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2013 | OriginalPaper | Buchkapitel

25. The Political Economy of Mental Health in India

verfasst von : Anup Dhar, Anjan Chakrabarti, Pratiksha Banerjee

Erschienen in: Development and Sustainability

Verlag: Springer India

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Abstract

This chapter looks at the political economy of mental health in the context of the transition of the Indian state from 'welfare medicine' to 'developmental medicine' to 'neo-liberal medicine' and the transition of the 'discourse on unreason' from unreason being seen as primarily a 'moral problem' to primarily a 'political problem' (where unreason is threat to both self and society) to primarily an 'economic problem' (where unreason leads to loss of productivity and efficiency). The chapter also sees how the political economy of mental health remains torn between 'incitement to discourse' around questions of mental health within the expanding 'circuits of global capital' and acute lack of resources, stigmatization, and ghettoization of unreason outside the circuits. The chapter works at the overdetermination of the axes of the ‘patient’ (which includes experience and suffering), the ‘professional’ (which includes listening, diagnosis, cure, care, and medical education), the ‘service provider’ (which includes public institutions with tertiary, secondary, and primary care delivery systems as also private clinics), and 'industry’ (which includes, on the one hand, circuits of global capital and global markets and, on the other, circuits of local capital and local markets).

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Vorheriges Kapitel HIV Epidemic: Global Response and India’s Policy

Freud (Beyond the Pleasure Principle 1920) understood Fort and Da (German for gone and there) as the dialectic between disappearance and return, absence, and presence. We see the dialectic between ‘whole’ and ‘simple determinations’.

India has a vast pharma market. Approximately, 50 % of the essential medicines that the UNICEF distributes in developing countries come from India. About 75–80 % of all medicines distributed by the International Dispensary Association (IDA) to developing countries are manufactured in India. “The strength of the pharmaceutical industry is evident in the existence of 5,877 manufacturing units in India producing 20,000 formulations under 8,000 branded names. … This rosy picture of the pharmaceutical industry however is reflected neither in availability of drugs for important public health problems nor in the affordability of drugs for domestic users [especially an estimated 649 million people, people below or near the poverty line, most of them not covered by insurance or social security mechanisms]”. Note worthy in this context is the (not-so-secret) connection between on the one hand, the indigenous drug industry and on the other, the space of medical education, research, and the majority of the national pool of psychiatrists. In India, the drug industry through its aggressive marketing mechanism and through a “structure of incentives, enticements and perks” influences even the thinking and practice of psychiatrists; such that the philosophy of suffering-healing come to be colonized by only neurobiological causalities and pharmaceutical remedies; it becomes difficult for most psychiatrists to see anything other than biology-as-causing-suffering and medicine-as-contributing-to-healing; economic-political-cultural causations and psychotherapeutic contributions to healing get severely devalued in Indian hospitals.

However, we do not wish to make this ‘turn to experience’, function “as an all the more seductive ante-room to the psychiatric clinic”, that will in turn intensify ‘psychiatrisation’ (see Parker 2011, p. 34). “What could work [perhaps] is a return—from the perspective of the excluded as resource—not authentic or originary, but appropriate. What could possibly work is an attention to possession as momentary cognizance, a momentary gift of abnormal vision that could help describe the dominant in terms different than its own, as also point to other possibilities” (Achuthan et al. 2007, p. vii).

The question of the procrustean act can also be raised in the context of the question of ‘cultural difference’: “Soltani et al. (2004) caution that ‘diagnostic categories for common mental disorders, usually developed in Western countries, may have limited validity’ in other parts of the world, and Patel et al. (2003) warn that variance in culture and health systems may affect key parameters such as rates of medication adherence” (Knapp et al. 2006).

Laurence Johnson, internet article, “‘I wish to dream’ and Other Possible Effects of the Crypt”.

This is one of the reasons why health systems in low-income countries are poorly equipped to meet the needs of the pediatric, the geriatric, and the adolescent population.

Which is also why we shall deploy suffering as trope for understanding the vicissitudes and complex predicaments of mental disease in India; in that sense, we have a twofold critique of ‘mainstream mental health’: one, premised on the ‘lack of access’ and the other, premised on the 'nature of access'; we thus emphasize, on the one hand, the need to attend to suffering, and on the other, the need to attend to it in a manner that does not pathologize suffering or make attention an ‘adaptationist enterprise’.

In some countries, there is debate about whether learning or intellectual disability (‘mental retardation’ in North American parlance) should be included under mental health.

