What is 'Pullepady Incident'?
The Hindu reports it as “Boy stabbed to death by neighbour” with details as excerpted below
The police, meanwhile, maintained that Aji had been mentally unstable and added that the exact reason for the attack was yet to be ascertained. “On a complaint from Aji’s mother, about his becoming violent towards her, we had earlier admitted him to a mental hospital at Thrissur. He was released only a week back,” said M.P. Dinesh, Commissioner of Police, Kochi city.However, local people claimed that the accused was addicted to liquor and drugs.
More sensational reporting in the vernacular press went with screaming headlines like “പത്തു വയസ്സുകാരനെ ലഹരിക്ക് അടിമയായ അയൽവാസി റോഡിൽ കൊലപ്പെടുത്തി” (Malayalamanorama); “പത്തു വയസ്സുകാരനെ മയക്കുമരുന്നിന് അടിമയായ മാനസ്സികരോഗി കുത്തി കൊന്നു” (Mangalam) and also the-Times-of India which said “Smarting over insult, man stabs neighbour’s kid 17 times” . The Times adds..
Before admitted at Thrissur health centre for the last time, Aji had reportedly been treated for mental disorder at five different psychiatric institutions across the state for the last 10 years.
In summary the 'Pullepady incident' is one where a 10 year old boy was stabbed repeatedly to death at road side by his neighbour who has drug dependence and possible mental illness. The entire state was gripped with shocking grief after hearing the tragic news.The incident raises issues of dangerousness of the mentally ill, adequacy of their treatment, stigmatizing and sensational aspects of reporting by media.
This write-up shall focus only on matters related to adequacy/inadequacy of treatment aspects of such people in our current mental-health-care system. The following are five observations which is aimed at strengthening (modernising) the mental health service infrastructure as it exits today in Kerala.
1. Role of disasters and untoward incidents in mental-health system reform.
Reform in mental-health system has generally lagged behind the general health-care system. Many reasons like low priority for mental-health in health policy, inability of patients or family caretakers to form pressure-groups to lobby due to illness related stigma and friction among professional groups regarding medical-care vs social-care can be implicated.The general culture of change in our system is also reactive and often forced-from-outside than through internal proactive considerations. A ready testimony to this fact can be seen in the disproportionate influence that incidents like the ‘Erwady incident’, ‘Nirbhaya’ and the more recent furore in Kerala over compromised dignity of suicidal patients; has had on system reform. Therefore it is pertinent that we dwell on any lessons that the ‘Pullepady incident’ can teach us.
2. Need to provide custodial-care services for mental-health and substance-use treatment in every district:
Pullepady is a place in Ernakulam district. This patient has taken treatment in psychiatric institutions (both government and private) in places as far as Thiruvanathapuram, Trissur and Idukki. The last admission, through an order of the district magistrate of Ernakulam was to the government mental health centre Trissur. Facilities for high security wards are probably not available in Ernakulam district to accommodate such admissions which need custodial care. Services for custodial care for mentally ill patients at all district headquarters have to evolve.
3. If families do not have the capacity to take the burden of care after successful inpatient (custodial) care, the system need to start thinking about what alternatives to provide.
Though family-support is a great boon which absorbs most of the responsibilities of after-care after hospital admission, in recent times we are seeing families who have diminished capacity to deal effectively with the care-burden. Tension between the formal service providers and family care givers (informal) are bound to arise in such cases.In this case forced admission of the patient who had created trouble at home was possible because the mother approached the police and the court for getting admission-order (news-report)
ഏറ്റവുമൊടുവിൽ വീട്ടിലെ ഉപദ്രവം സഹിക്കാതെ വന്നപ്പോൾ സിറ്റി പോലീസ്സ് കമ്മിഷണറെ കണ്ട് പരാതി പറഞ്ഞു.
There was tension at time of discharge also as is reported in the news report.
….. ഇയാളെ ഒരു മാസം കഴിഞ്ഞപ്പോൾ കൂട്ടികൊണ്ട് പോകണമെന്ന് ആശുപത്രി അധികൃതർ അറിയിച്ചു. ആരും വന്നിലെങ്കിൽ സ്വന്തം ജാമ്യത്തിൽ വിട്ടയക്കുമെന്ന് പറഞ്ഞു. ഇതെ തുടർന്ന്… കൊണ്ട് വന്നു. വീട്ടിൽ വന്ന ശേഷം മരുന്ന് കഴിക്കുന്നത് അജി പൂർണ്ണമായും നിർത്തിയതായി തങ്കമ്മ പറഞ്ഞു.
