Research and documentationVahista DastoorPhoto creditsConnor Ashleigh, Vahista Dastoor, Iswar Sankalpa teamDesignVahista D...
LIST OF FIGURESFigure 1: Disease profile of homeless mentally ill persons in Kolkata, Baseline Study (2007)      12Figure ...
CONTENTSPREFACE                                                   05ACKNOWLEDGEMENTS                                      ...
PREFACEB        ased in the city of Kolkata, West Bengal, Iswar Sankalpa is a non-profit organization that aims to        ...
ACKNOWLEDGMENTSCLUBS                                        Ms. Mallika Sengupta                                          ...
Shri. T.K. Mukherjee           KOLKATA POLICE                        PHARMACEUTICALShri. Prakash Upadhyay                 ...
THE INDIGNITY OF URBAN    HOMELESSNES    Harsh Mandars “Living Rough, Surviving City Streets,    a Study of Homeless Popul...
police and municipal bodies evict the homeless from               are the result of a complex interaction betweentheir spa...
Forty years later, on the eve of Indias Independence,        THE HOMELESS MENTALLY ILL -and after a detailed survey of all...
HOMELESS MENTALLY ILL PERSONSIN KOLKATA, WEST BENGALSoon after Iswar Sankalpas inception in 2007, theorganization conducte...
suffering from mania or the extreme self-neglect and       such as talking to oneself, laughing or singing wildly,erratic ...
CHAPTER 2                                                NAYA                                                DAUR    A COM...
productive members of families and community.                The Naya Daur team comprises psychiatrists, social           ...
The                                                                         media                                         ...
COMMUNITY BASED         MENTAL HEALTH     TREATMENT AND SUPPORT           ACTIVITIES        Case Finding and Engagement   ...
CHAPTER 3THE TREATMENT AND SUPPORT                PROCESSCASE FINDING AND ENGAGEMENT                                 Makin...
whether he or she is likely to remain in the sameneighborhood and therefore remain in contact for thenecessary period of t...
ASSESSMENT                                                  pharmacotherapy immediately; such cases remain                ...
TREATMENT AND SUPPORT                                            TREATMENT SPACESFor patients with caregivers, social work...
MONITORING OF PATIENTS                                                            Caregivers are also taught how to monito...
Pratap Singh, a former patient, earns a daily wagewashing utensils and doing odd jobs at a restaurant      Patients who ha...
Sabbir picks up the skills of shoe making and earnsa regular wage at his caregiver’s business                             ...
THE NEED FOR PROTECTED SPACES      - A THREAD RUNNING THROUGH THE PROCESSOne of the earliest challenges faced – and the mo...
CHAPTER 4  NOWHERE  NO  MORE                                                 IMPACT AT THE                                ...
TO HELL AND BACK                                             FULWARI AND FRIENDS, BUILDING                                ...
THE COMMUNITY OF CAREGIVERS                                  This is my family now                                        ...
MAKING THE INVISIBLE VISIBLE                                   by Iswar Sankalpa he saw no harm in helping out – it       ...
MENTAL HEALTH CAMPS - A POWERFUL ADVOCACY TOOL   Objectives         To identify and bring the homeless mentally ill of a p...
Some outcomes of a mental health camp! Homeless mentally ill persons who come to the   camp return clean and tidy, with a ...
Above: Awareness material being distributed                                                     Above: A member of the loc...
It is in the treatment of vulnerable sections of“     society that we see the real test of      governments duty to protec...
CHAPTER 6IMPACT AT THESTATE                                                        LEVEL                                  ...
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
Creating Space for the Nowhere People
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Creating Space for the Nowhere People

  2. 2. Research and documentationVahista DastoorPhoto creditsConnor Ashleigh, Vahista Dastoor, Iswar Sankalpa teamDesignVahista DastoorReview study supportedby the Navajbai Ratan Tata TrustPublished by Iswar Sankalpa © 2011
  4. 4. LIST OF FIGURESFigure 1: Disease profile of homeless mentally ill persons in Kolkata, Baseline Study (2007) 12Figure 2 : Bird’s eye view of Naya Daur - a community-based treatment and support programme for the homeless mentally ill 16Figure 3 : Treatment and support spaces 21Figure 4 : Process map of a mental health camp 31Figure 5 : Process flow showing roles and responsibilities of Kolkata Police and Iswar Sankalpa 41LIST OF TABLESTable 1 : Comparative costs per day (in Rs.) for community based treatment as against treatment in institutions 46
  7. 7. PREFACEB ased in the city of Kolkata, West Bengal, Iswar Sankalpa is a non-profit organization that aims to ensure the dignity and holistic well-being of persons with mental health problems, particularly those from less privileged backgrounds.Initiated in June 2007, Naya Daur, Iswar Sankalpa flagship programme, is a sustainable community basedcare and support programme for the homeless mentally ill, - a programme that weaves together state,private and community into a network of resources that not only cares for this forgotten population, butworks actively towards making them productive members of families and community. As far as theorganization is concerned, there can be no population more underprivileged and under-served than thehomeless mentally ill, and the model of care has been designed with the following objectives:! To bring together a range of agencies needed to take care of the needs of a homeless mentally ill person.! To provide facilities and services to counter the abysmal lack of mental health in the public health system.! To address discrimination in a class of people already marginalized by poverty.The primary purpose of this document is to chronicle the experiences of Naya Daur from inception till date,(June 2007 – March 2011), a period of about four years. Although the project is supported by documents,including case reports, the organizations periodic reports to funders, and annual reports, it is necessary tocollate the information in these in a comprehensive manner to record the evolution and processes of thecommunity based model of care and support for the homeless mentally ill, document the learnings throughthis journey, and to understand its outcomes and impact for the purpose of informing further action.Iswar Sankalpa feels that its community based model is innovative and cost-effective, and most importantly,addresses the discrimination faced by the mentally ill, whatever be their socio-economic status. The journeyhowever, has not been without its challenges and failures, and the organization would like to share itslearnings with other organizations and individuals who work in mental health and allied support services,both state and non-state. Iswar Sankalpa hopes that this document will be of particular interest toorganizations that have adopted community based mental health mechanisms.While the successes have been many, the untimely death of Dr. K. L. Narayanan, one of the founders andkey visionaries of Iswar Sankalpa, just a year into the project, has been a body blow to the team. His losshowever, has made us more determined to live up to his vision of a world where the mentally ill, whetherhomeless or otherwise, are treated with the respect and compassion that is their right.This report is a tribute to his vision.Sarbani Das Roy,Secretary, Iswar Sankalpa 5
  8. 8. ACKNOWLEDGMENTSCLUBS Ms. Mallika Sengupta Ms. Nilanjana Sanyal Shri. Arup DhaliRotary Club Shri. Manoj BhutoriaBehala young mens Association Mr.Rajendra KhandelwalSubhas Sangha, Kashi Mitra Ghat Shri. Sachchidananda SarkarNew Sporting Club, Kankurgachi Shri. Ranodeb RoyJhamapukur youth sporting Club Shri. K.P.SenguptaPradeep Sangha, Shyambazar Shri. Debasish DuttaguptaGulab Sporting Club, Cossipore Ms. Shefali MoitraJana Swasthya Committee Shri. Sushanta BanerjeeAmra Sabai Club, Collootola Ms.Sarbari GomesJunior Boys Sporting Club, Khidderpore Mr. Raghu AnantnarayananShanti Youva Sangha, Akra Ms. Sayantani ChatterjeeSwadesh smriti Sangha, Chetla Shri. Tapas BanerjeeKabardanga Auto Union Dr. Fuad HalimShahid Smriti Sangha, Chetla Mr. Mustafa MuchawalaPaddapukur Club Ms.Mousumi GhoshEast Calcutta Child Welfare Society Mr. Arul JyothiTollygunge Young club Dr. Ashim MallickGitanjali club, Chetla Kabir Suman66 Pally Shri. Ardhendu SenPhulbagan Society Shri. Saikat MitraPurbasha Ms.Banani GhoshPutiyari Club Shri. Ajay AdhikariMinister club Shri. Swapan SamaddarHastings Friends Association Shri. Arup BiswasBeleghata Sukanta Smriti Sangha Shri Arup GooptuSealdaha hawkers Union Ms.Chandraboli SenIndian Welfare Society, narkeldanga Shri. Suvendu DasguptaDhakuria Rickshaw Union Ms.Sarda MaheswariBandhuchakra Welfare Association Ms.Mita Sethia Shri. Rajat Bhattachatyya Shri. Amitava SenguptaINDIVIDUALS/WELLWISHERS Ms.Susmita ChatterjeeShri Bikashranjan Bhattacharya KOLKATA MUNICIPAL CORPORATIONShri. Goutam Mohan ChakrobortyMs. Deepanjana SarkarDr. Ranjita Biswas Shri. Sovan ChattopadhyayaShri. Tridib Das Roy Farzana AlamMs Margaret Waterworth Jb. Firhad haqimShri. Sibaprasad Roy Shri. Atin Ghosh 6