The highly centralized mental health services of the former Soviet republics were of poor quality, and the monopoly of the Snezhensky school for the training of psychiatrists provided the preconditions for the widespread abuse of psychiatry associated with the Soviet regime (Polubinskaya 2000 as quoted by Knapp et al. 2006).

The paucity of skilled mental health practitioners in low-income countries constitutes a severe resource limitation, a problem exacerbated by the migration of skilled professionals to countries offering better salaries and quality of life. India has a very limited numbers of mental health facilities and professionals (one bed per 40,000 population and three psychiatrists per million).

Differance represents in one turn the moment of difference-differing-deferring. It represents a passive difference already in place as the condition of signification, and an active act of differing, which produces-introduces differences as also deferral as silent, secret, and discreet suspension.

The National Human Rights Commission in India investigated 37 public mental hospitals (which are actually large psychiatric asylums, often colonial relics, starved of funding and decaying since independence) that housed 18,000 people. People were frequently required to sleep on the floor, and in some male wards people were required to urinate and defecate in an open drain. Water availability was a problem in over 70% of the hospitals, resulting in a lack of safe drinking water and washing facilities (National Human Rights Commission of India 1999). The work of Anjali, Kolkata and BapuTrust, Pune on the rights of the 'mentally ill' has further demonstrated the somewhat difficult processes through which the mentally dis-eased go through in state/public health institutions.

“They, these mentally ill vagrants are homeless in the registers of mental hospitals but may well overlap with the ‘missing woman’ records published in newspapers daily. One can imagine that someone is waiting for her somewhere but tragically also imagine that someone is glad to see that she has wandered away into oblivion herself” (Lacroix and Siddiqui 2012).

Iran and Thailand are two countries promoting mental health in primary care settings. WHO's Mental Health Atlas (2005) says that, as far as community care for mental health is concerned, India and south eastern Asia lag behind the rest of the world. We, however, remain a little skeptical of the process of making the primary health center also a mental health care unit. While one can never oppose or detest the possibility of the delivery of mental health care at any level, be it primary, secondary, or tertiary, given the general dearth of mental health services in the country, one still remains wary of the potential slippage of what is thought to be the expansion and deepening of care (and cure) to a paradoxical expansion and deepening of control and surveillance. We hope the District Mental Health programme (DMHP) and mental health care at the primary level indeed becomes care (and cure) and an alleviation of suffering; and not a psychologization and a consequent pathologization of (rural) life hitherto untouched by the mental health apparatus. We hope community mental health indeed becomes mental health for, of, and by the community and not community outposts or microversions of tertiary mental health institutions in rural areas. One thus remains wary of the possibility of what is increasingly becoming a pattern in urban areas or areas hooked to the circuits of global capital, becoming even a minor pattern in rural areas or areas outside the circuits of global capital.

See Zachariah et al. (2010, p. 188) for the new epidemics of the poor: “the poor are also affected by cardiovascular diseases—and that problem is a different one and of greater magnitude. Among the poor, IHD is a result of migration, changes in diet … smoking and urban stress.”

Since the introduction of the National Rural Health Mission (NRHM), some efforts of government to strengthen the public health system in the rural area are observed. However, will it indeed reach the rural poor (apart from the limited space of maternal and child health)?

Marx begins Capital with the following entry point: “The wealth of those societies in which the capitalist mode of production prevails, presents itself as “an immense accumulation of commodities”, its unit being a single commodity. “Our investigation must therefore begin with the analysis of a commodity”. Fair enough as a contingent object of enquiry or origin. Now let us take a look at the second paragraph of Capital: “A commodity is, in the first place, an object outside us, a thing that by its properties satisfies human wants of some sort or another. The nature of such wants, whether, for instance, they spring from the stomach or from fancy, makes no difference. Neither are we here concerned to know how the object satisfies these wants, whether directly as means of subsistence, or indirectly as means of production”. What if political economy also requires an investigation into what Marx had set aside? Is a commodity only an object outside us? Or does it have a life of its own? What if one also needs to look ‘inside us’? What if one needs to turn to the first footnote of Capital: “Desire implies want, it is the appetite of the mind, and as natural as hunger to the body…. The greatest number (of things) have their value from supplying the wants of the mind”. (www.marxists.org).

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Titel: The Political Economy of Mental Health in India
verfasst von: Anup Dhar
Anjan Chakrabarti
Pratiksha Banerjee
Verlag: Springer India
Buch: Development and Sustainability
Print ISBN: 978-81-322-1123-5

Electronic ISBN: 978-81-322-1124-2

Copyright-Jahr: 2013
DOI: https://doi.org/10.1007/978-81-322-1124-2_25