This illustrates not only a diminishing capacity among nuclear families to shoulder the burden of care in cases with overwhelming/complex needs, but also a lack of preparedness of the formal care system – which is attuned to care of patients with good family support – to be responsive to needs of such cases. Community based assessment of such patients with models of care delivered by field professionals adopting “case management” has to be developed.
4. Need for facilities for step-down care trough transitional facilities that are based on level of care-needs at the time for discharge.
Discharge planning in our system is predicated on an availability of a secure family support for the patient; who shall take the patient home, supervise drug administration and bring patient for regular follow up. We need to realise that many families in the modern world either do not have such resourcefulness or the needs of the patient are overwhelming to the available resources of the family. The mental hospitals often report that they face difficulty to discharge such patients as current default option available is only discharge-under-care-of-family. In the incident case too the patient who was admitted involuntarily due to violent behaviour at home was also discharged under care of the family after hospital stay. The need has risen for step-down transitional facilities for discharge, supported housing facilities to discharge patients who do not have families to return to.
5. Need to provide community-based after care options.
The mother report that soon after discharge patient stopped medicines. There is currently no formal system in place to inquire about drug adherence after a patient is discharged. Home-visits by dedicated field professionals who could take an ‘assertive’ approach to track patients with little chance of family supervision is a solution from the services-side. Care would have reached this patient if such a system of ‘active’ follow up was made available. Such community based after-care options have to evolve.
(views and opinion are personal)
Based on data collated at the state-nodal office of DMHP (District Mental health Program) of Kerala, this infographic was created. We could infer that training exercises are happening across the length and breadth of Kerala, different class of staff are being trained. It also indicates that it is time to start focusing on assessing the outcome of training exercises. One outcome measure that gauges training of doctors is their ability to run independent mental health clinics in their practices. This is found to be wanting. Also with increasing number of specialist psychiatrists (>400 for a population of 330 lakhs in Kerala), the deficit argument for training of general practitioners to run mental health clinics in Kerala also will have to be revisited.
Disclosure: Data was obtained via RTI query.
Unearthing Omissions and Commissions: The bureaucratic trail of decision making for ‘Day-care’ centers for the mentally ill.
Tracing the bureaucratic trail of the 'Comprehensive mental health program (New Scheme-2013)' of Kerala: A documentary search using RTI inquiry.
Finance Minister K.M. Mani earmarked Rs.20 crore for a new ‘comprehensive mental health programme’ to be executed by NGOs and schools.
A news-report on March, 2013 thus introduces the ‘comprehensive mental health program’ to the larger public. It has a comment by a key functionary of the professional community of psychiatric doctors of the state.
Dr. John, however, appreciated the announcement of a new ‘comprehensive programme.’ He said the NGO, Maithri, had recently launched such a programme in the Kizhakkambalam panchayat with the participation of the panchayat, schools, and social organisations. He said the Kizhakkambalam model could be adopted for the programme and the Rs.20-crore allotted for it could be used for the initiative in about 300 panchayats
The Kerala-state budget document of 2013 (available at http://finance.kerala.gov.in/) echoes what the minister reported to the press.(see relevant excerpt: page 356 below with highlights added).The source of the fund is designated as ACA (Additional Central Assistance), which means this money is provided by the central government directly to the state budget.
The Special working group meeting convened by the additional chief secretary-Finance for the consideration of administrative sanction (See minutes of meeting here and relevant excerpt below) also instructs certain particulars about how this program should be implemented as highlighted in red underlining (see below).
Now let us fast-forward one year to March, 2014 and see this news report which announces the actual roll out of the ‘Day Care Centers’ for the recovered mentally ill in the state.
So what is this write-up about:
One fact that can capture the discerning eye, when we look at all of the above documents in sequence, is that, as the program moves down the implementation pathway, certain aspects get edited out.The multi-disciplinary involvement with the social justice dept or the education dept or the NGOs which were envisioned in the earlier stages, vanishes when it reaches the final news-report on its actual roll out.