  9. 9. Shri. T.K. Mukherjee KOLKATA POLICE PHARMACEUTICALShri. Prakash Upadhyay COMPANIESMd. Amiruddin Ranbaxy Solus Shri R.K Pachnanda (CommissionerDr. Sekhar Ghosh Sun Pharmaceuticals of Police)Shri. Arnab Roy Alteus Biogenics Pvt Ltd Shri Debashis Roy (AdditionalJb. Sahidul Islam Intas Commissioner of Police IV)Shri. Aroop Mondal Nicholas Piramal Shri S. Sarkar (Jt. Commissioner ofDr. P.C.Karmakar Molekule Police,Traffic)Dr. Kaveri Mirta Micro Synapse Shri Jawed Shamim (Jt.Mr. Samir Chakraborty Neo Foreva-Unichem Commissioner HQ)Jb. Nijamuddin Shams Shri Goutam Mohan ChakrabortyShri. Brojendra Kumar Bose D.G. Armed Force)Ms. Mala Roy Amherst Street P.S.Bilqis Begum Alipore P.S.Pranab BiswasMr.Dhua Burtolla P.S. DONORS Chetla P.S. Entally P.S. Hope Foundation Gariahat P.S. Mani Devi JhunjhunwalaNGOS Hare Street P.S. Charitable Trust Hastings P.S. Coal India Jorabagan P.S.Forum For Mental Health ONGC Kalighat P.S.Paripurnata Tractors India Ltd Park Street P.S.Antara Navajbai Ratan Tata Trust Narkeldanga P.S.AntadarshanAantarikTracks INSTITUTIONSSoujatyoSapho For EqualitySanhati Rajabazar Science CollegeMissionaries Of Charity Indian Psychiatric SocietyFlight To Harmony Foundation Medica super Speciality HospitalAashroy Rotary ClubAnjali Jayprakash institute of SocialHIVE INDIA studiesManas Bangla AmrapaliPBKOJP CDMUBoulmon New Life Nursing homeCINI ASHA Salvation ArmySPARSHANew LightAVIEW STATE GOVERNMENTSraddha Foundation DEPARTMENTSFriends of Kolkata Elderly Department Of Health and Family Welfare Department Of Women and Child Development and Social Welfare 7
  11. 11. THE INDIGNITY OF URBAN HOMELESSNES Harsh Mandars “Living Rough, Surviving City Streets, a Study of Homeless Populations in Delhi, Chennai, Patna and Madurai” is one of the few insights available into what it means to be a homeless person in urban India. Being homeless means living a sub-human life – sleeping under a bridge or on a pavement, eating sub- standard, irregular meals, and performing daily ablutions in full view of others. Being homeless means bringing up a family without any privacy or protection, being vulnerable to the vagaries of nature, violence and abuse from street predators, or even sudden death at the hands of a careless drunken driver. Being homeless means having little or no access to even the most basic of public services, and paying for everything that has to be used. At the Sulabh complexes for instance, every visit to the toilet, every bath, must be paid for, in cash, immediately. At road- side taps, being homeless means have to wait till slum- dwellers – citizens with more rights – collect their water. Even night shelters – if there are any - come at a price. Yet, being homeless means being a non-citizen – being denied public rations, a BPL card or even a voters identity card. While the urban middle class look down on the homeless as people with no right to be where they are and wish they would go back to wherever they have come from, the state has an openly hostile relationship with them. State authorities look on the urban homeless as parasitical, lazy, unhygienic and largely criminal. In periodic beautification drives or ironically enough on Republic Day or Independence Day, the9
  12. 12. police and municipal bodies evict the homeless from are the result of a complex interaction betweentheir spaces so that the dignitaries who pass through biological, physiological and social factors, mentally illthe streets are not offended by their unseemly persons are continually stigmatized and discriminatedpresence. against in homes, communities, the workplace, and in healthcare settings. Mental illness is often seen as aThere are laws that criminalize the urban homeless, personal failure or weakness of character; mentally illincluding laws which provide for arrest, incarceration persons face loss of shelter and work, neglect,and custodialization for sleeping or loitering on the abandonment and outright violence. Many are deniedstreets, for merely having no ostensible means of the right to vote, marry and have children.livelihood or even for simply being a child in need ofcare and protection. Even when people with mental disorders are recognized as having a medical condition, the“ The picture that emerges in the relationship with treatment they receive is often less than humane. In the State is of great official hostility to some of many countries, including India, people do not have the most dispossessed residents of cities, access to mental health care at the primary level; the homeless men and women, boys and girls. They only available care is in psychiatric institutions, many of survive without resistance their periodic which have been associated with gross rightsonslaughts, as they feel profoundly powerless and violations, including degrading treatment and inhumanhave nowhere else to go. The State feels absolved of living conditions.any responsibilities except against the urban poor.There is an unstated de facto hierarchy of citizenship. The following excerpt from “Why mental healthThe legitimate citizens of the city who are deemed to services in low and middle-income countries aredeserve both protection and services from the State under-resourced, under-performing: An Indianare those who live in homes and settled orderly Perspective’ by D. S. Goel, published in The Nationalcolonies. Those who are too impoverished to afford Medical Journal of India (Vol 24, No. 2, 2011), gives athese are lesser citizens, with a downward hierarchy of historical background of mental health care in India:legitimacy, from residents of authorized slums, to thosethat are unauthorized, to those finally those who are atthe bottom of the heap, the wretched massof the cities homeless. To them, the State “ Though the history of state-funded public “owes nothing, except to drive them away hospitals in India can be traced back to thefrom the city to which they are seen to have times of Emperor Ashoka in the third centuryno rights whatsoever. BC, there was no tradition of institutionalizing the mentally ill, who were invariably treated - Harsh Mandar, Living Rough, Surviving City within the community. The first mental asylumStreets, a Study of Homeless Populations in Delhi, came into existence at Calcutta (now Kolkata) in 1787,Chennai, Patna and Madurai during the rule of the British East India Company, and catered mainly to insane soldiers. Initially, English laws such as the Act for Regulating Madhouses, 1774 provided the legal framework for these asylums.MENTAL ILLNESS - IGNORANCE AND Following the first war of independence of 1857, theDISCRIMINATION RULE OVER SCIENCE first British Indian law on the subject, the India LunacyAND REASON Act, 1858 was enacted. This was followed by the Indian Lunacy Act, 1912, which was replaced 65 years laterThe care of people with mental and behavioural by the Mental Health Act, 1987. Despite severaldisorders has always reflected attitudes and values attempts at reform, conditions in most of thesedriven by prevailing social perceptions of mental asylums, rechristened mental hospitals in 1920,illnesses. Although advances in neuroscience and remained abysmal.behavioural medicine have shown that, like manyphysical illnesses, mental and behavioural disorders 10
