(The struggle against the mental health laws is not a new one. This report is archival, covering a Bombay High Court Case on the status of mental hospital services in Maharashtra with recommendations for reform. Malati Tai Ranade was a crusader for human rights of institutionalized patients and she left behind a legacy of struggles of the forgotten peoples of the Indian state asylums. She initiated these procedures in the Mumbai High Court)
A CASE STUDY and a PLATFORM FOR DIALOGUE
Center for Advocacy in Mental Health, Pune
Credits and acknowledgements:
These materials were prepared for the CAMH workshop on “Facilitating Legal Activism in Mental Health 2- Mahajan Committee Report”, held at YMCA, Pune, on 20th October 2001. The papers and collections given to us by Malati Ranade are housed in our Library and documentation center. This compilation from our archives was done by Seema Kakade.
Remembering Malati Ranade
(August 10th, 1915- October 3rd 2001)
For me, meeting Malatitai was a rare and transforming event. Although we met very briefly (only 3 times just before she passed away), I carry with me a lasting impression of her, her energy and her fire. Meeting her, and talking to her at a time when her health was quite fragile, was one of those “aha” experiences I shall not forget. Those in our Center who engaged with her writings came away with astonishment and awe at the magnitude of her courage.
We dedicate this document and our ongoing advocacy activities relating to hospitals to Malatitai Ranade, the first psychiatric social worker to be appointed by the Yeravada Mental Hospital, Pune. I was very much overwhelmed by interacting with her personally over the last few months as well as reading about her awesome efforts in bringing quality care within hospital practices. At our Center, reading her work, we have been constantly amazed at how a “lower cadre” staff at the hospital can be so furiously committed to patient care and remain ever so motivated through a long career of 26 years. While many of us are talking about the reality of “staff burnout”, we have often wondered about the enormity of energies, which kept her full of spirit and enthusiasm. She has the singular distinction of having fought with every Superintendent in Yeravada and we salute her for this. We have been amazed at how, after this long tenure, she could continue with her crusading effort at reforming the hospital by independently accessing the law. Her distinguished career alone would have been enough justification for her to just retire peacefully from troubling issues and plan a gentler retirement life. Not she!! She had to move from government service to high court, file writ petitions, plan legal options and strategies, and fight a lonely battle till nearly the end. She had a sense of urgency that her legacy should carry on after her. It was this, which fired her to somehow trace our small, low profile organisation and start interacting with us.
I will always cherish the three long conversations that she had with me just before she passed on, the last one in the hospital where she was admitted. At the time, she had promised to attend our workshop on the Mahajan Committee Report. We discussed how we could organise transport and a wheelchair, if need be, so that she could come. A few days before the workshop, she passed on.
For us, working in community mental health, she is an icon and we cherish her memory. We are moved and grateful that she trusted us with all her precious legal papers and documents, and other general writings. She has left us a legacy with the hope that we all will move forward from where left off. We dedicate our ongoing work in institutional reform to her. In this document, we present snippets from the collection of papers that she left us.
Usually, when we see planning, policy, rights or advocacy papers, we see very distinguished professionals, scholars and doctors. Those in the public domain are often the administrators, superintendents, directors and those in charge of that mammoth system called ‘Public health’. So it is utter delight that we present here a view from the underbelly of this gargantuan colonial system, from someone low enough in the staff cadre to be more often dismissed as para-professional or a support staff.
Center for Advocacy in Mental Health, 2001
1. Malati Tai, the Lady who unleashed unheard voices
It became imperative for her to fight back injustice, when everyday she saw gross violation of human rights, taking place in the mental hospital. That is how unleashing unheard voices became her life’s mission. Malati Ranade was the first psychiatric social worker to be appointed at Yeravada Mental Hospital, Pune. She joined as a Social worker, in 1949, and retired in 1973. Sustaining for such a long period, in spite of disheartening encounters with the bureaucratic set up and without any support system, might have been an arduous task. But even after retirement, Malati Ranade did not give up this task. She provided free counselling and services to many patients from the hospital. She portrayed these experiences in her book, ‘Manorugnanchya Katha ani Wyatha’ (“Stories and Miseries of the Mental Patients”).
