Our mental healthcare systems need no less of a boost

I have lost count of the people who are reaching out to our organization for mental health help amid the covid pandemic. I have been attending to increasing cases of delirium, psychosis, depression, phobia, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and dementia during this crisis. India has less than 9,000 psychiatrists to cater to a population of 1.3 billion. One patient came to our hospital with recurrent flashbacks of his traumatic ICU stay. He was easily irritable, had crying spells, and avoided reading or discussing anything related to covid. I made a diagnosis of PTSD, and started him on therapy and low-dose medication. His story is largely generalizable, and reflects the shadow pandemic of mental health disorders accompanying covid.

A reliance on intuition instead of data, lack of attention paid to experts, and a lackadaisical attitude by the bureaucracy have contributed in equal measure to the second wave. Our policymakers were misled into believing that the endgame was near when less than 1% of the country was vaccinated. Instead of augmenting the existing healthcare infrastructure, centres dedicated to covid care were dismantled after the first wave. The Centre and states continue to blame each other, while the reality is that neither stopped the other from dismantling covid care centres. To add to India’s woes, hospitals ran out of beds and oxygen. No attempt was made to stock up on these even after the first wave. All political parties had immersed themselves in election rallies. India’s largest religious congregation, the Kumbh Mela, also saw covid spreading amid pilgrims. Experts believe that it should never have taken place during the pandemic.

The healthcare system in India has been fragmented from its original state. India spends an abysmal fraction of its gross domestic product (GDP), estimated at under 2%, on healthcare, while the UK spends 12% of its GDP on healthcare and the US spends 17.7%. Previous governments have done little to strengthen India’s healthcare infrastructure. Primary health centres (PHCs) are the nerve centres of a country’s system to look after people. India’s PHCs are so poorly equipped that most go for private options, which account for the vast majority of health services. The country has world-class talent in the form of its doctors, but inadequate infrastructure is gnawing at its healthcare sector from within.

It is difficult to govern India in the best of times, let alone during an emergency. In the first wave, covid was largely restricted to our cities. It has now spread its tentacles to rural India, where most of India resides. The country has seen overflowing mortuaries, decomposed bodies with no one to attend to them, and soaring cremation and burial prices. Our covid mortality numbers are probably undercounts.

We need to prioritize the restructuring of our public health systems into two broad categories. Right now, we need a triage-based management plan for cases, and for the future, a long-term vision for existing structures. A data-driven approach incorporating inputs from epidemiologists and virologists to counter the pandemic is the need of the hour. Vaccine hesitancy remains high and should be countered with awareness programmes. The public should be given incentives to get vaccinated. The country needs vaccination at an unprecedented scale and at very high speed to break the chain of viral transmission.

Above all, we must learn from our follies, and invest more in the healthcare sector. Ill-planned policies over the last 70 years have created an acute dearth of healthcare workers. India has an estimated shortfall of 600,000 doctors and 2 million nurses. Medical education is key. Data from the ministry of human resources and development shows that India currently has only 88,000 MBBS seats per year, and this needs to increase to 150,000 seats per year at least. The PHCs of India should be enabled with proper infrastructural back-up and manpower. These PHCs could have clinical collaborations with medical colleges to ensure adequate staffing. Every district should have a 500-bedded tertiary care public hospital. Postgraduate seats should be increased to at least 1,00,000 per year in liaison with corporate hospitals and those attached to the railway sector. India also needs to reverse its brain-drain in the field of medicine to the extent possible. For this, pay scales of doctors have to rise significantly.

India’s National Mental Health Survey of 2015-16 identified a mental-health treatment gap of 70-92%. This should open our eyes to the importance of integrating mental healthcare with the general healthcare system of the country. Even before covid, we had a looming pandemic of mental health problems. It is only now that attention is being paid to this problem.

Chronic underfunding has plagued mental health systems globally. It is now time to change this narrative in the direction required. Since I am an incurable optimist, I can only hope that our leaders will invest enough time and energy in improving overall healthcare in our country. It is heart-breaking to see underserved segments of our country suffer in silence.

Alok V. Kulkarni is senior consultant psychiatrist, Manas Institute of Mental Health, Hubli