  13. 13. Forty years later, on the eve of Indias Independence, THE HOMELESS MENTALLY ILL -and after a detailed survey of all mental hospitals in the DOUBLY DISADVANTAGED, DOUBLYcountry on behalf of the Bhore Committee, chaired by STIGMATIZEDSir Joseph Bhore, the then Superintendent of theEuropean Mental Hospital, Ranchi and Honorary Marginalized by mental illness and disenfranchised byConsultant to the Eastern Army Command, Colonel homelessness, homeless people suffering fromMoore Taylor, said: Every mental hospital which I have psychiatric disorders are among the most stigmatizedvisited in India is disgracefully understaffed. They have and vulnerable members of society in urban India. Theyscarcely enough professional workers to give more are often found, in various states of mental distress andthan cursory attention to the patients, to say nothing of physical neglect, at railway stations, bus stands, pilgrimcarrying a teaching burden… The policy of increasing centres and on city pavements. No one cares tobed capacity, which has incidentally led to gross understand that these people are not crazy – all theyovercrowding in most of the mental hospitals, rather have is an incommunicable mental disorder – athan personnel has been stressed in the past, but the medical condition that can be reversed with medication,cure of mental patients and the prevention of mental care and a little support. They are the nowhere peoplediseases will not be accomplished by the use of bricks – separated from – or abandoned – by their families,and mortar…. Finally, I would stress that the conditions ignored by welfare and health agencies, and pariahs toin some of the mental hospitals in the country are the rest of society.disgraceful, and have the makings of a major publicscandal… Victims of the vicious link between poverty and mental illness, the homeless mentally ill are the least able toOver the next few decades, concerned citizens brought take care of themselves, and yet are subject to ato the attention of the Supreme Court the terrible hostile environment that can only worsen theirconditions prevailing in some of the mental hospitals condition. More than other homeless people who stickthrough public interest litigation. The Supreme Court, together in families and communities and survive byshocked by the conditions and considering them a begging or working for minimal wages, the mentally illgross violation of the fundamental rights guaranteed are the most vulnerable because they are shunnedunder Article 21 of the Constitution of India, asked the even by other homeless people. Many have some formNational Human Rights Commission (NHRC) to survey of psychosis, and paranoia causes them to distrustall 37 government mental hospitals (combined bed others. They lose their memories, and wander aroundstrength of 18,918) in the country. The conclusions of in a constant state of hyper-vigilance and fear. Thosethe well-documented NHRC Report of 1996 are echoed who have depression and other mood disorders havein just one sentence: It was as if time had stood still. no motivation to look after themselves, and with no social or familial support to protect them from the painThe dawn of the new millennium heralded a new era in in their minds, remain lost in an inner world of tormentthe field of mental health in India. Perhaps for the first and trauma. The mental illness leaves them incapabletime in history, paucity of resources ceased to be the of even foraging for a meal, keeping themselves cleanlimiting factor in mental health planning at the national and protecting themselves from a hostile environment.level. The Tenth Five-Year Plan (2002–07) saw Mentally disabled women and children on the streetsquantum accretion to the National Mental Health are especially vulnerable to physical and sexual abuse.Programme, fiscally and otherwise. The initial With the mental disease having taken away all physicalmomentum could not, however, be sustained and there and psychological coping mechanisms, they are totallywere significant areas of under-performance. Many of defenceless against violence and rape.the past mistakes were repeated and contributed tothese failures. Tragically, few lessons appearto have been learnt and many of the same,and more, mistakes are likely to be made in “ Four out of five mentally ill homeless persons also have significant physical health problems. Unable to take care of themselves, they suffer from problems rangingthe Eleventh Plan. There is still time to heed from malnutrition, open lesions, rabies, untreateda wake-up call. wounds, HIV/AIDS and are especially vulnerable to communicable diseases. 11
  14. 14. HOMELESS MENTALLY ILL PERSONSIN KOLKATA, WEST BENGALSoon after Iswar Sankalpas inception in 2007, theorganization conducted a baseline survey of homelessmentally ill persons within the 141 wards of Kolkata.The survey, conducted over a period of 8 months,identified over 466 persons in need of immediatemedical treatment and psycho-social support.The disease profile of persons identified in the baselinestudy is illustrated in the graphic below: 2% 2% 6% 7% Delusional Disorder Depression Mental Retardation 19% Schizoaffective Disorder Not homeless mentally ill 64% Chronic SchizophreniaFIGURE 1: DISEASE PROFILE OF HOMELESS MENTALLY ILL PERSONS IN KOLKATA, BASELINE STUDY (2007)Other findings include the following: HOW DOES ONE IDENTIFY A HOMELESS MENTALLY ILL PERSON?! The majority of the persons were between 18 to 35 years Most homeless persons with severe psychiatric conditions are easy to identify by their outward! 20% of cases had major physical ailments appearance – an obvious lack of self-care and self- preservation is one of the indicators of mental distress.! 90% of the men had a physical injury While the onset of most mental illnesses are marked largely by subjective symptoms – complex feelings and! While women were the most vulnerable to sexual thoughts that cause mental distress to the sufferer - abuse and harassment, men were also subjected to there are a number of externally manifested symptoms physical abuse. that become apparent without timely treatment. While! A large number, mainly men, were prone to apathy and motor retardation, usually indicative of depression, are relatively difficult to detect on the substance addiction street, the restlessness and agitation of a person 12
  15. 15. suffering from mania or the extreme self-neglect and such as talking to oneself, laughing or singing wildly,erratic behaviour of a person with psychosis become eating from garbage cans, masturbating or defecatingapparent to even the casual observer. in full view of other persons, running around erratically or extreme agitation are signs that social workers onApart from long, matted hair, uncut and dirty nails and the beat look for.grimy clothing, a significant number of them carryopen sores, wounds oozing with pus and signs of Such persons are mostly alone – paranoia, or ill-various communicable diseases. Some have no treatment makes them stay away from others, and forbelongings except the scraps of clothes they wear; fear of violence or contagion, people on the street keepothers constantly clutch their motley possessions in an their distance, even crossing the street to avoid them.assortment of plastic bags and bundles. BehaviourHomeless no more January 2008 - when Iswar Sankalpa first came acrossPerhaps the most significant finding , a finding Manasi, she was a deranged terrified woman, lyingthat emerged as Iswar Sankalpa started the semi-conscious near a garbage heap.treatment process, is that a number of mentally illpersons are homeless because of cognitivedysfunction caused by the mental disorder - theysimply cannot remember where theyve come from.With psychiatric treatment, they remember theirnames and addresses, and have no reason to behomeless anymore.A few days later, she was persuaded to attend amedical camp being held by the organization in theneighbourhood. She had a wound on her right leg, andwas diagnosed with schizophrenia. Taken first to BaulMon Nursing Home, and then to Antara, she slowlyresponded to treatment, and remembered her address. March 2008 - Manasi returns home to her husband and a fulfilling family life. Iswar Sankalpa’s social workers visit her to top up her medication and check on her improvement. 13
  16. 16. CHAPTER 2 NAYA DAUR A COMMUNITY-BASED CARE & SUPPORT PROGRAMME FOR THE HOMELESS Based upon the findings of the STREET OUTREACH, SUPPORTED BY COMMUNITY CAREGIVERS baseline survey conducted in 2007, Iswar Sankalpa initiated community Working with the homeless mentally ill is relatively based mental health care and virgin territory in India, and the organizations that do so follow an institution based model. Initiated in June ongoing support for the target 2007, Naya Daur, Iswar Sankalpa’s flagship programme, is a sustainable community based carepopulation, concentrating its activities and support programme for the homeless mentally ill mainly in the wards with the highest in the metropolitan areas of Kolkata - a programme that weaves together state, private and community into a density of homeless mentally ill network of resources that not only cares for this persons. forgotten population, but works towards making them 14