How does this happen? Is it due to acts of omission or commission? Specifically at what places in the implementation pathway does this occur? What could be the reasons for it? Let us briefly explore. I try to explicate specifically, the bureaucratic trans-active processes at the decision making level. The relevant textual documents which gets generated in the administrative ‘due-process’ are analysed to throw light on the processes.
(Disclosure: All documents uploaded in this write-up are either in the public domain or have been received by the RTI (Right to Information) method. These documents are at 7 clickable embedded links in the text of this blog which are blue in colour)
We shall proceed by asking certain empirical questions as below.
What model of working for the ‘Day care Centres” have the state level planners envisioned under the ‘comprehensive mental health program’? Was it evidence based? Were there other models which also came for competitive consideration?
As can be seen, it is an over-the-top operational plan which the Health Department submitted for approval. Interestingly in each day care center (2 each for all 14 districts are sanctioned) Rs 4.69 lakhs was set aside for buying 30 “Iron cots”, mattress, pillow cover, and bed sheet! This is patently unscientific (act of commission no 1) and reveals a certain institutional character in thinking, quite unhelpful for planning community based services.Ironically the plan recommends recruiting contract nurses who are retired from mental health centers or have experience in psychiatric hospitals!!
The structure of the plan clearly reflect that the stakeholder consultations were not made. This was specifically asked in an RTI query to the health directorate which gave the reply that consultative meeting involving the social and educational sector or the NGOs were “not convened” and “committee was not formed” and the people involved in formulating the plan for the daycare centers were only “Experts from the health department were psychiatrists from medical college and mental health center and mental health authority” (act of omission no 1).
The minutes of the meeting by the finance secretary which considered the proposal for administrative sanction from the health dept (identified in the document as ‘administrative department forwarding the proposal’) clearly identifies the ‘implementation agency/department’ for the program as “committee with experts (as stipulated in plan write up)”. This ‘plan write up’ is probably what the health dept would have submitted as part of proposal generation before the budget.Though we do not have direct access to this plan write up, the snap shot of page 356 from the final budget document provided in this blog is representative of that.
So, one may infer that fidelity to the ‘plan write up’ was lost when the committees were not formed at the mid-implementation phase. And the submitted operation plan was thought-through by ‘psychiatrists from mental health centre, medical college and mental health authority’. Apparently no meeting was convened (see RTI reply). It is evident that neither the ‘Kirakkambalam model’ nor any other model including the one proposed by the Institute in Kozhikode for a block-panchayat based community action, did get a chance for consideration. (act of commission no.2)
Progress assessment of the functioning of the daycare centers which stated working.
Needless to say, the roll out of the program ran into implementation difficulties. The staff recruited did not know what to do, many patients dropped out, sustainable need for the services in the community could not be generated etc etc.
However in an appraisal done by the department by March 2015, it is reported that 22 daycare centers have started working and the remaining 6 are in the process of getting started.The shortcomings in the effectiveness of the centers were swept under the carpet as quoted below (page 2 of report) and further implementation responsibility was quietly transferred to the NRHM! A part of the money was diverted for procurement of medicines also.
The programme is first of its kind and is in the developing stage.It takes time for the centers to become full fledged in activities. More awareness has to be made among public for the smooth and effective functioning of the programme since there is social stigma to mental illnesses
It is ironical that the health directorate which shied away from multisectoral consultation in the planning stage, tried to do some late stage firefighting to salvage the program by issuing new guidelines instructing the nodal officers to involve NGOs and panchayats in the working of the centers! (see excerpt below) (Act of commission no 3)
Act of omission no 1
In spite of explicit directions in the budget provisions and the administrative sanction authorization, the health directorate omitted stakeholders like social sector dept and NGOs from the planning stage of the 'Day-Care Centers'
Reasons for the same could be attitudinal. It is know that “Resistance to social services can be substantial, because it involves an understanding of mental disorders outside the medical model.” Besides it is also doubted “whether clinicians are best placed to lead mental health services development in countries unless they have a public health training and perspective to facilitate planning at the population level. There is a need for better access to public mental health training for key decision-makers in LAMIC” (Reference: Chapter 41, Overcoming impediments to community mental health in low and middle income countries, Oxford textbook of community mental health, 2011),
With respect to this particular program, insider sources inform that adopting a model of using the money to financially support an NGO-run/ social-department-run ‘day care’ center was not to the liking of the medical professionals within the health department as they viewed it as fund diversion to outside agencies.
