Blog by Dr. Migita D’cruz
The novel coronavirus pandemic has been called the great equalizer or leveller of society. The grim reality, however, is that it is anything but that. The global response to the pandemic has accentuated, if not exacerbated existing social inequities and one of the corollaries to this is compromised mental health. India, a country with wide and glaring social inequities, even prior to the pandemic, appears to have become further unequal now.
In 2004, the World Health Organization defined mental health as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. They defined the social determinants of mental health (SDH) in 2011 as the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.
Oxfam India has noted that healthcare is a luxury in India, with 63 million people being pushed into poverty each year due to health care costs—2 every second. If healthcare is a luxury, mental healthcare is even more so for the country. This is despite the 2016 National Mental Health Survey 2016 reporting a lifetime prevalence of 13.7% for any mental illness and the Global Burden of Disease Survey 2010 noting that mental illnesses in the country contributed to 31% of the years lived with a disability. With 80% of healthcare in India being delivered by the private sector, the affordability of mental healthcare has always been a challenge. Income has been the most commonly identified cause of inequity in healthcare in the country (61.2%) followed by education (45.4%) and gender (36.1%). The implications of this are healthcare in general and mental healthcare in particular are less accessible to people with lower income and education levels and to women. Research on mental health inequity is a low priority, accounting for only 4.5% of all published Indian research between 1990 and 2016. The magnitude of social inequity’s contribution to the mental health burden in India remains unquantified.
The COVID-19 pandemic and the global/national response to the same has served to heighten and accentuate social inequity in India. Reports of income, gender, rural-urban, communal and caste inequity in the country have increased. Estimates indicate that poverty is likely to double Between 70% and 93% of the total workforce in the country is unorganized and made up predominantly of migrant labourers—the worst hit by the pandemic. India is staring at an unprecedented migrant crisis, the scale and magnitude of which was last seen during the Partition in 1947. The International Labour Organization reports 400 million informal workers in India will be pushed into poverty due to COVID-19. Schools have shut down and education has been digitised. Yet, only 21.3% of students in government schools (private schooling in India is a marker of socio-economic privilege) had access to computers in 2018.
How does the increase in social inequity affect mental healthcare? Poverty, unemployment, homelessness, starvation and other forms of deprivation are psychosocial stressors that increase the vulnerability to all forms of mental illness, from depression and anxiety to substance use disorders, bipolar disorders and schizophrenia. Age-, gender-, caste-, religion- and ethnicity-based stigma and discrimination mean that the mental health of minority communities is disproportionately affected. Preliminary reports in March 2020 from a survey by the Indian Psychiatric Society reports a 20% increase in reports of mental illness during the nationwide lockdown. Prohibition on the sale of alcohol during the initial stages of the lockdown resulted in a doubling of the number of people presenting in complicated withdrawal in the initial phases of the lockdown.
Simultaneously, access to mental healthcare is also disproportionately affected. Government hospitals in India have shut down elective services including out-patient consultation, psychotherapy, psychiatric social work, elective admissions and electroconvulsive therapy (ECT) for 2 ½ months during the lockdown period. Patients below the poverty line (BPL) who access free or subsidized care from government hospitals have run out of psychotropic medication they cannot otherwise afford during this period, with increase in drug discontinuation and related relapses. Visits to mental health centres have dropped between 20% and 50% – another indicator of a barrier to mental healthcare. Among consumers, women, older adults and rural dwellers find it harder to access mental healthcare due to constraints. The mental health gap in India (between what is urgently needed and what is available to reduce the burden of mental illness), which was as high as 83% in 2016, has clearly increased.
Tele-psychiatry has been offered as a solution. However, despite the 50% increase in internet consumption since 2011, the National Digital Literacy Mission estimates digital illiteracy in India may be as high as 90%. Only 22% of mobile phone users utilize the internet on their phones. Tele-psychiatry therefore, is least available where most needed and only serves to heighten inequity.
If things are to change (and they must), remodelling mental healthcare to allow door delivery of free medication for the BPL population and targeted interventions for vulnerable populations are necessary. There is little mental health care can achieve without social security and equity.
References:
- Singh O P. Mental health of migrant labourers in COVID-19 pandemic and lockdown: Challenges ahead. Indian J Psychiatry 2020; 62:233-4
- Andrade C. COVID-19 and lockdown: Delayed effects on health. Indian J Psychiatry 2020; 62:247-9
- Balarajan Y, Selvaraj S, Subramanian SV. Health care and equity in India. The Lancet. 2011 Feb 5;377(9764):505–15
Dr. Migita D’cruz is a psychiatrist currently training as a resident doctor in geriatric psychiatry at the National Institute of Mental Health and Neuro Sciences in India. She was the recipient of the Young Bioethicist of the Year Award by the Forum for Medical Ethics, India in 2019.