Thursday, January 14, 2010

The Germ of an idea: microhealth

At a meeting today with Dr Rita and Dr Annie, the first germs of an entirely new, community centred, asset based approach to mental care have been cast into fertile soil. I am repressing any premature excitement, but perhaps you can tell by the way I am typing how enthusiastic I am.

The problem: debilitating mental illness and mental impairment is a huge burden in rural India. Let's face it, it's no picnic in the UK, but in India it is catastrophic. According to the WHO only 1% of India's health budget is spent on mental health. There are a puny 3500 psychiatrists in India. By that I am not passing judgement on their stature or relative musculature. Considering there is a lifetime prevalence of 22% of mental illness in a country of 1 billion, 3500 psychiatrists does not go very far. Of course most of those doctors will be in the cities and as already mentioned earlier in the blog, 70% of the country’s population is rural. Mental health in the villages is in a dismal situation: there is quite simply no help.

So starting any mental health program is a gargantuan task. The need is enormous and the resources microscopic. When Dr Rita, Dr Annie and I first spoke about this last year, fresh from the introduction to asset mapping as opposed to needs assessment, we explored the new concept of figuring out how, given that they have absolutely nothing, these people are managing; because somehow, however crappily, they are; like the elderly at Keelalathur before we came along to offer food, who were also somehow managing. They had a life. It probably was not great, but we did not account for any of it and as a result we simply increased dependence.

Dependence in mental health is ruinous for two reasons, firstly it impedes recovery and welfare, secondly, it unleashes the untameable beast of unmeetable need. No health care service can solve the problem of mental illness; it's not like removing footprints from a polished floor. Mental illness is messy, complicated, intrusive, pervasive and, most of all, endemic. In fact, most of all, it is embedded within the lives of individuals and their community. Solutions therefore must necessarily mostly be born from within those communities. Any health care professional who fails to acknowledge that from the start is starting a long journey across a hot desert in a thermal snowsuit with lead weights in his boots. Without water. Or a phone. In other words, it is madness. The astounding thing is that the madness of mental illness is indeed in those very professionals for the idea of actually asking people how they cope is not only incredibly new, but it is not done well: "Ask a mad person how to manage their mental illness? Are you mad? That would be like asking a heart translant patient if they had any hot, new suturing tips." It would appear then, that the idea of starting a project with this concept is new. I’ve researched it and I cannot find anything along these lines. If anyone knows of anything similar I would love to hear of it.

So, the plan: at RUHSA there is an occupational therapy clinic for children with mental impairment. There are some extremely keen mothers who come every week and have already noticed a difference. These mothers have to look after their children 24/7 so there is no time to do any income generating activities. The double whammy of illness and poverty. So the plan is to tap into this keenness and have a training session for these women. Firstly, learn how they manage – effective techniques can be disseminated to others. Secondly, equip them with generic skills for caring such as hygiene, nutrition etc. Add in specific skills for children with learning difficulties and adults with severe and enduring mental health needs. Then, and here is the genius bit, train them to look after more than person. Now send them back to the village with back up from the community staff already in place, such as RUHSA’s Rural Community Officers, family care volunteers, health aids who have been working for the medical care team for the last 30 years, who will now be additionally trained to recognise and destigmatise mental illness in order to identify other families in the village in need. Let the women in their own community persuade other families of the benefit of OT work and then encourage them come for training and then to form co-operatives so that the care burden can be shared. This will allow some women to be relieved of their 24/7 caregiving role to enable them to generate an income which can be shared. As more people benefit, the training programs can become more specialist and directive according to need. It seems to be a win win situation. Serious problems are more likely to be delflected with better care or recognised with increased experience and then can be directed as appropriate to the medical team.

This idea is so simple, I like to call it microhealth because, like microfinance, it draws on the big ideas, but brings them to a simple, manageable practical solution for the individual and leaves the medics to deal with cases which cannot be managed except by medication. The outlay of the mental health system then becomes training plus appropriate, hardcore management rather than getting bogged down by taking on problems indiscriminately; the momentum and power is generated by the community, for itself.

I think you’ll agree, it’s genius in its simplicity, but as I mentioned before, this is just the beginning and the road to make this idea a reality will be long and hard. It will need passion and dedication and effective leadership to make it work: Dr Rita & Dr Annie embody these values.

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