The face of death

The spate of suicides by farmers in Vidarbha region of Maharashtra continues to hit headlines. Some reports peg the number at 452 in the first three months of 2015. The number of farmers killing themselves is over 600 all over the state during the same period. Agricultural and horticultural belts of the state are under severe stress due to crop losses resulting from hailstorms during 2014 and this year. Food grain, fruits and other cash crops worth billions of rupees over several million hectares have been destroyed across districts. In many other parts of the country, large tracts of farmlands have been adversely hit due to hailstorms and untimely heavy showers. All this is adding to the stress of farmers. Since the agrarian crisis in Vidarbha has been going on for several years now, suicides there continue to grab attention. This does not mean that situation of farmers in other regions us any better. In Uttar Pradesh, dozens of farmers have reportedly died due to shock and several have committed suicide after their crops were destroyed in recent hailstorms. The situation is so bad that the Institute of Mental Health and Hospital in Agra is flooded with farmers reporting signs of shock and mental sickness, and has been forced to establish a special cell to treat such cases.

Till now, we have been treating farmers’ suicides as a farm sector issue and the one related to financial bankruptcy caused due to sudden crop failure. This kind of approach has resulted in loan waivers, special financial packages and payment of compensation affected families. Arguably such an approach has not made any difference on the ground or has sent suicide numbers tumbling. While this approach may be necessary for most cases because after all we are dealing with people whose primary vocation is farming, there are other ways to look at this crisis.

Globally it has been recognized that mental illnesses such as depression are a public health issue, not just in the developed world but also in middle- and low-income countries. Research also shows that mental illness – which if left untreated could result in extreme actions like self injury – is not just an urban or city phenomenon but affects people in rural areas too. The World Health Organisation treats suicides -- whatever may be the underlying causes -- as a public health problem. A report released by the world body in September last year put India on the top -- India reported 258,000 of the 804,000 suicide deaths worldwide in 2012. The suicide rate in India -- 21.1 suicide deaths per 100,000 people – is nearly double the world average. One of the main reasons for the situation is the pathetic condition of mental healthcare in India. On top of it, suicide or attempt to commit one is seen as a criminal act. Thankfully this is being corrected through amendment in relevant laws.  It’s time we start placing farmers’ suicides in this larger context and start addressing the problem as a public health issue. 

Indian research institutions, central and state health ministries have failed to recognise links between poor mental healthcare infrastructure and rising burden of suicides. There has been practically no long-term field research to look at underlying causes of suicide in farm belts so that proper interventions could be designed and lives saved. For instance, there is scientific evidence that exposure to certain pesticides leads to depression, but we have not been able to act on this or gather any new evidence on our own. 

As regards mental health services, the National Mental Health Policy, released in October last year, talks about universal access to affordable care but the policy is still to be implemented. The District Mental Health Programme (DMHP) was rolled out in 1996 to spread mental health services by training general physicians and healthcare workers at the district level, but has been lagging due to various reasons including shortage of staff. Moreover, it takes a top heavy clinical approach rather than more sustainable community approach to care. The very fact that stressed farmers from hinterland are rushing to tertiary care hospital in Agra shows that the DMHP is dysfunctional in Uttar Pradesh. It is ironic that a country of 1.2 billion has just 3,500 psychiatrists most of whom are working in cities. The shortfall of other trained staff for mental health services is also huge.

Treatment costs in city hospitals are sky high.

In such a situation, India needs low-cost psychosocial interventions that can work at the community level. Fortunately, we have some evidence of this from nowhere else but Vidarbha where mental health researcher Dr Vikram Patel (who featured in the TIME magazine list of 100 most influential persons recently along with Narendra Modi) is engaged in a path breaking study. Under this model, which is being tested in 30 villages covering total population of one lakh in Vidarbha, each village has a trained health worker who is a resident of the village. This person is tasked with creating awareness about mental health and alcoholism through self-help groups, gram sabhas etc, and also maintain one-to-one contact with vulnerable families. Such community workers are trained in providing mental health first aid and also assess suicide risk in people showing signs of mental illness. Problem cases are referred to health counsellors who visit villages whenever needed, and provide help as per well laid out protocols. Only if the problem persists, the person is referred to a psychiatrist. The objective is to pick up signals of mental illness early on and prevent extreme actions like self-harm. The results of this unique four-year experiment are still being compiled but the model appears to hold immense promise.

The success can be gauged from the interest shown by gram sabhas in the study area which have passed resolutions urging the government to provide mental health services in primary health centres. 

We need more such field studies in agricultural belts across the country so that not only can we find real causes of the crisis but also test low-cost interventions which can save lives of people irrespective of whether they are farmers, young housewives or others. Quick fix prescriptions like loan waivers are not going to provide lasting solutions to this deepening crisis in our farms. 

The writer is a columnist and author based in New Delhi