  17. 17. productive members of families and community. The Naya Daur team comprises psychiatrists, social workers, psychologists and activists who work with the Community-based models per se are not a novel community, hospitals, homes and shelters to bring concept - globally, enlightened governments are acutely needed medical treatment those homeless restructuring mental health services to take cognizance people suffering from psychological disorders. Key of the holistic well-being of persons with psychiatric activities include assessment of the mentally ill on the disorders, with community based services providing streets, treatment and rehabilitation (both on the streets delivery of mental health services at the primary level. and in institutions), and restoration and reintegration of However, most community based models assume the recovering cases into family, if there is one, and in the presence of a family that initiates an enquiry into the community. mental state of one of its members, and secondly, assume the presence of a community that can be What is unique in this model, both from the point of mobilized in support of the same. Unfortunately, most view of homelessness and from the mental health homeless mentally ill persons have the support of perspective is the attempt by the organization to treat neither community nor family - Iswar Sankalpa as many patients as possible on the street, supported therefore mobilizes all sections of civil society and the by an ecosystem of caregivers drawn from the government to create a community that acknowledges neighborhood community. While acute cases of mental their presence and takes responsibility for their and physical illnesses are treated in hospitals, quite a treatment and reintegration back into society. Moreover, few patients do not need hospitalization - all they need in the stark absence of even basic mental health is regular medication and some help in caring for services at the primary level, let alone integrated themselves. In such cases, Iswar Sankalpa mobilizes services, Iswar Sankalpa works as a nodal agency people in the neighborhood to act as caregivers - to creating a referral network of appropriate support regularly give them their medicines, take them for a services, and making them accessible to the homeless hair cut or a bath, and ensure that they are protected mentally ill. from abuse and other crimes as far as possible.MENTALLY ILL THE ROLE OF CIVIL SOCIETY THE ROLE OF STATE AGENCIES Designed on the premise that each and every one of The baseline study (2007) not only identified the Indias estimated 4,00,000 homeless mentally ill number of homeless psychiatric cases in each ward of persons has a right – a right to care, a right to dignity, Kolkata and their disease profile; it also identified and and a right to all the resources that other citizens of this enumerated community resources such as medicine country enjoy, Naya Daurs community based model shops, NGOs and CBOs, pharmaceutical companies, also mobilizes state agencies in taking responsibility for other corporates and concerned individuals as potential a section of people whose absence is conspicuous in players in the community based treatment and care policy and planning, not just at state levels, but at model. Using these resources, a wider support national levels as well. network is formed by bringing together private individuals and organizations – both profit and non- Key amongst the public agencies that support the profit - to create an integrated mental health service network are the Kolkata Police, the states social model – a model that reaches out to the patient, rather welfare department, the Kolkata Municipal Corporation than in reverse. and of course, the health departments psychiatric hospitals where Iswar Sankalpa takes acute psychiatric cases for treatment. 15
  18. 18. The media Health& The Welfare community Depts The patient Other Iswar NGOs/CBOs Sankalpa Kolkata Police Naya Daur personnel ! Project Coordinator (1) ! Social workers (9) ! Counselor (1) ! Documentation (1) ! Part-time psychiatrists (2) ! Ambulance driver ! Accountant BUILDING A NETWORK OF SUPPORT through advocacy and coordination with agencies and Communities, and Mental Health campsFIGURE 2: BIRD’S EYE VIEW OF NAYA DAUR - A COMMUNITY-BASED TREATMENT &SUPPORT PROGRAMME FOR THE HOMELESS MENTALLY ILL 16
  19. 19. COMMUNITY BASED MENTAL HEALTH TREATMENT AND SUPPORT ACTIVITIES Case Finding and Engagement Assessment Intervention Planning Treatment and Support RehabilitationReintegration into community / restoration to families Follow upNAYA DAUR IS DESIGNED TO:! To bring together a range of agencies needed to take care of the needs of a homeless mentally ill person.! To provide facilities and services to counter the abysmal lack of mental health in the public health system.! To address discrimination in a class of people already marginalized by poverty. 17
  20. 20. CHAPTER 3THE TREATMENT AND SUPPORT PROCESSCASE FINDING AND ENGAGEMENT Making initial contact with a potential patient on the street is a delicate and pain-staking process, one that could take days, or even weeks, that is of course, if theSocial workers on their daily rounds identify and assess person has not moved out of the social workers beat.cases of mentally ill persons on the street. Each social Using eye-contact, initiating non-threateningworker has a regular beat - the constancy of a social conversation, offering food or a cup of tea, the socialworker in a community is necessary so that he / she worker begins to build rapport and assess the mentalbecomes a familiar face to the community, as well as a state as well as the physical needs of the patient. Thepart of the physical and psychological space of the rapport building process also gives the social worker aidentified mentally ill person. chance to assess the potential patients daily routine – 18
  21. 21. whether he or she is likely to remain in the sameneighborhood and therefore remain in contact for thenecessary period of treatment. Rapport building issometimes an long and arduous process because ofthe lack of a common language - some persons are All patients who are identified do not come under thefrom other states and speak only in their own mother coverage of treatment becausetongue. ! Being shelter-less and itinerant, they are sometimesIdentification of caregivers hard to locate after the first meeting ! Some refuse to engage with social workers, andSimultaneously, the social worker tries to identify andbuild rapport with a potential caregiver – usually allow no scope for negotiation.someone who is visible on the street all day. Some ! In many cases, even if persons are approachablepatients are already being given food by good and engage in discussion, they refuse to come forsamaritans on a regular basis – these persons are best treatmentposited as caregivers, as they already have some kindof daily interaction, however tenuous, with the mentally Just as Iswar Sankalpa believes that the right to careill person. In some cases, caregivers have readily come is an inalienable right of all persons, it also believesforward, in many cases, social workers face an outright that all persons with psychiatric disorders have the rightrefusal.Others come forward when they see the social to refuse medical treatment, the latter right only beingworker taking care of the person – sometimes out of over-ridden if the person is likely to cause harm tocuriosity, sometimes to offer help, and sometimes to himself or others. Negotiation for treatment thereforedemand that the person be taken away from the an important step in the process, as the cooperation ofneighbourhood. Such interactions provide social the patient is essential for treatment over a long term. Ifworkers with the opportunity to spread awareness - the persons family has been identified, rapport is builtabout mental illness, about the curability of the disease, with them and their consent is sought for medicaland about the need to treat the homeless mentally ill treatment.with compassion and respect.Negotiating with a caregiver involves addressing thecaregivers lack of knowledge about mental illness,dispelling the common myths about the threat ofdanger and violence, and outlining the supportive roleof Iswar Sankalpa in the process.Other referralsWhile case finding is a part of a social workers daily outreach routine, periodic advocacy and mental health campsheld in partnership with community organizations are also instrumental in identifying persons in need of help. Suchcamps, although focused on the homeless mentally ill, also encourage others in the community to reveal mentalhealth problems, either in themselves or in their families, and such persons, are referred to other organizations –for medical and psycho-social help. Other outreach activities such as consultations with government officials,private organizations and individuals also result in a number of referrals.A number of homeless mentally ill persons come to the notice of the police or concerned citizens because of theovert symptoms of psychiatric distress – they are highly agitated, behaving irrationally, often causing a disturbancein the neighbourhood - and if left without medical and psychological intervention, are a danger to themselves andothers. In such cases, Iswar Sankalpa’s Emergency Response Unit works together with the Kolkata Police to dealwith the immediate crisis, obtain custody of the patient from the court, and bring the person into the treatment andsupport process. 19
