Mumbai, mental health legislation and a considerable number of cows

Like most years, 2018 brought all kinds of changes and events. But for me, the highlight was another trip to India, a country of which I simply do not tire.

Mumbai airport is a microcosm of India itself: Thronged, bustling and very loud. Soldiers with guns are everywhere, glaring ferociously at travellers one moment, smiling benignly at children the next. Taxi drivers throng the doorways, money exchangers vie for attention, and the traffic outside is as thunderous as it is chaotic.

India is huge and Mumbai is its most populous city, with over 12 million people in the city itself and 21 million in its metropolitan area. Arriving in India is always a culture shock but it is a very welcome one. India overflows with colour, life and contradiction where great beauty and great wealth exist alongside squalor and unimaginable poverty.

And then there are the cows. Mostly scrawny and unkempt, sacred cows drift about the place, utterly unfazed by the traffic, the continuous honking of car horns, and the general chaos. But it’s not real chaos, of course. A traffic intersection in India is an intricate feat of mutual adjustment and interaction, as dozens of people alter their trajectories and speeds very, very subtly based on the trajectories and speeds of others, leaving just millimetres and milliseconds to spare between them.

The newspapers in India, even the English-language ones, are always a joy. The Times of India reports that Diwali, the annual Hindu festival of lights that is roughly the equivalent of Christmas, was less noisy in Mumbai in 2018 than it was previously and produced less pollution. Elsewhere in the newspaper, readers are urged to switch to natural gas: ‘If you care, change the air.’

We’ve travelled to India again as a part of a research project looking at India’s new Mental Healthcare Act, 2017, which was commenced on 29 May 2018 and seeks to comply with the United Nations (UN) Convention on the Rights of Persons with Disabilities. The new legislation grants a legally-binding right to mental healthcare to India’s population of over 1.3 billion people, which is one-sixth of the planet’s population. The Act also provides a new definition of ‘mental illness’, revised consideration of ‘capacity’ in relation to mental healthcare, new ‘advance directives’, governmental authorities to oversee services, mental health review boards, and new admission procedures.

The Act also de facto decriminalises suicide in India, which is an important step forward. (Ireland decriminalised suicide in 1993.) On the day we arrive, The Times of India reports the case of a Mumbai schoolboy who died by suicide after he was suspended from school for allegedly beating-up a classmate. The boy’s parents blamed the school principal and teachers but the High Court concluded that they were not responsible. The Court said that while the suicide was deeply tragic, there was no evidence that school staff abetted or instigated it.

On the same day, the Mumbai Mirror reported that a priest was held by the police for allegedly raping a mentally-ill woman behind a temple in the Behala area of South Kolkata. This story was an especially sad one. The woman had been married in the past but, according to the newspaper, her husband refused to accept her as his wife when he found out that she was mentally ill. This is not an uncommon occurrence. The woman then went to live with her sister, who reported the alleged rape. Local residents beat-up the accused priest before handing him over to the police. This, again, is not uncommon in parts of India.

Despite these kinds of problems and the poverty that blights so much of the country, India is still a fascinating place, bursting with life, promise and innovation. The news media are full of enthusiastic reports about economic success, endless accounts of social initiatives, and many, many articles on health and lifestyle themes. Even the serious-sounding Economic Times has a lovely column titled ‘The Speaking Tree’, with advice about what to do when you’re feeling lonely, alongside other, similar pieces.

And, of course, India’s new mental health legislation is also a big step forward, even if its ambition likely exceeds what is possible in the short-term. The many challenges include resourcing both mental health services and the new oversight structures proposed in the Act, and adjustment to the increasingly legalised approach to care outlined in the legislation. Particular concerns include potentially lengthy judicial proceedings and possible paradoxical effects of the legislation resulting in potential barriers to care, such as revised licensing requirements for general hospital psychiatry units. There is also ongoing controversy about specific measures, such as the ban on electroconvulsive therapy (ECT) without muscle relaxants and anaesthesia.

Despite these challenges, India’s new legislation clearly offers substantial potential benefits, not only to India but also, by example, to other countries that seek to align their laws with the UN Convention on the Rights of Persons with Disabilities (which Ireland has ratified). Ultimately, all of these measures aim to improve the position of the mentally ill, enhance services and improve quality-of-life.

Hopefully 2019 will see further progress in these areas. These problems occur in all countries, and all countries still have plenty of room for improvement. Happy New Year.