(Incidentally budget-2013 also had another program as mentioned by the finance minister in the same news-report – “He also proposed opening care homes for mentally challenged children in every district in partnership with NGOs and allocated Rs.10.5 crore.”. It will be interesting to investigate how the latter program actually panned out. If the NGOs really got involved in the latter program, it can well act as a naturalistic control to the ‘Comprehensive mental health program’ in an evaluative study of comparative implementation-effectiveness.)
Act of commission no 1
An unscientific and cost-ineffective plan for running day-care centers was thrust upon the public mental health space of the state. Surprisingly and unfortunately none of the nodal offices of the DMHP/CMHP asked for a course correction in the plan and mechanically implemented a defunct plan.
Reason for this lapse could be that the plan was make by hospital-based psychiatric clinicians who did not have a clear community mental health or public mental health orientation. Stakeholder participation which could have cleared this lacunae however was deliberately not sought. Deliberate ‘nodalofficization’ of the implementation machinery for community mental health in the state helps only to maintain a ‘business as usual’ attitude among the downstream implementing agents, precluding any constructive criticism/creative-engagement with plans and proposals thrust upon them.
Act of Commission no 2
Even though alternate models for running the 'Day-Care' centers were offered/available to the planners, they chose to ignore them for a less valid model.
It indicates a certain legacy model of ‘command and control’ style of functioning in a non-consultative, over-the-top fashion, which is quite unbecoming of the modern practices of planning for community-based mental health services.Certainly this is not evidence based practice.
Act of Commission no 3
As part of a downstream course correction, the directorate may have tried to exonerate itself by thrusting on its subordinates, things which it itself could not do or should have done. Instructions to involve stakeholders in the fag end of an implementation cycle will be unlikely to be beneficial.
In conclusion, this case example of poor implementation fidelity of a program even at its operational planning level indicates that a lot needs to change in our planners when dealing with community mental health services. This will include change in attitude, developing evidence based thinking, a consultative mindset, facilitating inclusive planning etc etc. It may be argued that certain system level impediments like the administrative, social and cultural distance between sectors are the actual reasons for this outcome, in which case we will have to appreciate that a mere declaration of intent for multisectoral involvement in policy and plan documents can only serve the purpose of rhetoric. Innovative models of planning and financing that can bring about joint ownership and stewardship of programs will then have to be devised for addressing this implementation gap.
The initial news-report (March, 2013) which proclaimed the new scheme also contained a pertinent comment by Mr. Litto Palathinkal, president of ‘Kanivu,’ a collective of mental health rehabilitation and care homes. He said there is need for a “clear policy statement for the mental health sector ….with visions for both treatment and rehabilitation”. One major reason for the current mess was the lack of coordination among the four departments— Health, Police, Social Welfare and Local Self-Government, the report added!
Added on 20.05.2015 :Blog Impact!
News report in asianet news channel (see video below) and paper report in Janayugam newspaper.
An un-starred question was also incidently raised in nyamasabha (legislative assembly). see reply here
Information at the level of health systems will be important for better policy making and charting out reform agenda for change. The reform agenda for mental hospitals of Kerala has not, as yet taken off, though it has long been repeatedly articulated since 1979 (Pai committee report). The latest of such reports being the 6th estimate committee report (PDF) (2012) by the legislature under V D Satheesan MLA. A lack of a mental health information system which can capture data on health system variables may have contributed to the reform gap.
I have collated here, data on a few variables which I felt was important. These data were requested from the three government mental hospitals (GMHCs –Government Mental Health Centres) through RTI (Right To Information Act, 1987) query to the public information officers of these institutions. The data on financing of the institutions was collected from the annual plan document 2013-14, Government Of Kerala, which is available in the public domain. Data points (see Table 1) are clustered under three domains and certain data points are elaborated and commented upon in the discussion.
(1) Admission and Discharge: Total admission in 2014 was 7113 out of which 874 (12%) were admitted via reception order under Mental Health Act. (Unfortunately I did not ask for the number of prisoner patients admitted, therefore this data is not available)
A total of 154 patients as on 2014 are admitted and staying the Mental Hospitals for more than 10 years out of which 100 are in GMHC, Kozhikode. In absence of a plan for this subset of patients it is possible that these patients will remain in the centers for the rest of their lives. It was reported that a total of 60 patients were discharged and transferred to private rehabilitation homes.