In 1988, Mr. Shukri from Bombay filed a writ petition in the Bombay High Court. He complained that his mother, who was an inmate of Yeravada Mental Hospital, died due to negligence of the staff. The High Court appointed a committee to look into the affairs at the Hospital. The committee was directed to submit a report regarding the improvements that needed to be carried out. The Committee was known by the name of its chairman; Dr. Mahajan. Malati Ranade was of the members of Mahajan committee. In 1989, the committee submitted its report along with sixty-eight recommendations. Malati Ranade felt these were inadequate. She penned down a separate report, emphasizing the need to adapt a humane approach towards the patients. The “Refresher Course” designed by her for the psychiatric social worker reflects her valuable insights. However, her report was not accepted on the ground that it was submitted late. Malati Ranade did not surrender. She exposed the apathy and hypocrisy of the hospital staff as well as the High Court at every stage. In a way, she challenged the existing power equations. However, her unvarying efforts did not bear any fruit. The High Court disclosed the matter by disposing off the case in 1998.
The Mahajan Committee episode is not an out of date account. On the contrary, it represents the current phenomenon very effectively. This handbook is an attempt to provide a framework for addressing issues pertaining to the rights of the mentally ill persons, a due homage to Malati Ranade, who has set a model in the field of mental health advocacy. She would remain a source of inspiration for everybody, who wants to serve the cause of persons with mental illness.
2. Institutional Treatment: Cure or a Curse?
Malati Ranade, in one of her interviews to a Marathi Magazine said, a majority of the patients who are on the path of improving, never recover fully, just because of lack of affectionate human contact and inhumane living conditions.
At times, there was only one tap for the purpose of taking baths and drinking water, in a ward for several months, there was no tap in the latrines.
Walls were red with dead bedbugs, and most of the patients couldn’t get any sleep at night.
Every patient was given a bath twice a week. 10-12 patients were shoved into one bathroom, in the nude. Attendant then first poured soap water & then threw a few mugs of water to wash off the soap. Towels were not adequate, and seldom the patient got laundered-clean clothes to wear.
No wonder, the patients were found to be suffering from white lice on their bodies.
All the patients never got food on time, because sufficient numbers of plates were never served, for the reason that they get misplaced.
Preparing tea: when 40 kgs. of Sugar was required only 9 kgs. would be used, and instead of 80 litres, only 40 litres milk would be used.
The “Ayahs” were called “Rakshashinis” (she demons) by the patients, and the psychiatric doctors as “shock-doctors”, as they did not provide any other psychiatric treatment than electric shock treatment (Electro Convulsive Therapy).
Once, a 25-year lad expired within 9 months. During this period he did not get any treatment other than 17 electric shocks. Records did not mention any severe disease as a cause for his death. Five months after his admission, he was transformed to the ward for weak patients, one day he was recorded as ‘serious’, and the next day register recorded his expiry. There was no discussion about this death.
Patients, who were on the road to recovery and the chronic patients both, were kept together. Due to lack of supervision and efficient management, such recovering patients had to undergo severe mental torture. Many of them even relapsed, reinforcing the saying “once a patient, always a patient.”
In some wards, there was excess number of staff, while in some there was total absence of them. Medical Staff was underemployed, as very few patients required “medical treatment.” Rehabilitation was absent. Therefore, these doctors had to spend most of their time in playing chess.
In 1980, there were 1100 lower & higher grade employees at the hospital to look after 2700 patients, still none of them could shoulder the responsibility of arranging recreational activities for them. Thus, although recreational activities proved to be facilitating recovery and rehabilitation of the patients, they did not continue more than a month.
Crores of rupees were spent on the hospital, however only one third of the amount was spent directly on the mental patients, while 2/3rd was spent on running expenses.
None of the higher-grade authorities bothered to follow the provisions under Indian-Lunacy Act. Visitors’ Committee provides strong evidence to this statement. The Visitors’ Committee was supposed to both visit the hospital and monitor the conditions. However, neither did this committee take a single round in the whole hospital, nor did it find a single objectionable instance, although misappropriation, apathy and cruelty towards the patients, were an everyday practice.
(Source: pages 4 -21,Shree Weekly, September 27, 1980.)
