A resident at the Divine Care Center rests during a group exercise session. (photo: Peter Lemieux)
A sister at the FBA home distributes medications to residents. (photo: Peter Lemieux)
Social worker Justin Mali leads regular group exercises for residents at the Divine Care Center. (photo: Peter Lemieux)
Pharmacists at the Divine Care Center prepare prescription drugs for residents. (photo: Peter Lemieux)
Male residents eat lunch in the Divine Care Center’s cafeteria. (photo: Peter Lemieux)
Students at Lisie College of Nursing take final exams for a bachelor’s degree in nursing. (photo: Peter Lemieux)
In Keralas rural region of Chennaipara, the hallmarks of the states upwardly mobile urban culture are remarkably absent. Though less than 16 miles outside Trichur, Keralas third–largest city and a major financial and commercial hub, no billboards obstruct the idyllic view along the narrow highway. Rubber and coconut plantations blanket the lush, rolling hillsides.
Here, set back at the end of an unpaved drive, far from the stress and anxiety of urban life, is the home of the Friends of the Birds of the Air (FBA). Founded and operated by the Syro–Malabar Missionary Congregation of the Blessed Sacrament, the home offers its 335 residents more than just the fresh air and tranquillity of Keralas countryside. It offers them a measure of hope.
The home cares for mentally ill men and women who would otherwise face unthinkable fates — homeless, alone, untreated. Most adult residents suffer from schizophrenia and other serious disorders. Many have no family or relatives able to care for them.
Theyre totally abandoned people, explains Father George Kannamplackel, who has headed the home for the past 15 years.
We gather people found on the streets, in the railway and bus stations, anywhere. We give them shelter and the maximum care to treat their mental illness. If theyre in old age, well keep them here as long as they want to live here, he continues.
The FBA facility in Chennaipara is located in a compound that also houses the congregations motherhouse and headquarters for the more than 20 similar homes it operates across India.
If they need different or greater treatment, we move them to another center that provides it. If they have little ones, we give them schooling and support them until they find a job in a professional field. And if a patients family or loved ones somehow misses them, or if a patient, who has forgotten his family due to mental illness or disorder and later remembers after treatment, we try to contact the family. If we can return them to their homes, we do that, too, concludes the priest.
Though the staff works to reintegrate residents into society, such breakthroughs are rare. All too often, they stay in the FBA homes for the rest of their lives.
The facility in Chennaipara underscores a painful reality facing the region. Though Kerala has a nearly universal literacy rate — head and shoulders above all other states in India — it is also notorious for its alarmingly high suicide rate. Keralites represent 3 percent of the countrys total population, yet they commit 10 percent of all suicides in India each year.
The underlying causes for this are multiple and complex — including the decade–long crisis in the agriculture sector, which has driven large numbers of sustenance farmers to take their own lives.
The reason you commit suicide is because you have a mental health problem, says Professor Usha Marath, dean of the Lisie College of Nursing in Ernakulam. Thats why people — adolescents and young adults in particular, the two groups with the most mental health issues — commit suicide.
According to recent reports by the Kerala State Mental Health Authority, the number of clinical diagnoses of mental disorders and cases of alcoholism and drug abuse are on the rise throughout Kerala. And, these problems impact people from all social backgrounds. In fact, these reports indicate that most affected are members of Keralas new generation of highly educated, professional urbanites.
These findings can be explained in part by increased awareness about mental illness — both in the medical field and larger society — throughout the world, particularly among the well educated. Doctors now diagnose and treat mental disorders sooner and more accurately than ever before.
But Professor Marath sees other causes for the rise in diagnoses.
If you look at Kerala, a more nuclear family structure now predominates, says the professor, who holds a masters in psychiatric nursing. Not too long ago, an extended–family system was the norm — with grandparents, uncles and aunts all living together. So, there was a lot of emotional support. Nowadays, we have just the husband and wife. Both of them are often working, and there is not as much time devoted to the children, which isnt the way our culture used to be. The children are overprotected and less prepared. Such people find it difficult to cope with the challenges of the world.
Professor Marath sees much of what she describes in her students.
A considerable amount of my time is spent counseling students, she says. They cannot handle even small challenges. They have to be counseled at every phase.