A possible alternative could be to contact the Dept. of housing of Gov. of Kerala and explore means for building permanent housing for them. Any of the GMHCs could pilot a model of supported housing for these patients.
(2) Staff pattern sanctioned and currently present: Till date, shortage of staff in GMHCs had been a persistent problem. Thanks to proactive measures by the government via post creation (See here ) shortage is being steadily rectified. Currently sanctioned posts for doctors are steadily getting filled though the requirement as put by the centers are very high (Click to see a table from appendix of CAG performance aduit report).
We can see that currently, there is no shortage for doctors in sanctioned posts but shortage of other professionals does exist.
(3) Financing available to the institutions in the year 2014-15 is 323903 thousand rupees (32.39 crores) of which 28 crores( 86.44%) goes towards salary of personnel. During the corresponding period money allotted to community mental health services of all 14 districts was 4.79 crores.
Much of the annual state budgetary allocation for mental health under the health budget currently goes to the three mental hospitals of Kerala.
Tail piece: Regarding the reply to the question on “how many patients are currently admitted and staying more than two years” : as the question was little ambiguous the figures may not be reliable, nevertheless the total number is 273. These patients were engaged in various activities in the centers as per table 2. I am afraid many of these interventions may not pass the test of a rigorous state of the art evidence-based-rehabilitation techniques of modern times.
Table 2 (Activities in GMHCs for patients staying more than 2 years)
PS: A quick look at the impact of DMHP on IP and OP of Mental hospitals is pertinent (document extracts)
- The programme has been so successful in the district that it brought down the number of OP and in- patients at the mental health Centre by more than half, and even received a commendation from the WHO. DMHP Tvpm currently has about 2000 regular patients across the district. Dmhp annual activity report 2011-12 (PDF)
- The implementation of the DMHP/CMHP in four districts (Kasargode, Kozhikode, Malappuram and Wayanad) by IMHANS helped to reduce the workload of MHC, Kozhikode as evidenced by the reduction (22.61 per cent) in intake of inpatients at MHC, Kozhikode from 31,802 (2005) to 24,610 (2009). According to the cost-effect analysis of the MHC, Kozhikode made by the Institute during the year 2009, there was saving of 26.15 per cent in expenditure on diet, medicine and drugs due to reduction in intake of inpatients. Bed strength and average occupancy per day during 2005-10 in MHCs (Kozhikode, Thiruvananthapuram, and Thrissur) revealed that the percentage of occupancy ranged between 102 and 118. The excess occupancy was due to overstay of improved patients, heavy admission of relapsed cases, non- utilisation of new wards due to shortage of staff and non-completion of works, etc. Overstay of patients was due to non-availability of adequate rehabilitation centres, non-availability of proper address of the patients who were admitted by court orders, non-acceptance of recovered patients by their families etc. The three MCHs had a total bed strength of 154 (Kozhikode: 71, Thiruvananthapuram: 43 and Thrissur: 40).(?? Tvpm has 570 beds, KKD 474 as per another report) The average bed occupancy per day during 2005-10 was 42, 40 and 18 in MCHs, Thiruvananthapuram, Kozhikode and Thrissur respectively. CAG performance audit 2010 (PDF)
- The mental health centre was an ally of the primary care programme and benefited from the newly- integrated services through for example, fewer referrals. WHO-WONCHA report 2008 (PDF)
(Added on Aug,10, 2015) The data from this post got represented in an infographic (see below) which came in Times of India article.
Excerpts (total ~6 min audio in malayalam) of comments by Dr Ramankutty, Achutamenon Centre for Health Science Studies (~4min) and by Dr B Iqbal, public health activist and academic (latter 2 min) on the new draft health policy of India. The audio is extracted from a seminar on the challenges of public health care in India, organised as part of the state conference of the Communist Party of India (CPI) at Kottayam on 27th February 2015.
The under-funding of Community Mental Health services in Kerala State gets media attention as District Mental Health Programs (DMHP) in certain districts are folding back because of lack of funds. Seen above are excerpts from a media report – article in Ente Vartha, Malayala Manorama on Friday 19 December 2014. (see PDF version here).