Although, the Mental Health Act (1987) replaces the term ‘asylum’, by ‘Hospital’, it has not changed the attitudes of the staff. This is evident in the treatment given to patients by staff. Malati Ranade’s description of a “good patient” pinpoints this irony:
“The Asylum does not accept that the mentally ill patients have their rights. If the patients complain of harassment by fellow patients or have disagreements with the attendants or other members of the staff, the latter have the right to lock them up in the “excited” ward. A well-behaved patient is one who sits quietly in one place for hours together, one who accepts cold tasteless food without any complaint or a meagre cup of cold tea without a murmur of protest, one who is completely docile and dumb. A person who accepts being herded like cattle into halls and from halls to wards, a person who accepts dirty soiled mattresses and stinking sheets and does not complain about disturbed sleep. Such patients are considered good patients by the staff, people without a spark of life, who it is very easy to keep in “safe custody”
(Source: page 8, Mental Hospital at Yerawada , Malati Ranade,1989)
3. Unsuccessful Reforms
Malati Ranade also gives us an account of the failure of reform – opportunities to introduce any structural innovation, required to address the real issues. Whatever changes took place, were unfortunately superficial in nature:
A) After independence, mental hospitals were included in the five-year plan and a tremendous increase of staff was recommended. However, quantitative improvement did not lead to any qualitative improvement. Care and services provided to the patients did not change a single bit.
B) In 1958-59, the Government acknowledged the need for a substantial measure against the degrading conditions in mental hospitals and appointed a committee for their expansion and improvement. Superintendents of all mental hospitals were members of this committee and well-known medical and psychiatric experts were appointed as President and Secretary.
However, in spite of a number of meetings and visits to the hospital, recommendations of the committee were rendered mere scrap-material, as they were perceived to be “impractical”, by hospital authorities. This was indeed an irony, because none of the superintendents could suggest even a single practical measure for the betterment of their patients.
C) Around 1960s, an article appeared in the “Readers’ Digest”, entitled “Mental Hospital with Open Doors” written by the superintendent of Dingelton Mental Hospital. This superintendent had given an account of a revolutionary experiment – “open door mental hospital”. The doors of the mental hospital cannot be unlocked suddenly, as it would lead to chaos, however, every endeavour must be made to improve the nurse-patient relationship. When a satisfactory stage of nurse-patient relationship is reached, then the doors can be thrown open. This implies a “dialogue with the patient”. Nurses learn to work as “healers” instead of as mere “jailors”, and as a result, patients feel wanted and secure, which lead to their recovery. This was the core of the experiment. This new approach proved to be extremely useful even in the treatment of chronic patients. Government took cognisance of this article and called a meeting of superintendents of four mental hospitals in Maharashtra. Creation of an “open door ward” was the result. This served the purpose of separating new admissions from chronic patients. Thus new patients got freedom and company of patients, who were on the road to recovery. However, epileptic and chronic patients were left out, and even those who were included, could not benefit to the optimum, as the words “open-doors” were taken literally, and the very spirit, viz – “satisfactory nurse – patient relationship” was completely ignored. Thus, the miserable, inhuman conditions at the hospitals remained the same.
Malati Ranade was optimistic, inspite of these disheartening episodes, that is why she has described the appointment of “Mahajan Committee” as “another opportunity to improve conditions in the hospital”.
(Source: page 20 -24, The Mental Hospital at Yerawada, Malati Ranade, 1989.)
4. Why was Mahajan Committee appointed?
When a majority of the mental patients and their relatives have to be mute sufferers, one Mr. Shukri filed a writ petition (No. 7560) in Bombay High Court in 1988. He complained that his mother, who was an inmate of Yeravada Mental Hospital, had died due to negligence of the hospital staff. Mahajan. Committee was appointed in response to this petition by the High Court. The Committee was directed to look into the affairs of the hospital and submit a report about the improvements needed to be carried out.
Malati Ranade was invited to be a member of this committee. Other members from the committee were:
1. Dr. V.R. Mahajan (Central Institute of Mental Health and Research, Pune.)
2. Dr. (Mrs.) Blanche Barnes (S.N.D.T. Women’s University.)
3. Dr. V.R.Deo retired Superintendent (Mental Health Institute, Pune.)
4. Mr. D.D. Naik (Advocate, Bombay.)
(Source: pages 24-25, Mental Hospital at Yeravada, Malati Ranade, 1989.)
5. Mr. Shukri’s Petition
Before going into the details of Mahajan Committee Report, it would be worthwhile to have a glance at the petition filed by Mr. Shukri. We reproduce the petition in full below:
Dated : July 1988
The Hon’ble Chief Justice,
& the other judges,
of the Hon’ble Bombay High Court,
BOMBAY 400 032.
I) The squalid state of affairs, and unhygienic and dreadful condition of the wards, appalling callousness and gross negligence on part of Doctors and staff of the “Central Institute Of Mental Hygiene And Research”, Yeravada, Pune.
