent at The Kathmandu Post. Follow him @manshgautam