“Initially, medicines will be given, and then we need to study the case”: Medicalized perspectives about chronicity and mental health care in Kerala

Abstract

In response to the global call to upscale mental health services in low-­income countries, mental health non-governmental organisations (MHNGOs) have sprung up in Kerala to address mental health needs by partnering with pre-existing locally grown, bottom-up, community-led pain and palliative clinics (PPCs) to increase access to mental health care through task-shifting. The MHNGOs mandate filtering only patients with ‘severe mental disorders’ from low socioeconomic backgrounds for their free services. This eligibility criterion mandated by the MHNGO is ruffling feathers within the palliative clinics that oppose such ­classifications. They believe that suffering cuts across all divisions and should not be discriminated against based on economic background and severity of illnesses. When chronicity and suffering are held universal by the MHNGO and palliative care, respectively, it brings to the fore the enactment of two perspectives of care. Drawing on observations of clinical interactions between patients, MHNGO staff and mental health professionals and interviews with community volunteers of palliative care clinics in Kerala, this paper demonstrates how chronicity narrative promoted by MHNGOs based on biopsychiatric model gains hegemony, whereas the community care model loses traction progressively. The state, caught between these two narratives, frontstages development by submitting its health machinery to the MHNGOs flouting basic medical safety laws in its services to marginalised people like the tribal population. This paper argues that the rising dominance of chronicity narrative in community mental health clinics as well as in popular media discourses evolves out of power relations between the MHNGOs and the palliative clinics.

Keywords:

• Community mental health
• chronicity
• care
• deservingness
• task-shifting

Acknowledgements

We are also thankful to the palliative volunteers and mental health professionals for taking out their valuable time and the reviewers and the editor for their very helpful comments.

Geolocation information

Kerala, India.

Disclosure statement

There are no competing interests to declare. The submitted research was approved by the institutional ethics committee, Indian Institute of Technology Hyderabad, Hyderabad.

Notes

1 See Sax and Lang (2021) for an extensive critical review on the (movement for) global mental health from South and South-East Asia with some chapters exclusively focusing on the tension between western and local forms of mental health practices in India.

2 For a detailed analysis of the density of associational life in Kerala, see John and Chathukulam (2002) and Heller (1996).

3 The community-based palliative care programme launched by Pain and Palliative Care Society in 1993 in Kerala was the first such initiative in a Low- and Middle-Income Country (LAMIC). For additional reading on the current status in palliative care in India, see Rajagopal (2015).

4 ASHAs refers to Accredited Social Health Activists who are literate women drawn from the local community to act as bridges between the government run primary health systems and the community. ASHA becomes the fulcrum for implementation of government run health programmes.

5 This analogy is inspired by Lord Macaulay, a law member in the Governor General’s council who introduced the Indian Education Act 1835 spearheading English education in the colonial (British) India. He envisaged loyalty of Indian people by creating ‘a class of persons Indian in blood and colour, but English in tastes, in opinions, in morals and in intellect’ through imparting English.

6 See Jain and Orr (2016) for a special issue devoted to ‘Ethnographic perspectives in global mental health’

Additional information

Funding

This study was funded by the Ministry of Education, Government of India.