II) Illogical and tragic death of my mother in the infirmary of the above hospital due to severe dehydration.
With due respect to this Hon’ble High Court, I the undersigned, a deeply aggrieved, despondent and oppressed person, residing in Bombay at the above mentioned address feels exigent and important to bring the prevailing state of affairs of the afore said Institute to the notice of this High and Honorable office of Law and Order.
On my part, I would feel myself an offender towards society if I do not unmask the ugly, blotted and black faces of so called medical staff, who with their butcherism are playing with the lives and destiny of hundreds and thousands of patients in the so called central institute of mental hygiene and research.
Honorable Sirs I shudder with sweat to submit the appalling and brutal callousness of the doctors who treat their patients so disgusting with utter infuriation and shameful aversion, and the butcheries of the attendants and the servants who do not feel themselves ashamed in beating up the helpless patients so violently, and who do not hesitate to inflict or cause to inflict corporal injuries on the body of patients under their care. The staff act as if they are the lords of the hospital and the patients under their “kind” care were not human being but animals. Humble Sirs, it will be in true fitness to call therefore country’s this greatest institute of its kind as “Central Institute of Destitutional Hygiene and Research on Merciless Killing.”
My mother was admitted in the above Institute on 8th June 1988 vide order no. NA 37/88 passed by Judicial Magistrate P.C. of Court No. 4 Pune, for her necessary treatment, who becoming a victim of doctor’s bureaucratic callousness expired on 26th June 1988, due to the reason of severe dehydration, as maintained by the doctors. A few days before her death only, I had decided to take her discharge, but the fake and false assurances of those awfully shrewd doctors made me feel however to postpone it, in great hopes to see my mother in improved condition. I, having visited her for five continued days during 19.6.88 to 28.6.88, left for Bombay in the late evening on 23.6.88. Before returning to Bombay I had good consultations with the senior doctors and staff responsible for the patient’s treatment, to know whether my mother was in any serious state or condition. I was told by them that my mother was not in a serious condition and I should not worry about her so much. A senior doctor, when consulted by me, he informed that the patient needed more medical care and was not serious, and as such he advised there was no point for me to worry. In view of the injuries which were sustained by the patient in the infirmary on her head, and to know the state of her condition as also for my dissatisfaction over the treatment and care, when I contacted the Superintendent, he told me that he already had passed his good instructions in this respect, and he told he had visited the patient as was requested by me. He further added to my enquiry that a particular injury (a distinct lump) was an old one on her forehead. He assured that the things with my mother were alright except the weakness, and further assured that the patient will be looked after with due care. On consulting, the doctor explained that he had once visited the patient and has passed necessary instructions and would further be visiting as and when needed. assured me of extending all the possible care and treatment to the patient in case it becomes necessary. He also advised me that I should not worry at all and should not wait there any more but return to attend my work in Bombay, since the patient as he added, was not in any serious condition of state.
Therefore on the basis of such advise and assurances extended to me by the responsible doctors, I preferred to continue my mother in the hospital for a few days more and postpone my decision of taking a discharge for the next week, and left for Bombay some what satisfied.
The superintendent, although I paid on demand the medical examination charges, but did never examine the patient before or after her admission, which I expected him to do at the time of admission. His peon or ward-boy, who displayed a malafied courtesy in me from the main gate of the hospital to the Superintendent on the first day of my visit with the patient, acted as an agent for admission. He forced me to pay to the doctor his so called medical examination fee at Rs. 50, otherwise without which as he determined the medical examination and admission were not possible. He further demanded an amount of Rs. 300/- as the expenses of other formalities which however I did not pay. But, the office staff who is responsible to look into new admissions collected Rs. 150/- from me as court expenses. I was further advised to avail of the facilities of a special ayah as private attendant to the patient, which is provided by the hospital, and accordingly the hospital office engaged a special ayah as private attendant to the patient. I paid the extra charges for the special attendant the very next day of admission, but an in-experienced and irregular attendant was arranged by the hospital on the seventh day i.e. on 15.6.88. We were further instructed not to visit the patient for further 11 days from the date of admission as it was a rule, though I wished to continue visiting the patient for a few days more but then was unable.