  22. 22. ASSESSMENT pharmacotherapy immediately; such cases remain under the social workers caseload, being monitored for further deterioration / improvement. InterventionOnce the social worker feels that sufficient rapport has planning includes:been built up with the potential patient, theorganizations psychiatrist visits the patient on the Health Interventionstreet, conducts a mental and physical assessment,and prescribes medicines. Assessment comprises the ! Planning how to provide medicines – either by thefollowing areas: caregiver or the social workerHealth Assessment Psycho-social Intervention! History-taking and mental state examination by the ! Fixing short-term and long-term goals of treatment psychiatrist, with provisional diagnosis with the patient! Risk assessment – including risk to self, to others, ! Fixing day-care or drop-in-centre activities and lack of self-care, physical condition of patient ! Institutional care / shelter for vulnerable patients! Capacity assessment – the patients insight – i.e. awareness of his / her own mental state, and the ability to give consent to treatment.Psycho-social Assessment! Degree of hygiene and self-care! Food habits! Clothing! Living skills – e.g. the ability to cook, shop, understand the concept of money! Social skills! Communication – through behaviour and inter- personal interaction! Vocational / occupational ability Medical Regimen! Vulnerability – the degree of support the patient gets The type of medicine and its dosage is fixed depending from the community, the chances of physical or on the patients condition, the availability of a caregiver, sexual abuse, and of drug or alcohol addiction and the likelihood of the patient continuing treatment (while some persons remain in a geographical area, some are highly itinerant and may becomeINTERVENTION PLANNING untraceable).If the psychiatrist feels that the patient does not need Medicines are usually kept to a minimum – usually ahospitalization but needs only a daily dose of once-a-daily dose and side-effects are explained to themedication, the patient is treated in the community caregiver as well as to the patient, wherever which he/she is habituated to. In some cases,the psychiatrist may not even recommend 20
  23. 23. TREATMENT AND SUPPORT TREATMENT SPACESFor patients with caregivers, social workers give eachcaregiver a weeks supply of medication, which thecaregiver gives to the patient once a day. If there is no Hospitalizationcaregiver available, or a caregiver drops out of theprogramme, then social workers give the medicine andfood to the patient during their daily rounds. ! Aggressive, agitated patients in an acute stage of mental illnessPatients – are encouraged - and helped to have a bath– usually at the local Sulabh complex, to cut their nails, ! Patients with severe injuries and otherand are given a change of clothing when required. acute medical problemsThose who dont receive regular food from others, orhave no means to cook their own food, Iswar Sankalpaarranges a daily meal for them. Currently, food forpatients in the Sealdah and Beniapukur areas is being Shelter / Transit homessponsored by The Samaritans Free Kitchen; in othercases, the social worker persuades a local food vendoror restaurant to provide a meal a day, either for free or ! People who are temporarily unstable dueat a cost which is borne by Iswar Sankalpa. More often to the stressors of homelessnessthan not, once people in the community overcome theirinhibitions, they volunteer to provide regular food and ! Patients who tend to wander from place toclothes to the patients. place ! Patients susceptible to sexual abuseInitially there is a tendency on the part of the ! Patients who are recuperating aftercommunity to force the social worker remove the discharge from hospitalpatient from the community or to take the fullresponsibility of the patient by institutionalizing him/her. ! Emergency cases referred by the KolkataAt this point it is critical to explain to the community that Police awaiting the courts custody ordersthe social worker is not the guardian of the patient,rather is the facilitator of a process of recovery andreintegration in which the community plays a significantrole. Community based TreatmentOn the other hand, there have been instances whencommunities have shown their protective side and ! Patients living in the community over ahave stopped Iswar Sankalpas social workers taking a period of time, with or without a caregiver.patient away from the street – perhaps to a clinic orhospital – assuming that the social workers weretraffickers or exploiters. FIGURE 3: TREATMENT AND SUPPORT SPACES 21
  24. 24. MONITORING OF PATIENTS Caregivers are also taught how to monitor progress inApart from the daily monitoring by social workers, the patient: to observe changes– whether in speech,patients are visited by the organizations psychologist or in appearance or behaviour, and most importantly, toonce every two weeks and once a month by the monitor treatment compliance. More involvedpsychiatrist. caregivers – with other locals pitching in – take charge of improving the patients personal hygiene, provideMonitoring is essential to: them with clean clothes, a sheltered space to sleep in,! Understand the progress / deterioration of the and step in to protect their care-recipients from abuse and violence. patient! Understand the patients needs and requirements.! ·Plan new strategies and interventions for the patient! ·Evaluate the social workers’ effectiveness in REHABILITATION dealing with patients and planning future action Rehabilitation is often a slow and difficult process,A case file is maintained for each patient, with records during which the patient gradually re-learns self-carebeing kept both on paper and in a database. Several and social skills and begins to engage in the activitiesdocuments are maintained – the social workers of daily living.maintain daily worksheets, which are supplemented byrecords written-up by the psychologist and On 5th December, 2009, Sri Goutam Mohanpsychiatrists. Key monitoring indicators are as follows: Chakraborty, Commissioner of Police, inaugurated a Drop-in-Centre for the Homeless Mentally Ill atFunctional Indicators – this refers to the capacity of Hastings Police Station. Iswar Sankalpa uses the Drop-performing tasks and activities that people find In-Centre as a rehabilitation space for recoveringnecessary or desirable to perform in their daily lives. patients whose families are yet to be traced, or for! Hygiene – brushing teeth, bathing regularly, those who have no families to go back to. Daily, a number of street-based patients from various localities personal cleanliness, healthy and hygienic food are transported in the organizations ambulance, habits offered bathing facilities and food, and introduced to a! Communication – regular and normal verbal / steady routine through occupational therapy, art and drama therapy. Activities include gardening, paper bag gestural communication with social workers and making, and clay-modelling. Recovering patients, others particularly males, often become victims of chemical! Functional daily activities – understanding the value addiction on the street, and the drop-in-centre has been especially useful in preventing them from falling of money; working (wage work or household prey to street drugs. chores), helping others, shopping, using public transport Similarly, at Sarbari, the organizations night-shelter-! Recalling home address, and the desire to return cum-rehabilitation-centre for homeless women at Chetla, female patients are exposed to drama, dance home and art therapy, and participate in vocational activities which prepare them to return to a meaningful, self-Psychological indicators – including mood, sleep, reliant life.anger, excitement, lethargy and obsessive behaviour. 22
  25. 25. Pratap Singh, a former patient, earns a daily wagewashing utensils and doing odd jobs at a restaurant Patients who have community caregivers are ! On an average, in 3 -4 months the patient starts encouraged to engage themselves in some kind of helping the caregiver in simple chores occupation as soon as possible within the community itself. Sometimes they are engaged by the caregivers ! By the end of 18– 24 months the patient is capable themselves, in their shops or restaurants. of earning wages at par in service. Rehabilitation and reintegration of the patient into a normal life then becomes a seamless part of the ! Selling vegetables, cooking in roadside eateries, recovery process. assisting in eateries, washing cars, tending animals in the farm, assisting shopkeepers in buying and selling merchandise are some of the different activities patients are involved in. 23
