At first glance, Durga is a happy young woman. Her bright smile contrasts with her fading yellow saree, and her long, neatly pleated hair shimmers in the sun. A yellow thread lay snugly around her neck, and a pair of golden earrings beamed against her dark complexion. Her serene appearance, however, belies the stress weighing down on her, and as she recalls her days from October last, the smile weakens, and tears bead in her eyes.
Durga, a Dalit, was a helper at a government school in Kotikalapudi, a village in Ibrahimpatnam mandal of NTR district. During the two years she worked, she and another helper would sweep the school compound and clean the four bathrooms and nine classrooms every day.
“It was tough,” says Durga, “I would prepare lunch for my husband and children and get them ready for school before leaving for work,” says Durga, who felt it was her responsibility to help her husband, Ravi, in running the household however she could. And her ₹6,000 a month did indeed shore up Ravi’s earnings of ₹400-₹500 a day, helping their family of four navigate the vagaries of life.
So, Durga was crestfallen when she lost her job last year, and mounting debts, anxiety over their children’s future and a debilitating poverty took a toll on her mental health. She confined herself indoors and burst into tears when no one was around. She did not eat for days and spent sleepless nights battling thoughts of ending her life.
Lacking any proper education, the 29-year-old did not understand what afflicted her. “My head throbbed constantly, and my outbursts of anger alienated my children and husband,” she says.
What exacerbated her suffering was the constant fear of prying eyes spinning tales about her. She dreaded being branded a “mental” (mentally ill), or worse, ‘possessed’. Durga claims that it is common in her village to take such individuals to a temple, durgah or a church, where elaborate rituals are performed to “shoo away the spirit”.
Around 10 kilometres from Kotikalapudi, at Ibrahimpatnam town, John sits in his old auto-rickshaw outside a tin-roof house. A tall man with the expressions of a child, he wears a confused look on his face. Two of his lower front teeth are missing, and words slurred mildly as he spoke.
John says that he has been suffering from a mental illness for the past 12 years and believes that his mental health began to deteriorate after an accident at a construction site in the town.
In a voice broken by grief and despair, the 54-year-old narrates how he used to wander the streets at night, bang his head against a wall and shout at his wife and son. Worried, they took him to a temple and made him drink water mixed with vermilion and turmeric for six days, believing it would make him better.
“Nothing seemed to work. There was no one to advise me on which medicine to take or what to drink,” says John, who belongs to a BC community. His eyes well up as he recounts his long trips to Vijayawada and visits to countless doctors on Nakkala Road in the city, searching for a cure.
While John does not know the exact nature of his condition, the medical officer of a team from Vijayawada-based NGO ‘Vasavya Mahila Mandali’, who examined him as part of a survey, found him to be exhibiting the symptoms of schizophrenia.
John drives his auto-rickshaw rarely, when he needs money. If he gets a headache, he parks it by the road and sleeps, he says. He, too, earns ₹500 a day but spends most of it on medicines, consultation fees and check-ups, which he undergoes once every month at a private hospital in Vijayawada. He says his family has fully disowned him now because he could not give them anything.
“I sleep in my autorickshaw and eat from outside every day … I feel terrible, but I want to live and need these medicines,” says John, holding back tears. Asked why he never went to a government hospital, he says he did not know where to go for his condition.
A brewing storm
The cases of Durga and John may well represent a larger problem coiling around Andhra’s rural landscape. The National Mental Health Survey, conducted by National Institute of Mental Health and Neurosciences (NIMHANS) across 12 States in the country in 2016, found that socio-economic factors played a key role in causing mental disorders. It found poverty, limited education and low social status to be closely linked with one’s mental state of being.
According to the survey, while the overall mental morbidity was higher among males, specific mental problems such as depression, anxiety and neurotic disorders were identified more among women.
NGO Vasavya Mahila Mandali’s survey, conducted in association with ‘The Live Love Laugh Foundation’ in several villages of Ibrahimpatnam mandal as part of a pilot project titled ‘Santwana’ or Community Mental Health Programme, found that over 440 people in 15 villages were suffering from mental disorders—women constituted approximately 70% of them, says project director Rama Rao, who earlier worked as District Programme Officer of National Health Mission in Guntur for 15 years.
“None of the individuals understood what was happening to them or where to seek help. It was only after we spoke to them that they realised it required medical care,” says Dr. Rama Rao. Out of 440-odd people, 216 are on medication. The others, presenting mild symptoms, are hesitant to seek medical care owing to the social stigma associated with it. Moreover, superstitions affected 30% of the 440 cases surveyed, added Dr. Rama Rao.