Hon’ble Sirs, to sum up the clouded affairs of the saddest incident most tragically I am bereaved in my life by the so called custodians of hygiene and protectors of lives, I become mentally frenzied to realize that all my efforts; verbal, physical, moral and monetary I had rendered in my small capacity in great hopes to see my mother’s good care and treatment were in vain. My repeated requests to the staff concerned fell on deaf ears with no moral and practical response but promises and assurances only. During all my visits I noticed that my mother was not given with any glucose normal saline or proper medicines or proper diet. I was simply assured all the time that she will be given such things as and when she needed. I feel that the doctors have made no efforts either to look into patient’s improvement or to save her life. The doctors even ignored the careless and rough handling of my mother by the ward servants, which twice had caused injuries on her head. I strongly feel, my mother being in the hospital surrounded by medical staff under all the possible facilities could have received anticipatory care and remedial treatment, the dehydration developed was therefore due to negligence and the death occurred of dehydration was due to further negligence.
The doctors staying close by the Hospital are supposed to be available at short notice but it was a rare case that a particular doctor was found at his place of duty or at home. The cot of the patient in the so-called infirmary was full of bed bugs. The entire female Infirmary looked filthy, stinky, and unhygienic. The clothing of the patients was found unclean and dirty. The ward servants aggressively force a routine of their behaviour. One of them as I personally experienced, acted in a most disgustingly and extremely unfair manner. She appeared to be worst than any other patient present there, or mischievously quarrelsome with certain intentions for no apparent reasons, and behaved herself extremely uncivilized and barbaric.
The entire staff of the “Institute” from top to bottom is out of their duty conscience, and are in habit of paying no heeds to patients under whatsoever serious be their conditions. They are dangerously accustomed to negligence and carelessness as their normal routine. The ailing patients lay helpless by virtue under their mercy, therefore no relatives of any patients could ever dare to question them or argue over their negligence or contemptible attitude, apprehending which perhaps could bring adverse results over, their nearest and dearest under their control. The staff in the hospital understands that nobody could do anything against them, for the obvious reason that they were the Governments permanent employees. Therefore, taking anyone of them to task for their wrongs either by any superior or visitor could bring no result or improvements in the spoiled set up. As described by one of the authorities, it could result into her own transfer the moment she tries to interfere or question the other staff. The staff is habituated to pushing up the responsibility on each other and express great aversion and arrogance over the visiting relatives. The departments are extremely passive and lousy and their internal communications with each other, as a result of which the matters of emergency are also delayed to the criminal extent and the relatives themselves have to run up and down helplessly and miserably. The regular strength of the staff as put up in the Superintendent’s office is 1131 besides unspecified strength of private special attendants arranged by the hospital and casual labours. Thus, the ratio of the staff with around 3000 patients comes in a close proportion as 1:2 or may be 1:3, which shows that the hospital is sufficiently equipped as far as the staff strength, is concerned.
Your lordships, I want to know, is this biggest Govt. hospital of our country meant to cure only the mental patients of strong health? Or is it to treat Govt. employees only? Or else, is the hospital staff obliged to cure the patients allegedly involved in criminal offences only so to make them physically and mentally healthy enough for their court trials or punishments? Is it not meant to cure with the similar care the other hundreds of patients of different categories, of different age under different physical conditions, being unfortunate of having different mental discordances? In the case of my mother the dreadful callousness of staff resulted into severe dehydration. I wonder, the patient could have received all the possible treatment including oral; intravenous, glucose or saline, or at least plain water, which was conveniently consumable by the patient orally. During the span of my last visits from 19.6.88 to 23.6.88 neither any time I was informed nor I felt myself any symptoms of dehydration or diarrhoea on the patient. Therefore I suspect that the staff was not at all alert of the changing state of the patient. And your Lordship I strongly feel that my mother died due to gross negligence and carelessness. Another cause of death as specified is diarrhoea. It is difficult to believe how it could develop so rapidly to become fatal which could have been avoided by treating the patient in time with needed medicines and alternative diet.
The saddest point on part of learned doctors, who have assured me of their best attention and good medical treatment is this, that the doctors most concerned and responsible for the patients had no knowledge of the demise. After hours together had passed, the concerned doctors received the information, all of them came to know of the sad news when only informed by us on approaching them. The necessity of informing the Superintendent of the demise did not arise as the Superintendent was out of town as usual. I feel pity over the state of affairs to imagine that the doctors who had no news at all of the death of their patient under their “best attention”! What sort of efforts or what kind of anticipatory treatment they might have ever rendered before and after the patient’s condition had tended to a serious state?