  26. 26. Sabbir picks up the skills of shoe making and earnsa regular wage at his caregiver’s business FOLLOW-UP REINTEGRATION INTO In 2010-2011, Iswar Sankalpa conducted a follow-up COMMUNITY AND of patients who had been repatriated to their homes RESTORATION TO FAMILIES outside Kolkata. The results have been disappointing – while most patients are still with their families, many have discontinued medication, either because of a lack The goal of Iswar Sankalpas intervention is the of availability of medicines or lack of initiative or ability eventual integration of the patient into the community – on the part of the family to continue treatment. While a and if there is one – the family. As mentioned earlier, few have resumed normal lives, most have no skills or many patients are on the street because of a decline in opportunities to contribute productively, and are cognitive functioning caused by the mental illness, and engaged in little or no activity beyond a few domestic a tendency to wander and get lost. As the treatment chores. progresses, they recover their cognitive faculties, remember their names and their homes. With the help For future repatriations, the organization plans to of the Kolkata Police, all attempts are made to locate conduct a deeper assessment of the family and the their families. community resources, and a longer engagement with both to ensure that the patient returns to a family that If the families cannot be located, or refuse to take the is clearly aware of the patients needs and abilities, patient back, or if the patient is unwilling to return to and that a network of community resources drawn the family, Iswar Sankalpa makes other provisions for from neighbours, panchayats, self-help-groups, the relocation of such cases in safe spaces in the Anganwadi / Asha workers, primary health centres etc community, or in the case of the highly vulnerable, in are mobilized into supporting the patient, as well as institutions. providing opportunities for productive activity. 24
  27. 27. THE NEED FOR PROTECTED SPACES - A THREAD RUNNING THROUGH THE PROCESSOne of the earliest challenges faced – and the most intractable – was, and to some extent still is,finding a transit space where the homeless mentally ill can be temporarily sheltered. The sheltercould be for a couple of hours, overnight or for a number of days/months.Recovery from mental illness is often a slow and fragile process, some cases having highchances of relapse. Some hospitalized patients recovering from acute phases of illness cannotbe expected to return to the rigours of street living - or even living at home, assuming they havea family - until they are sufficiently mentally and physically resilient enough, yet, their conditiondoes not justify them remaining in hospital. In such cases Iswar Sankalpa places such patientswith other non-profit or community-based shelters and homes, and follows-up with psychiatrictreatment and monitoring.Mentally sick women are even more vulnerable Often, emergency patients need to be kept in athan men – physical and sexual abuse and sheltered place – often overnight - before the legalrepeated pregnancies adds to the trauma of formalities necessary to take them into themental illness and homelessness. Even organizations are completed.recovering women patients remain vulnerable -one of Iswar Sankalpas patients, Tuku, was However, Iswar Sankalpa found that no state agencyvisibly upset when she was given a bath and was willing to take the responsibility of providing afresh clothes – she said that her dirty body and transit space – the Social Welfare Department felt thatfilthy, matted hair kept men away - and that since these were psychiatric patients, they were thethey had taken away her only protection. Just responsibility of the Health Department, and the Healthhow vulnerable women can be was brought Department believed that since these were homelesshome to them when a female patient with people, they were in the Social Welfare Departmentsschizophrenia - recovering after many months domain.of treatment by a community caregiver on thestreet – was gang-raped and left for dead one In the absence of a shelter of their own, Iswar Sankalpanight in a vacant building lot. would have to admit emergency cases in private nursing homes or shelters till they got a court order.Iswar Sankalpa runs Sarbari, a 100-bedded Currently, while Sarbari, Iswar Sankalpas night shelter,night-shelter for homeless women, where 50% provides the necessary space for female emergencyof the beds are reserved for mentally ill cases, men still need to be housed in private care.women. Sarbari, inaugurated on the 25th ofApril, 2010 is a joint venture with the KolkataMunicipal Corporation.It must be understood however, that institution based care is not an end in itself – it isonly the means to an end – the end being integration of the person back into thecommunity – and family, if there is one. Only in highly vulnerable cases – such asrecovering women who have no means of support, the severely mentally ill with highchances of relapse and the elderly, does the organization consider long –terminstitutionalized care. 25
  28. 28. CHAPTER 4 NOWHERE NO MORE IMPACT AT THE INDIVIDUAL LEVEL Figures and fact-sheets do not however tell of theKey figures for the period June 2007 to March 2011 changes in quality of life of the persons being cared that the project has: For all, life has changed in small, but significantly! Identified over 1114 homeless mentally ill persons human ways.! Provided food to 1015 cases on a regular basis, For one, they are guaranteed the basics of life – some clean clothes and a daily meal. clothing to 765, and hygiene care to 765.! Has medically treated 615 cases of which 78 were They re-learn to look after themselves - bathe, use sanitary toilet facilities whenever possible, cut their emergency cases nails and hair, wash their hands before eating – all of! 69 cases have been restored to their families – which not just maintains hygiene and reduces sickness, but also enhances their sense of self and dignity. they are homeless no more.! Currently, 174 cases are under regular treatment, They receive a package of mental health services – diagnosis, psychiatric treatment and psycho-social and 44 of the 69 restored cases have been support and rehabilitation. This includes providing followed-up, with the remaining underway. treatment for co-morbid physical problems. 26
  29. 29. TO HELL AND BACK FULWARI AND FRIENDS, BUILDING COMMUNITYIn March 2008, Malleswari was found in Kalighat. Shewas a bizarre sight- a woman in her mid forties wearing Sealdah station, home to the maximum number ofa loincloth, her head smeared with vermilion, marigold homeless people in the city, is where an unlikely newgarlands strung around her neck. She was thrashing community is being born. A group of our patients, allthe cars passing by with the branch of a tree. Suddenly women, have come together of their own accord, anda taxi driver stopped his vehicle and got down to beat take care of each other. They cook together, batheher. Dr. Narayanan, who lived near witnessed the together, sleep together, and watch out for each other.incident and intervened immediately. He brought theagitated Malleswari to his home and there she wasgiven food, clothing and helped clean up. One among them, Fulwari, is the leader of the team. She keeps a motherly eye over her little community,She was very aggressive and muttered curses the and reports to us when someone is missing or notwhole day long. After informing the police, social being cooperative. When they sit down to share theirworkers took her to a nursing home, and then to food, one of them divides it equally and then distributesAntara Psychiatric Centre for treatment. Later she was it. Even though they do not communicate well withmoved to Paripurnata- a rehabilitation centre. After each other, they know that they are safe and secure -about three months she began to recover, and the they have each other workers discovered that she was fromHyderabad.Through the Kolkata Police Missing Persons SquadIswar Sankalpa located her husband and young son -who had not seen her ever since the day she hadwandered away from home in a psychotic haze sixyears ago. On the 16th of January, 2009, a socialworker from the organization escorted her home andreunited her with her family. Mother and son stared ateach other incessantly - it seemed for ages - until theyreached out and wordlessly embraced each other.Women are protected to the extent possible bypredators on the streets – those who are vulnerable arehoused in Sarbari or with other shelters. All patientswho are psychologically or physically vulnerable aresheltered to the extent possible.As their mental state improves their ability to take careof themselves increases, as well as the ability to takedecisions about their own lives. While the indignities ofurban homelessness still envelope them, in thecommunity spaces they inhabit, they are no longerinvisible and untouchable. For those with families, thereis a very real hope of being reunited with them; forthose who do not, they are being supported in theprocess of creating social bonds with the urbancommunity around them, or are provided space inshelters and long-stay homes. 27