Its the pressure. Theyre not able to respond to stress positively. If they perform poorly on a particular exam, or if you tell them something, even a small criticism — even when its told for their good — they cannot take it in a constructive way. Their expectations are very high, as is the pressure from the parents who want them to succeed.
Father George Kannamplackel agrees. In his view, the computer generation, as he calls it, focuses too narrowly on economic gain and professional success, which can cause mental health problems.
Todays youth dont bother with what is best for society. Theyre motivated by their own achievements. Day by day, they want to increase their income or get better jobs. Theyre never satisfied with what they have, says the priest. In the process, they lose all contacts and relations with society and the people around them. Many of them are isolated. And later on, when a crisis erupts, they get lost and find it difficult to sustain themselves.
Kakkanad, an eastern suburb of Ernakulam, Keralas second–largest city, typifies the hectic, achievement–oriented Kerala both Professor Marath and Father George decry.
The suburb is home to two 100–acre industrial parks: the Cochin Special Economic Zone and the Infopark Smart Space Kochi. The former offers commercial space to a wide–range of private companies, including manufacturers of electronics and textiles, a food processing plant and firms offering information technology and engineering services.
But it is the nearby Infopark Smart Space Kochi that captures best Keralas fast–changing economy and way of life. Established in 2004, the gated, campuslike property consists of sleek high–rise office buildings, whose tenants include some of the states most successful information technology companies. At any given time in the workweek, scores of sharply dressed young professionals can be seen hurrying about their business among the buildings.
Both office parks blend in seamlessly with Kakkanads new residential neighborhoods, condominiums and shopping centers. Area residents might easily forget that 40 years ago this was a remote village — and the perfect setting to establish a psychiatric hospital, Kusumagiri Mental Health Center.
It bears the distinction of being the oldest private psychiatric hospital in Kerala. These days, with more people settling in Kakkanad, the center makes a special effort to protect the privacy of its patients and their families.
Our secrecy has to be maintained, says Sister Joyce Mathew, who has directed the center since 1972.
Stigma is a big concern. It is the same all over, in the U.S., too. But in the West, even if you have an illness or problem, the family will live peacefully. Here in Kerala and across India, we have a very strong family–centered culture. Family requires total commitment. Before marriage, a family thinks seriously whether it should make an alliance with another family with a history of mental illness.
The Kusumagiri Mental Health Center has earned a reputation as a leader in the field. Founded and operated by the Syro–Malabar Catholic Medical Sisters of St. Joseph, the center treats 100 residents and also runs a school for autistic children. With four psychiatrists and some 100 staff, including 25 sisters, the center boasts one of the best patient–staff ratios.
However, no statistic can accurately measure the staffs tireless commitment.
We work 24 hours a day. We dont look at the time, says Sister Joyce. Whenever theres a need, were there to provide care. Even when residents become abusive toward us, with love and confidence, we serve them. Were trained in every aspect — nurses, psychiatrists, social workers, autism specialists, clinical psychologists, speech therapists, lab technicians, occupational therapists, pharmacists, accountants, special educators and physical therapists. We have confidence in the quality of our care.
Our sisters joined the congregation before we joined the medical field, she continues. We follow the vision of our founder: to give to humanity with a compassionate heart and bring about wholeness. Were trying to impart this compassion to the patient in our service — but not only the patient. The wholeness comes from the patient, the family and all of society.
This emphasis on family points to the centers most striking feature — its family–centered approach to rehabilitation. Unlike most other institutions of its kind, Kusumagiri admits a patient on the condition that a family member stays with him or her at the center.
We believe nobody will take care of the patients better than the families themselves, explains Dr. Rajan Mathai, a psychiatrist who has worked at Kusumagiri for the past 27 years. By staying with them here, the families get information on how to manage at home.
At home, families observe the changes from normal to abnormal, explains Sister Joyce. At Kusumagiri, they observe the changes from abnormal to normal.
A strong proponent of this family–centered approach, Professor Usha Marath of Lisie College sends all of her nursing students to Kusumagiri for six weeks of training.
By the time they come back, we see an improvement in their nursing techniques, says the professor. They are more empathetic with their patients.