Your Lordships, I question with blood boiling in me, and tears in my eyes, is whether the formerly known simple mental hospital upgraded or changed decoratively into “Central Institute of Mental Hygiene and Research” just to deceive the innocent public? Or to meet the high salaries of those useless careless and moral less staff for their foul plays and misappropriating hospital expenditures out of the earnest funds of the public exchequer? Or to equip that squalid hospital not with any sophisticated but at least with needed amenities for its those deteriorated wards in which far away thinking from an amenity, a mere glass of water is never found kept at the access of an ailing patient who was unable to stand on her own feet.
Hon’ble Sirs, I hail from a family of Bombay whose members are known to have fought for the cause of public. To avail the needed treatment in any government hospital is one of the fundamental rights of the bonafide citizen of this country without any discrimination of what so ever respect. I feel if this condition is the very concern of public’s great and essential cause remains unstirred and due justice remains untended to it by this hon’ble High Court, then the corrupt and dirty stream of the set up of that institute will continue causing severe damages and sufferings to the society, and as for me, I would be compelled to disbelieve any supremacy of judiciary in this social secular and democratic country. Your Lordships this hon’ble High Court or no other place of justice can ever bring my mother back over to me, those awful doctors have made devoid of whose shadow from my life. None can ever compensate me for my loss I suffered in the death of my mother in any best way. But, if your lordships would please to institute a detailed inquiry, the facts pertaining to the squalid state of affairs of that great hospital and the bureaucracy and corrupt practices of the staff in it will come to light.
I earnestly request your Lordships to please hold an enquiry into the GENERAL WORKING of that institute and also the surprise inspections of the unhygienic and dreadful wards so that it should not be repeated again in case of other citizens and patients are not compelled to meet the unfortunate fate of my beloved mother.
J A I H I N D
A Despondent Citizen
The Mahajan Committee was appointed in response to this petition.
6. The Mahajan Committee Report:
The Mahajan Committee was constituted in March 1989 following/pursuant to the order of the Bombay High Court in Writ Petition No. 5760 of 1988. The Committee was appointed to look into the affairs of the Central Institute of Mental Hygiene and Research, Yerawada, Pune; and to submit a report about the improvements to be carried out in the Hospital. The Committee had several meetings and visits to the Hospital, and came out with the Mahajan Committee Report on 5th August, 1989. The Report has taken up 8 specific aspects:
(iii) Staff for the care of the patients
(iv) Method of treatment
(v) Conditions at the hospital
(vi) Internal control
(vii) Orientation and
(viii) Arrangement for specialised treatment.
The Report makes recommendations with regards to each of the above 8 aspects, and the following are the brief observations of the Committee on each aspect.
It was found that the environment and general atmosphere in the hospital is not congenial to the well-being of the patients and it is not helpful to improve their mental conditions. “The Committee members took a round inside the walled area of the Hospital with a view to ascertain how far the environment and general atmosphere in the Hospital area was congenial to the well-being of the patients and could help to improve their mental conditions. After visits to the wards and dormitories the members of the Committee came to the conclusion that the patients were living in an environment which could not promote their physical and mental well-being.” The structure was in a dilapidated condition and required immediate repairs. The sanitation facilities were inadequate.
According to the Report, the patients in the hospital are not living in good, humane, psychological and physical environment. The psychiatric treatment given does not correspond with the modern methods of treatment. Due attention was not being given to the patients.
It was observed that the hospital incurs 62% of its total expenditure on its staff. However, the patients were being neglected. The patients were subjected to manual labour and there were instances of injuries inflicted on patients. “No proper watch on the conduct of the member of the staff entrusted with the care of the patients was being kept. Similarly close watch on the conditions of the patients was not being kept.”
(iv) Method of treatment:
The medical staff concerned with treatment of patients is psychiatrists, clinical psychologists, psychiatric social workers, and medical officers o general duty. “This line of treatment is not likely to give the desired results as the method adopted does not give scope to reach to the root of the cause of illness of the patient”. The modes of treatment adopted are quite outdated and patients have to languish in the hospital for years. Menial labour had been prescribed as a mode of treatment – and to do work for which paid employees have been appointed in the hospital.
(v) Conditions at the hospital:
The Report states that the patients in the hospital are compelled to live in such conditions that it appears that they are not being considered as human beings. They are locked up inside their wards between 6 p.m. and 7 a.m., and thereafter, they are locked in the dining hall, where they have to spend the entire day. Hygiene conditions are poor, and the food served is sub-standard.