Noted psychiatrist and former president of the Indian Medical Association Indla Ramasubba Reddy says there could be many more in every mandal or district suffering silently. “Lack of awareness, stigma, superstitions, unavailability of easy mental healthcare access prevent people in rural areas from seeking medical help for mental disorders,” adds Dr. Ramasubba Reddy.
A solution, neglected
Back in 1996, the Centre launched the District Mental Health Programme (DMHP) in an attempt to bridge the gap between people and mental healthcare in rural areas. It is a component of the National Mental Health Programme (NMHP), which was launched in 1982 to ensure access to mental healthcare for all. Under the DMHP, mental healthcare is provided at the community level by integrating it with the general physical care delivery system.
To achieve this, frontline workers, including Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwife (ANMs), are given training to identify individuals with symptoms of mental disorders. Such people will be taken to the nearest Primary Health Centres (PHC) on the day of visit by a special medical team comprising a psychiatrist, a clinical psychologist, a social worker and a staff nurse.
For two days a week, this team provides outpatient services at an allotted hospital and makes field visits to PHCs in the district on the other four days.
As per information shared by the office of the Commissioner of Health and Family Welfare, the team is required to counsel symptomatic people and refer those requiring further treatment to government general hospitals (GGHs). Under the DMHP, at least one member of the team should visit a PHC once every 15 days.
The DMHP, however, is not functioning properly in the 13 new districts formed in the State in 2022, says Dr. Rama Rao, alleging that in other districts, too, the visits to the PHCs are not regular.
Dr. Ramasubba Reddy, too, feels that the programme has failed to achieve its objective of taking mental healthcare to people.
As per information received from a PHC doctor in Ibrahimpatnam mandal of the new district of NTR, who sought anonymity, the team is not making any visits in their area. However, a PHC doctor from Prakasam district said, who did not wish to be named, the visits are being made there. In Tirupati district, a front line worker told this reporter that no visit has been made in the past six months.
Responding to the allegation, an official from the office of Commissioner of Health and Family Welfare said, on condition of anonymity, that while every district needs to have a four-member team, 22 posts of psychiatrists and clinical psychologists (11 each) for the special teams lie vacant, and all of them are in the new districts.
“The Medical Recruitment Board has been apprised of the vacancies, and we expect the posts to be filled by next year,” the official said, adding that there are, however, Tele Manas helplines for those in need.
Time matters
Durga suffered alone for a month before help came to her from outreach workers during the NGO’s survey. They counselled her and referred her to the GGH. She shudders at the thought of what might have happened if she had not found help.
A dearth of access to mental healthcare affects one’s quality of life, productivity, family relations, finances, children and contribution to village activities, says Dr. Ramasubba Reddy, adding that treatment delay can also lead to addiction to alcohol or drugs or even people ending their lives. “They must receive immediate treatment,” he cautions.
Lakshmi, a 38-year-old resident of Mulapadu village, says she started feeling lonely and depressed after her daughter got married last year. She has been single since her husband left her 20 years ago.
When she withdrew herself from society and avoided going out, no one came to check on her. “When I told my brother I went to see a doctor, they [her family] laughed at me asking if I was going to the mental hospital. When my own family makes fun of me, what can I expect from others?” she asks. She later received counselling from the NGO workers.
Kesava, who works for ‘Santwana’, pointed out that ASHAs, ANMs and Anganwadi workers, who have direct contact with people in rural areas, do not have much understanding of mental health disorders. When asked, an ASHA from Tirupati, on the condition of anonymity, says while the newly joined frontliners know about the symptoms of mental disorders, senior ones do not. “There is not much awareness among ASHAs,” she says.
Distance severing treatment
In cases of mental disorders, it is critical that one completes their medication, he said. In the absence of the DMHP in NTR district, however, the distance from one’s village to the GGH has become a deterrent for many to seek timely medical care. Though Durga was put on a six–month medication, she has paused it currently as she has not got a chance to visit Vijayawada.
“I never go to the city alone. I wait until others from the neighbourhood also feel the need to visit the hospital. Usually, we wait until there are ten of us so we can share autorickshaw charges. If I go alone, it will cost me around ₹150, but ₹50 if I am going with others,” says Durga, not realising the repercussions of discontinuing her medicines.
Holding it together
Despite the poverty and social stigma, both Lakshmi and Durga have now taken it upon themselves to educate the public about mental disorders. Lakshmi recently took a young man, an alcoholic, to the Vijayawada Old GGH. “I am also taking my sister, who recently lost her child, to the doctor. When there is medical care available for our condition, why should anyone suffer?” she asks.
(Names of individuals with mental disorders have been changed)
(Those in distress can dial 14416 Tele MANAS for help)
Published – March 07, 2025 11:46 am IST