A nation is truly inclusive, rights and capabilities promotive, and embedded in a culture that values justice and equity when it respects and cares for its most vulnerable. Despite progress in science and technology, and strong nudges in the direction of development and growth, the lives of one segment of society — homeless persons with mental illness — remain unchanged. This group lives on the fringes, invisible and forgotten.
“I was so unwell that I offered to sell my child for a bowl of curd rice. If I hadn’t been rescued by the police and introduced into a treatment system, I would have lost my child forever.”
“The maggots jumping out of my unhealed wounds… they didn’t grab anyone’s attention. And I was too ill to feel them myself. My matted hair, soiled clothes, stench and unsavoury demeanour, however, did. I was swept away from the centre of the city where the rich lived to a slum-like area that would tolerate people like me.”
“The voices — they drove me mad. They were angry, judging and unkind. In hindsight, quite like the world we live in.”
These are voices of homeless persons with mental illness; individuals who continue to struggle in a world that prides itself on advancements in rights and morality. The state, science and society have failed this group on many counts. In this fast-paced world, the capacity to engage and to remain engaged with persistent problems is limited, especially with those problems that open up ambiguities and pose everyday challenges.
Despite progressive human rights legislation meant to preserve individuality, the rights of this group remain largely violated. Freedom is an essential attribute of what these rights constitutes. I would, however, argue that freedom, when placed in the capabilities framework, thrives much more. Thus, merely addressing the right to live freely on the streets is disregarding the more valuable right to a full life.
It is no coincidence that both World Mental Health Day and World Homeless Day occur on the same date. The relationship between mental illness and homelessness is bi-directional and tragically symbiotic, each bolstering the other. Abject poverty and social disadvantage, untreated mental or physical illness, migration, and poor access to healthcare are some of the causal pathways that render a person homeless. Particularly vulnerable are persons with mental illness who either lose their primary caregiver, or experience multi-dimensional distress on account of glaring inequities and social deficits such as poor nutrition, unemployment and inappropriate housing.
Limited mechanisms are available to respond to this crisis today. While the Supreme Court directive that mandated the presence of a shelter for every one lakh population has been gradually gathering momentum, its implementation remains somewhat uncertain and ambivalent in the case of this constituency that presents a complex set of problems.
Existing care pathways — apart from these shelters — include mental hospitals, civil society organisations, beggars’ homes and, sometimes, prisons. Mental hospitals often hesitate to admit such persons owing to cumbersome judicial procedures, persistent and chronic mental illness that often doesn’t remit easily, absence of a caregiver, and human rights related challenges. Even when they do admit the patient, the state of mental hospitals in our country leaves a lot to be desired. The lacunae are not just in their poor management. Running a large facility that caters at any point to around 500 to 1,000 individuals, all afflicted with a range of mental disorders, in an environment ridden with limitations and scarcity, particularly inadequate human resources, would be an impossible task even for a high quality management team. Further, mental hospitals carry the legacy of their rather unpalatable history of power play and social exclusion.
For many homeless persons who have no family or home to return to, long-term institutional care remains the only option. This results in people languishing in mental hospitals for extraordinarily long periods of time. A spectrum of services for homeless persons with mental disorders needs to be developed, including care on the streets, inclusive living options in the community, counselling kiosks, social entitlements, skills development and livelihoods facilitation. The first Indian Mental Health Policy and the proposed Mental Health Care Bill refer to the unique needs of this vulnerable group. While this signifies positive intent and affirmative action, its translation into meaningful response on the ground calls for a more concrete, tangible and strategic action plan.
In this context, state, science and society have key roles to play: the state because it will have to liaise effectively with many stakeholders and use convergence as a strategy to respond to the layered needs of this group; science because it will have to find an evidence base — from practice, existing models of care, and grassroots level social innovations — to build strong and varied experiments in different settings that are contextually relevant and culturally nuanced. Society, because we have thrust upon these persons the unitary identity of a homeless or mentally-ill person and used it as a central feature of oppression, disregarding the transience and multi-dimensionality in one’s identity construction. These men and women were born in homes like you and me. They aspired for a bright life like you and me. Somewhere down the line, their lives changed, as they were deprived of what you and I continue to enjoy — life, health and personhood. And then their narrative changed.
At the turn of the century, Martha Nussbaum listed 10 central capabilities that she thought were integral to every individual. Homeless persons with mental illness are deprived of almost every capability on this list, be it bodily integrity or bodily health, the ability to affiliate, play, exercise political will, own individual space or exercise control over one’s environment. Despite the explicit emphasis in our Constitution, to protect all its citizens, especially those who are fragile, both the State and us — its people — have failed to uphold this value and vision in action and spirit. It’s now time to reverse this trend.
The writer is co-founder of The Banyan and the Banyan Academy of Leadership in Mental Health (BALM).