  31. 31. THE COMMUNITY OF CAREGIVERS This is my family now A resident of Bishnupur in South 24 Parganas, PrabirIt goes without saying that the small army of caregivers Kumar Sardar worked as a labourer at a factory in– 45 in all – one of whom is homeless, has been one of Ballygunge. When he became mentally ill, his familythe success stories of the programme. shunned him, and one day he left home never to return. No one knew where he went, and his familySo who makes a good caregiver in this programme? made no attempt to find him, not even to lodge aThere are a few qualifiers – the caregiver needs to be missing persons diary at the police station. He used tovisible to the patient every day, appear trustworthy to roam naked and eat from garbage vats in the Kalighatthe patient, and must be willing to hand over the Rashbehari area. The people used to make fun of him.prescribed medication once a day. And as one person Because of his flowing beard, long moustache and histakes a step forward, others overcome their inhibitions habit of offering prayers, locals called himand follow, and slowly a community of volunteers – Ramakrishna. A local lad, Sivaprasad Roy, developed aeach playing a small role – often forms around the fondness for him and brought Sardars case to Iswarpatient. The other qualifier – the willingness to help a Sankalpa. Today, after a year of treatment, Sardar is afellow human – is really the baseline requirement. changed man, with little resemblance to the ill-kemptThere are those who can look away, and there are pagol roaming the streets. He continues to live on thethose who dont. The key is to tap those who dont. And footpath, and takes a bath everyday at the Sulabhoften, when one person overcomes their fear and acts, complex. The very locals who tormented him earlier,others follow. now take care of him.When one looks at the profile of the caregivers, what Iswar Sankalpa contacted his family, who came to visitstands out is that most of them are people of very little him and broke down on seeing Sardar. They wanted tomeans themselves. Some run small businesses, one is take him home, but Sardar refused to leave the area.a school girl, and one is a homeless person himself. The closeness he has developed with the locals, andMany caregivers already play an informal caregiving the neglect he suffered at the hands of his familyrole – if one were to call it that – in the community members have forced him to stay back. Even the localsanyway. From giving alms and food to the poor, do not want to lose him. They are planning to help himlobbying for services with local counselors, helping open a tea stall very soon. Sardar said: “ I have nopeople get beds in hospitals, using donations from the home. I want to stay here. These people are my familylocal wealthy to run free clinics for the poor – there is members”no dearth of people who work quietly for a socialcause.Caregiver at fourteenNasreen, a fourteen year-old schoolgirl in Rajabazar, comes from an impoverished but genteel family living inRajabazar, one of the most congested areas of the city. Her father retired some years ago, and her elder sisterdropped out of school to take care of the family as her mother’s health deteriorated. Nasreen is Wahib’s care-giver.Wahib was a former neighbour - a young man whose family had moved away some years ago - but had returnedonly to dump Wahib back on the pavement of their old house because he was mentally ill. When the IswarSankalpa social worker was looking around for a caregiver - the spunky young Nasreen volunteered to give himhis medicines. Not only does she give him his daily tablets, she scolds him if he doesn’t bathe regularly, andmakes sure he gets at least one square meal a day. If the neighbours demur at providing food, she gives himsome from her own kitchen. This from a family that is always worried about where their next meal is going to comefrom. When asked why she and her family continue to support Wahib she simply shrugged her shoulders, grinnedwidely and said, “If I don’t then who will?” 29
  32. 32. MAKING THE INVISIBLE VISIBLE by Iswar Sankalpa he saw no harm in helping out – it didnt take up any time or energy – all he had to do was handover Darshan’s medicines with his food.It must be understood that the community based modelworks at two levels. At one level it provides mental Although he had to take much flack from others –health treatment and support services to the homeless Javeds attitude was “if you dont want to help, thenmentally ill. At another level – equally significant – it dont – just let me get on with what Im doing. Theworks for social change. The slow but obvious changes objections became weaker as people noticed visibletaking place in the person being treated on the street – changes in Darshan, both in his physical condition andthe transformation of an incoherent derelict into a demeanor, and most acknowledge that Javed hadhuman being capable of coherent thought and action is done the right thing.a very public demonstration of mental health in action, -action, that as always, speaks louder than even the And some of those who objected have come up to himmost evocative words spoken at any advocacy meeting later asking to be introduced to the pagalo ka daaktaror awareness camp. so that someone in their family could be treated.The very visible act of treating someone on the street -that too someone who is on the outer fringes ofuntouchability - has created ripples of change in theminds of those who have been witness to it. There Advocacy meetings, awareness gatherings and mentalhave been those who have come forward – the health camps are a core part of the support networkcaregivers, the volunteers, people who have donated creation, clothes, and medicines and so on. These are thevisible ripples across the surface of a hitherto The following figures relate to 2007 - March 2011:indifferent society. And for every passer-by who sees acaregiver – a paan-vendor perhaps, handing over Mental health committees formed: 2 (25 people)medicine to a pagol, and asks why – a ripple iscreated. And for every person on the street who sees a Awareness camps held : 87 (2425 people)doctor sitting at the edge of a pavement attending tobundle of stinking rags with a human being inside, and Advocacy meetings conducted : 12 (345 people)who turns away, whether in denial or in disgust – aripple has been created. That what is consideredhuman junk, is after all, human, and cannot be ignored.The stigma and ignorance around mental health doesnot affect just the homeless - there is a shroud ofsilence over mental illness at all levels of society, and ahigh degree of ignorance of how to deal with a mentallyill person. Yet, the management of homelesspsychiatric patients in public spaces has given thosewatching some food for thought, and at awareness andmedical camps, a number of persons have ventured toasked about the availability of such care for peoplethey know.Javed, a caregiver in Rajabazar recalls that peoplewould ask him why he was giving Darshan medicine.His family had been in the area for generations, and inhis experience – many such hapless people wouldroam the area, and sometimes come and stand silentlyby the hotel. And they would be fed. When approached 30