“The aims and objects of the new legislation and the methods like group therapy, recreational therapy, psycho drama, music therapy, etc. all these winds of change have not reached the doors of this Hospital.
“A soap water is sprinkled on patients and thereafter cold water is sprayed like on the cattle or on the cars for cleaning. After a bath in such a manner is given the patients are made to dry themselves in the open without any towel to soak the water.”
(vi) Internal control:
The Superintendent heads the structure of internal control. The Deputy Superintendent assists the Superintendent. The Committee observed that there is a lack of proper system of internal control. There is also a lack of proper coordination. There is no security arrangement to protect the property of the hospital.
(vii) Orientation and training of staff:
The Committee observed that the staff of the hospital needs proper training, to develop the right attitude towards the patients. “There is therefore an immediate need of conducting orientation training programme for the members of staff at all levels. These training programmes should aim at bringing about a desirable change in the attitude of the members of the staff towards the patients, to increase their professional skill and to acquaint them with the modern methods of treatment of staff to discharge their duties and responsibilities with better understanding and required efficiency.”
(viii) Arrangement for specialised treatment:
Muktangan, a special ward was established in the Hospital in 1986 for drug and alcoholic addicts. The treatment is meted out in 6 weeks, and includes group therapy and counselling.
7. Summary of Mahajan Committee Recommendations:
The following is a summary of all the recommendations of the Mahajan Committee, contained in Chapter X of the Report:
(a) Immediate steps to be taken to improve the environment conditions by creating a more humane and pleasing environment wherein the patients can live with human dignity.
(b) Dilapidated buildings to be repaired or reconstructed.
(c) Additional dormitories or wads to be constructed to provide sufficient living space to patients.
(d) Essential amenities, such as drinking water and toilet facilities to be provided inside the wards.
(e) Bathrooms and lavatories to be kept clean, and provided with water.
(f) Construction of new wards and dormitories to enable patients to live in comfort and safety and ensure their privacy.
(a) No patient should be made to do menial work, which is to be done by hospital employees.
(b) No patient should be subjected to cruelty.
(c) Drab and obnoxious clothing and clothing used by other patients should not be given to patients for use.
(d) Patients should be provided with a cot, mattress and sufficient linen, which is frequently changed.
(e) Patients should be given a bath daily and should be provided with toiletries. Attention should be paid towards the cleanliness of patients.
(f) Medical examination of patients should be conducted on a weekly basis.
(g) Wholesome diet should be provided to patients.
(a) Staff should be provided with orientation and regular in-house training.
(b) Staff should be assigned duties, and duty charts to be accordingly prepared.
(c) Medical officers on duty should make rounds of hospitals and record their findings in day record book. Medical officers should be available in the duty room in the hospital.
(d) Observations about patients should be recorded in the night round book.
(e) Employees treating patients in a cruel manner should be strictly dealt with.
(f) Special arrangements should be made for emergency cases.
(iv) Method of treatment
(a) The individual treatment plan should be prepared by qualified professionals for each patient. Medical professionals should constantly review this individual treatment plan.
(b) Patients should undergo a comprehensive physical and mental examination on admission.
(c) Appropriate treatment for physical illness should be available in mental health institutions.
(d) Case file and medical record of the patient should be maintained.
(e) E.C.T. (Electro convulsive Therapy) should be given in modified form and in decentralised units. Patients undergoing E.C.T. should not witness shock treatment received by other patients.
(g) Code of conduct prescribed in the manual with regard to duties and responsibilities of medical and nursing staff should be strictly enforced.
(h) Sufficient number of clinical psychologists should be appointed.
(v) Degrading Conditions:
(a) Not more than six patients should be kept in a room. Each patient should be allocated a minimum of 56 ft. floor space.
(b) New wards and dormitories should be constructed and existing wards should be repaired. Wards should be periodically treated for pest control. Sufficient toilet and lavatory facility should be provided inside wards, and such facility should ensure privacy to patients.
(c) Bathing facilities should be provided in a manner so as to ensure privacy. Both hot and cold water facility to be provided.
(d) Patients should be provided with proper dining facilities.
(e) Kitchen should be properly maintained and diet should be constantly changed. The co-operative society of the staff should not be awarded contract for supplying provision or any other material.
(f) The system of keeping patients locked up should be discontinued.
