Lessons from the Erwadi Tragedy for Mental Health Care in India

Sir, The death of 26 persons with mental illness killed in the tragic fire accident on 6th August 2001 has again focussed the need for organised mental health care in the country. The response of the general population, the administrators, the politicians, the press and the professionals has been one of shock and outrage. The response to the single incident has been manifold. The press has seized the moment to throw light on the larger issues of mentally ill persons. Some of them have written about situations similar to ERWADI in Hyderabad, Ranchi, Ahmedabad, and Patiala. The National Human Rights Commission has called for a Report. The Supreme Court has initiated action on the matter. As a result, it can be expected that there will be many changes not only in Erwadi but also in the different parts of the country. There is need to view the tragedy in the larger perspective of the country situation and a longer time frame. The inhuman conditions in which persons with mental disorders are cared for were the focus of a NHRC Report (1999) released last year. The observations of the NHRC about the mental hospitals is very similar to the conditions in Erwadi as seen from the following excepts from the Report. " 38% of the hospitals still retain the jail like structure that they had at the time of inception... nine of the hospitals constructed before 1900 have a custodial type of architecture, compared to 4 built during pre-independence and one post-independence...57% have high walls ... patients are referred to as inmates' and persons in whose care the patients remain through most of the day are referred to as warders' and their supervisors as overseers 'and the different wards are referred to as enclosures', (p.32)... overcrowding in large hospitals was evident...(p.34) the overall ratio of cots: patient is 1:1.4 indicating that floor beds are a common occurrence in many hospitals { p37) in hospitals at Varanasi, Indore, Murshadabad and Ahmedabad patients are expected to urinate and defecate into open drain in public view(p38)....many hospitals have problems with running water...., water storage facilities are also poor in 70% of hospitals... .lighting is inadequate in 38% of the hospitals... .89% had closed wards while 51% had exclusively closed wards....43% have cells for isolation of patients(p.39)... leaking roofs, overflowing toilets .eroded floors, broken doors and windows are common sights (p.44)....privacy for patients was present in less than half the hospitals...seclusion rooms were present in 76% hospitals and used in majority of these hospitals....only 14% of the staff felt that their hospital inpatient facility was adequate(p.47)...in most hospitals case file recording was extremely inadequate less than half of the hospitals have clinical psychologists and psychiatric social workers...trained psychiatric nurses were present in less than 25% of the hospitals... (p.48)....even routine blood and urine tests were not available in more than 20% of hospitals...81% of the hospital in-charge reported that their staff position was inadequate(p.54)."This is the situation in 1999, somewhat similar to the situation in the hospitals in Western countries at the end of the 19th Century! The report notes "the deficiencies in the areas described so far are enough indicators that the rights of the mentally ill are grossly violated in mental hospitals"(p.50). As recommended by the NHRC, there is an urgent and massive need for change in the situation relating to mental hospitals, to become centers of care and treatment rather than be custodial institutions. The current attempt is to place this bigger picture and identify a variety of areas for intervention.