  33. 33. MENTAL HEALTH CAMPS - A POWERFUL ADVOCACY TOOL Objectives To identify and bring the homeless mentally ill of a particular area under the umbrella of Naya Daur. ! To include these persons in the community space and encourage the community to take responsibility for their care ! Bring together a range of people – local clubs and associations, welfare organizations, pharmaceutical companies and interested individuals into the process ! Spread awareness of mental health and advocate for the rights of the homeless mentally ill Pre-camp activities Identification of an area Advocacy with local organization Engagement and negotiation with a high number of homeless in the vicinity for hosting camp – with homeless mentally ill mentally ill persons usually a club or a welfare to undergo treatment association Identification and negotiation Arrangements for toilet, bathing Notify and invite with potential caregivers space, water, food, barber, clean local police station, ward in the locality clothes, medicine, chairs/tables councilor, medical etc representatives, media for coverage At the camp Ambulance brings Patients given tea and biscuits, Patients mental state willing patients to the camp and history recorded by social examination by psychologist worker. First aid provided if necessary Diagnosis and prescription by Hygiene care (cutting of hair and nails, bath and change of psychiatrist. clothes) and a hot meal given by social workers and community volunteers Post-camp activities ! Willing patients and caregivers become a part of the daily treatment and care process ! The camp brings about a degree of change in the perceptions of the community about the mental health, the homeless mentally ill. FIGURE 4: PROCESS MAP OF A MENTAL HEALTH CAMP 31
  34. 34. Some outcomes of a mental health camp! Homeless mentally ill persons who come to the camp return clean and tidy, with a full stomach- at least for that day, have a new set of clothes and a towel, and are encouraged to stay in touch with social workers for their treatment.! Patients who are maggot affected, have injuries and dog-bites, or serious health problems are given first-aid and taken to hospitals if necessary. Seriously mentally ill patients are referred to government hospitals.! Patients willing to go back home, if they can recall their home address, are restored back to their homes.! The club in which the camp is held is motivated to work with the organization.! Care givers are appointed for patients who agree to come into treatment.! Curiosity of the local people, club members and Above: Patients being other onlookers turns into serious concern when helped to alight from the they see social workers dealing with patients with ambulance compassion and lack of fear.! Social workers, when they, touch, talk, converse, Right: A new patient tentatively sips water bathe, feed and engage with the roadside mad persons leave the community people awestruck. Some go home touched and some become motivated to give the social workers a hand. Below: A general! The community witnesses the transformation of a physician conducts a hopeless bundle of rags into a human being, and physical assessment of begins to believe that they are just like all the others a new patient – normal but ill. Left: Advocacy material in Bengali and English 32
  35. 35. Above: Awareness material being distributed Above: A member of the local club addresses the gathering Below: The social worker explains theBelow: Even those who are not homeless come by to camp’s proceedings to curious childrenconsult doctors about their mental problems 33
  36. 36. CREATING AN INTEGRATED NETWORK THE ROLE OF THE MEDIAOF PRIVATE ENTERPRISE Apart from giving the organizations successful efforts“ Civil society can play an important role in publicity and support, sensitive reporting by the media supporting people with mental health conditions has been instrumental in raising awareness and in to access needed resources and to integrate helping families locate their lost ones. fully into the community, through direct service provision and advocacy. Services provided by Jhuma, whose family saw her in a television coveragecivil society can include health care, social services, of one of our health camps. Jhuma had been missingeducation programmes, and livelihood (income for over 5 yearsgeneration) projects. In addition, civil societycan advocate to government and funders forthe need to recognize and support people with “mental health conditions.World Health Organization, Mental Health andDevelopment: Targeting people with mental healthconditions as a vulnerable groupThere are numerous CBOs, NGOs and otherorganizations dotting the city of Kolkata working for thebetterment of the under-privileged and marginalized.Many however, work in small geographical areas, in aparticular sector and in isolation to other services.Relatively few work for the homeless – those who doso, such as the Missionaries of Charity, mostly providefood and clothing, and provide shelter to the absolutely Babais photograph in the Telegraph was recognized byvulnerable. However, provision of medical treatment to a neighbour who alerted his family. Babai had beenthe homeless mentally ill seems to have slipped missing for over 2 yearsthrough the cracks – perhaps because of the nature ofthe illness and the population.Naya Daur has, therefore, attempted to tie theseresources together to create an informal network ofcare. A number of NGOs who treat and shelter mentallyill persons and are part of our referral network –providing shelter, food, rehabilitation and other servicesto vulnerable patients who cannot be treated on thestreets. Some NGOs provide food, some organizations– including pharmacists, provide free medicines andother supplies, yet others clothes and other supplies.Some pharmaceutical companies provide drugs atsubsidized costs, the short-fall is made up by collectingmedicines given as samples to psychiatrists. 34
  37. 37. 35
  38. 38. It is in the treatment of vulnerable sections of“ society that we see the real test of governments duty to protect, respect andfulfil the rights of the population. Developmentstakeholders have important obligations in thisregard…. ………. development that only improvesthe lives of some people – while others remain asbadly off or even worse off than before – isfundamentally deficient in nature. Improving thelives of the most vulnerable is in itself a coredevelopment objective.Through targeting by development programmes,people with mental health conditions can beempowered to reach their goals and participatefully in society. In order to achieve this they musthave access to opportunities and services, beliberated from stigma and discriminationand be free to exercise their fundamental “human rights. World Health Organization, Mental Health and Development: Targeting people with mental health conditions as a vulnerable group 36
  39. 39. CHAPTER 6IMPACT AT THESTATE LEVEL state hospitals admit emergency cases, as well as in locating the families of patients, many of whom are not from West Bengal. The Kolkata Police have also allocated a space at the Hastings Police Station which is used by Iswar Sankalpa as a Drop- in-Centre for recovering patients. Certain officials however, have expressed reservations about hosting such facilities at police stations – fearing public outcry if any mishap were to happen to a patient on their premises – a fear that really has no basis, as the patients who are brought to the drop- in-centre are those who are relatively stable and are on the road to recovery. ! The Kolkata Municipal Corporation, who have been a part of the project since its first activity, the baseline study of homeless mentally ill persons in the Kolkata Municipal areas. The erstwhile Mayor, Mr. Bikash Bhattacharjee has been a staunch supporter, and through his good offices, Iswar Sankalpa was gifted an ambulance by Dr. ArjunThe state government is constitutionally responsible for Sengupta, Member of Parliament. Since April 2010,the delivery of health-care services to all citizens, and the Corporation has provided a space to Iswarits resources, though inadequate, are still vastly larger Sankalpa which is used as a night-shelter forthan any other organization. Where the state women, where 50% of the beds are reserved forgovernment significantly fails is in the convergence of homeless mentally ill women who need shelter. Asplanning and service delivery, both to the homeless and on date, the Corporations primary health careto the mentally ill. centres have no provisions for psychiatric care, a fact that Mr. Arnob Ray, Commissioner, KolkataMuch of the last four years has therefore been spent in Municipal Corporation puts down to a lack of pushintensively advocating with the state government and from national health departments, and a lack of pullits diverse arms to bring psychiatric care and allied for services from to the target population. This advocacy hasresulted in various liaisons - key amongst the ! The states general and psychiatric hospitals, whichgovernment players partnering the programme are come under the Health Department. State hospitals! The Kolkata Police, who initiate emergency calls such as Bangur, NRS, R.G Kar, and S.S.K.M have admitted patients and helped in their recovery, when they locate mentally ill persons on the street although they lack the necessary resources and who appear to be either a danger to themselves or infrastructure to take care of patients who may be others, and play a significant role in ensuring that 37