From a meeting room where she sits with Dr. Mathai, Sister Joyce calls in the mother of a 32–year–old patient who has been battling schizophrenia for 18 years. The woman, a retired high–level government official, appears upbeat as she enters the room. She smiles easily and greets them cheerfully. But when the conversation shifts to her daughter, the mother does not hold back.
This has been the greatest challenge of my life, she admits. After years of treatment of all sorts, her daughter continues to suffer relapses.
Though others dont say anything, she hears voices, says the mother. Shes not on good terms with others — even neighbors. She feels theyre all against her. Shes paranoid. The voices tell her everyone abuses her and everyone wants her to kill somebody. They tell her she has already killed somebody and that she will be arrested soon. And, she has thoughts about killing family members, which are very disturbing for her.
Dr. Mathai, who knows the patient well, shakes his heads in empathy. She believes her actions are due to her medicines, he adds. She says the doctors give her this medicine to kill somebody. She suspects everybody.
To protect her daughter and improve her chances at a healthy and happy life, the mother tries to keep her daughters illness a secret. But now that her daughter is well past the usual age a woman marries in India, she worries neighbors suspect the truth.
At age 20, people start asking in our culture, explains Sister Joyce.
‘She doesnt want to marry, is what I tell people, says the mother. She behaves properly to some extent. But when she needs hospitalization, we say that shes visiting family in central Kerala. Only very intimate friends know the truth. Otherwise, I wont tell.
Though the mother understands the severity of her daughters condition, she still hopes that she will recover, maybe even marry.
It depends on how treatment goes and if we see improvement. You cant predict, says Dr. Mathai. We will try to prevent further deterioration, he says, softening his voice. But the longer the duration of illness — an 18–year history — and the worsening of symptoms, it may be difficult for us.
Patients at Kusumagiri and other church–run institutions are among the more fortunate. Stigma associated with mental illness, especially in poor, rural areas, compels many families to shun modern psychiatric care. Those who do seek it discover most public facilities are overcrowded and understaffed.
Though most struggle financially, church–run institutions fill gaps in the states public health care system, especially when it comes to treating the poor and those with severe disorders.
Its the responsibility of society as a whole to support those who are unable to live by themselves, says Father George. But we, the Syro–Malabar Church, take on more responsibility. We treat our residents as our own brothers. We demonstrate our concern and sympathy, which we derive from our Christian faith. But, its a big problem. Only by raising public awareness can we truly solve it. But we have a long way to go.
The churchs institutions at present cannot admit all those who apply, particularly when it comes to long–term inpatient care.
The Divine Care Center in Chalakudy, for instance, has a waiting list of around 2,000 applicants. Established ten years ago on the Divine Retreat Centers expansive grounds north of Ernakulam, the center houses and treats 400 residents with severe mental illness.
The Divine Retreat Center, which each week welcomes between 5,000 to 10,000 guests on spiritual retreats, plans to expand its Divine Care Center to accommodate many more residents. Gopi Krishnan, the centers director, hopes to make the center one of the largest and most reputable institutions for the long–term care of the mentally ill in Asia.
Our residents are admitted on a lifetime basis, says Mr. Krishnan. They usually have undergone treatment in other asylums. Once discharged, their families find it difficult to care for them. So, we admit them here and continue their managed care as prescribed by their physicians. We give them occupational therapy, medications, food, clothing and shelter. Relatively few will return home.
Despite the extraordinary work in places such as the Divine Care Center, the FBA facility, and Kusumagiri, the hard reality is that Kerala is grappling with a crisis in mental health care. The need is great, and growing. Much more needs to be done by all parties — the government, the private sector and the church.
Recently, the government enacted stricter requirements on health care providers, but offered no financial assistance to help struggling institutions meet them.
If restrictions go up, then costs to provide adequate care also go up, says Dr. Mathai. The government says that for every ten patients, there should be one psychiatrist. For every six patients, there should be one psychiatric nurse. But some government hospitals dont even have one psychiatrist.
So how can they expect private hospitals to? Whats the alternative? Open the doors and have these people roaming the streets?
We still dont have adequate space to care for everyone. We have a long waiting list, laments the psychiatrist. But we cant take them in because once you make a long–term commitment to current patients, you have to honor it.
Award–winning journalist Peter Lemieux reports from Africa and India for ONE.