Oldest, but is it the best?

The IMH could be a model mental health institution for the country. But, why has it not matched the expectations? GOUTAM GHOSH analyses the functioning of the 200-year old hospital.

FROM THE outside, the Institute of Mental Health (IMH), Kilpauk, Chennai does not give a clue to the life of its in-patients. The 63-acre hospital, that was started in 1794 as a private home for the mentally ill among the privileged European community, has well spaced but nearly 200-year-old buildings and huge trees that offer respite from a scorching sun.

The IMH could become a model mental hospital. But the care for the mentally ill patients in the IMH today cannot be stated to be the best in the country. That is not just a result of a low budget. Funds matter but money alone is not enough. The crucial input is attitude &151; of the health professionals and the ward- level staff who deal with the patients. Taking care of the mentally ill is not just another job for a salary. It involves a commitment. That zeal matters has been proved by the SCARF in Chennai, Shrishti in Madurai and more recently, The Banyan in Chennai.

Many patients who have been in the IMH for decades loiter around and accost relatives of other patients for food, cash or cigarettes. The dehumanisation seems complete when you find a patient diving for a cigarette butt before it is crushed under the sole. Clad in ill-fitting green shirts and shorts, often kept in place with a knot because none sews the missing buttons, these men do their assigned duties, despite the visible, and often debilitating side-effects of the drugs.

Why do these men beg in the hospital? Because, according to some patients, the hospital diet is so insipid and so inadequate, that one cannot overcome the urge to hunt for a change. The average cost of maintaining a patient was stated to be Rs.121.80 a day in 1999 by a National Institute of Mental Health and Neuro Sciences (NIMHANS) team from Bangalore which studied all the Government mental hospitals in the country and submitted its report &151; ``Quality Assurance in Mental Health'' (QAMH) &151; to the National Human Rights Commission, New Delhi.

Not all the patients toss their dignity into the trash can. But some who are reduced to total helplessness by a debilitating mental illness &151; and you will find a host of definitions, ranging from F00 to F99, under the International Classification of Diseases (cf. ``Psychiatry'', A. Venkoba Rao and K. Kuruvilla) &151; and a hopelessness because they have to live in this pitcher plant-like mental institution, dumped probably because they were unmanageable physically, emotionally or financially.

Even the mentally ill master the techniques of survival and learn the price of unstated benefits. So it was no surprise to find a patient cleaning an IMH staff member's motorcycle. Dr. Mohan Isaac of NIMHANS later explained in Bangalore that rehabilitation has occupational therapy as an important component and the bike cleaning could be seen as a form of therapy.

But occupational therapy is a group activity. Cleaning the bike is a one-to-one correspondence between a patient and a care giver -- either for some direct favour or to avoid some form of abuse. The patients are helplessly dependent on the care givers for everything, and must do whatever they are asked to. Any presumption, that the action is beneficial to the patient because it raises his self-esteem, will be unsustainable because there is a pay-off, whatever its form.

The IMH campus not only has a high, 12 foot wall but its wards are miniature jails within, each with high walls and huge steel- barred doors. Patients are counted every evening. This is no different from a head count in a prison. Add to this the green uniform that all men patients have to wear for easy identification and the picture of custody, where personal freedom is compromised, is complete.

The bias of the system against the in-patients will be obvious when you consider that out of an annual budget which remained static at Rs.8 crores between 1992-96, 35 per cent went as salaries for 796 staff members (Rs.280 lakhs), only 10 per cent on diet (Rs.80 lakhs) and 1.25 per cent on medicines (Rs.10 lakhs) (QAMH, pg 278).

As there are 1,600 in-patients on an average everyday (more now after the addition of those from Erwadi), the monthly average is Rs.416 for each patient's food, whereas a staff member draws an average monthly salary of Rs.2931. So the daily allocation on diet is an abysmal Rs.13.86 that covers the cost of breakfast, lunch and dinner. A bottle of mineral water could cost more.

If you add the three classes of diet, you will find that the reality is worse. The diet of a patient in the general class is worth Rs. 5 a day. You can barely get two cups of coffee with that money from a roadside tea shop. The abysmal allocation on food also explains why many patients are willing to compromise on their dignity by begging those who bring food for their hospitalised kith and kin.

The attempts to assess the condition of the patients, particularly the 152 who had been sent to the IMH from Erwadi, were stonewalled because the director, Dr. B. Sivachidambaram, refused to allow access to the wards to meet these people. Given that some of these patients had shared their views in Erwadi, there was every reason to find out how they felt in the IMH and whether their kith and kin visited them after they were admitted. These questions remain unanswered. The larger issue is, why should a visit to the wards be denied unless the hospital had something to hide?

It is not that all the services are poor at the IMH. The occupational therapy unit seems to be managed well. The de- addiction ward seems to work well and patients and their relatives seemed to be happy. One addict, who said he no longer needed brown sugar, stated that water was a main problem at the IMH and he had to carry water from a far-away tap for his needs every morning. The Kilpauk Water Works is less than 400m away.

The women's ward is less crowded, but sad tales abound. There is a tribal woman from the Santhal Parganas who has been here for more than seven years after she was found in the Chennai Central Station. She does not know any language other than Santhali. Attempts to send her back home were not successful as no woman was found who could take her to Purulia. The hospital and some individuals tried, but without success. She is not given any drug but enjoys the hospitality of the State, albeit in its mental hospital.

Trainees from city colleges provide some relief at times. Viji and Divakar Chandran, occupational therapy students of SRM College, were recently seen trying to get a patient to give his best. ``The idea is to assess his disability,'' they said. Their thoroughness and sincerity were impressive. One only hoped they would retain their zeal after they graduated.

It is not without reason that the ``Quality Assurance in Mental Health 1999'' highlighted that ``many of the outdated buildings need to be demolished,'' ``walls to be lowered. Prison like gates to enclosures must be removed,'' ``living condition, toilets, privacy, personal appearance need to be paid immediate attention,'' ``the attendants need to be trained, sensitised...'' ``more doctors to be available after 2 p.m.,'' among other suggestions to improve the IMH.

It is human to be sensitive to the systemic flaws when one heads the system, but unless the doors are opened to all, the possibility of making the IMH a model institution for the rest of the country will remain nullified forever.

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