The programmes of Institute of Mental Health and Neuro Sciences (IMHANS) Kozhikode, including community mental health programme, child development disability programme and child development services, which catered to thousands of patients in Kozhikode, Wayanad, Malappuram and Kasargod districts, are in trouble due to the fund crisis.
What is pertinent to note about such reports is that, matters relating to financing of mental health services, which are customarily relegated to the inaccessible policy spaces, are now becoming public debate. The report literally quotes figures like – What is needed is 1.6 crores, but what is provided is 50 lakhs. Such instability of funding is undoubtedly unsustainable for community mental health services in the state.
These facts are reflected in some technical reports as well -for example the WHO/WONCA report on primary care integration of mental health, dwells in detail on the inception (1999) and financing aspects of DMHP, Thiruvananthapuram. It says
Without an initial start-up grant from the national government, the programme would not have been implemented.
Following approval…by the national government, funds were allocated for an initial period of five years… At the end of the initial funding period, the state government was not able to earmark funds to continue the programme, although this was planned and expected by the central government. The programme continued by using some of the original funds that were not yet spent, and with financial support from the mental health centre …Now state funding for the programme has been secured for 2008 and 2009.
So, how much indeed, are the funds available for mental health services in the state? How is it being spent now? Where is it being spent? Are Community Mental Health services getting adequate funding? Or are most of the available funding going to institutional facilities? Lets explore…..
One way to get an overview about the “financing” aspects of mental health care delivery in the state would be to extract data from the annual plan (and the budget thereof) of Kerala State, which is available in the public domain. That is what, this write up will primarily do.
But before doing that lets us have a brief look at the fundamentals of mental health financing. This shall be in Page 2 (see icon below, can be skipped to proceed to main matter). It includes some basic definitions, about why to look at financing at all, and what are the key questions in financing which are relevant when we are thinking about the development of community mental health services.
We shall then zoom into the Kerala context and examine the current resource allocation pattern and look at the key questions that are relevant for the development and expansion of community mental health care in the state.This shall be in Page 3(click on page icon below). However you can grab a quick summary of the findings below.
Summary of findings on financing of mental health in Kerala Finding 1 In the absence of a strategic plan logically derived from the policy, the short term annual operational plans or the budget allocations themselves have become the defacto policy in Kerala. Such occurrence has been forewarned and recommended to be avoided in the WHO service package document on mental health financing(see Page2). Finding 2 Of every 100 Rupees of the health budget ear marked via line items for mental health care, only 12 Rupees of it is allotted for community mental health services in Kerala now. Finding 3 Persistent 'Contractualization' of staff in Community mental health services may relegate this service into an inferior cadre in comparison to staff in institutional facilities.
Dr Babu Paul (IAS Retd.) was the chief guest at the Palliative Day observance at Caritas Hospital, Kottayam last week.He talked about palliative care with respect to the ethical aspects involved. He disclosed an advance directive which he had made for himself. See video excerpt below (~ 2min, Video courtesy Dr Manu John, Palliative care Dept, Caritas Cancer Institute, Kottayam).
I am 72, going on 73.I am happy in my current situation but ready to be called home by my creator any time now. I therefore make the following wish list.
I may not be kept alive by artificial life support systems except as a purely temporary measure up to 6 hours and for unavoidable medical reasons.
I should not be resuscitated…..
In Summary the doctors are allowed to undertake comfort measures. I would prefer not to be shifted to any hospital….No artificial or IV feeding at all. May my body go in peace and my soul rest in peace.
As advance directive in mental health care is being introduced in India by the new act, it needs to be remembered that we are only at a stage of advance directives slowly evolving even in end-of -life care in our country.
article on new bill on end of life care (manorama 19/07/2016)
The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.
Here’s an excerpt:
A San Francisco cable car holds 60 people. This blog was viewed about 850 times in 2014. If it were a cable car, it would take about 14 trips to carry that many people.
My presentation at Central Tranvancore Psychiatric Society (CTPS) monthly meet at Kottayam yesterday, was on the topic of mental health interventions in schools. Prof Varghese Punnose, HOD, Dept of Psychiatry, Gov Medical college, Kottayam was the chairperson.
See above a matrix of existing mental-health provisions in schools of Kerala and see slides of my presentation below.