(vi) Internal Control:
(a) Post of Superintendent should be upgraded to Senior Class I Officer. Post of Deputy Superintendent should be upgraded to Class I Officer. Deputy Superintendent should co-ordinate the work of psychiatrists, clinical psychologists and psychiatric social workers. Staff should be under administrative control of the Deputy Superintendent.
(b) A special House-Keeping Department should be created for maintaining cleanliness of wards, etc.
(c) Watch and Ward Department should be created for making security arrangements and protecting property of hospital.
(d) Post of Personnel Manager should be created to deal with matters pertaining to staff and employees.
(e) Matron trained and qualified in psychiatric treatment methods should be appointed. A post for male nurse equivalent to that of the matron should be created.
(f) Senior Administrative Officer trained in hospital management should be appointed to look after the entire management of hospital, subject to the control of the Superintendent.
(a) A Comprehensive orientation programme should be conducted for staff at all levels.
(b) Syllabus of the training course should include legal provisions and provisions relating to functioning and management of mental health institutions.
(c) Short term and long-term courses to be conducted. These courses are necessary to acquaint the staff with new approaches in treating patients with mental disorder.
(d) Intensive training should be given to the staff to ensure that the staff will perform their respective jobs efficiently.
(e) The role of psychiatrists, clinical psychologists and psychiatric social workers should be defined and co-ordinated. Workshops and training programmes should be conducted for specialists in which their respective roles should be explained.
(viii) Arrangement for specialised treatment
(a) “Muktangan”, a ward for drug and alcohol addicts should be brought under control of the mental health institution. The staff of Muktangan to be brought under administrative, disciplinary and financial control of the institution
(b) Survey and research to ascertain the effectiveness of the six weeks course of de-addiction should be carried out.
8. Limitations of the Mahajan Committee Recommendations:
Emphasis on the quantitative aspects of hospital life seems to be a prominent feature of these recommendations. Malati Ranade felt that these were inadequate and penned down a separate report, in order to draw attention to the ground-realities of the issue. “A Note on Psychiatric Social Work” by Malati Ranade highlights the qualitative aspects, which were not addressed in the recommendations. Her separate submission later on to the court was rejected on grounds of “being late”. Even a small excerpt from this report illustrates the dire need to address the qualitative issues. For Malatitai, the snake pit was a lasting metaphor for describing the condition of the residents in the hospital.
(Source: page 232, A Note on Psychiatric Social Work, Malati Ranade, 1989.)
However, the Court overlooked this vital aspect, which needed immediate intervention and gave orders to the State Government to improve physical conditions in the institution as per Mahajan Committee recommendations. A Visitor’s Board was to be formed to see that the recommendations were fully implemented. Just before this, in 1987, the Parliament had also passed the Mental Health Act (MHA), which was an attempt to amend the law relating to the treatment and care of mentally ill persons. This Act was brought in force by the State of Maharashtra also.
9. Follow up by the State
After a period of three months, on the10th of November 1989, the High Court directed the Board of Visitors to monitor the implementation of Mahajan Committee recommendations. This committee was headed by a State programme-officer and Superintendents of all the 4 Mental Hospitals in Maharashtra were its members. However, none of them was aware about the charge upon them. Malati Ranade, a member of the Committee, by following up the issue arduously, proved that there was no reference to the “monitoring” of implementation of recommendations in the Visitors’ Book right from 1989 to 1993, and that the committee was a non-starter.
Therefore, the Government appointed a special Committee to “evaluate” the implementation on 13th September 1993. This Committee visited the mental Hospital on January 4th’, 1994 and reported that most of the recommendations were implemented.
Malati Ranade raised objections that questioned the very authenticity of the report. Here is a summary of those objections:
(Source: Malati Ranade, 1995)
These objections went unnoticed by the High Court. Malatitai continued on her brave crusade, writing to various authorities including the WHO, at this time, and assiduously collecting her own information on human rights issues in her area of work. She also wrote for the media and gave interviews highlighting the plight of the residents of mental hospitals in Maharashtra.
10. Follow up by Malati Ranade
In 1995, after her retirement, Malati Ranade filed a writ petition in the Bombay High Court in which she addressed the issue of non-compliance of the Mahajan Committee Recommendations. The High Court directed the then District Judge, Pune, to submit a detailed report regarding the extent to which these recommendations had been complied with. Following are some excerpts from the report about the District Judge’s visits:
“Howsoever temporary, the magic effects of the affection received by the patients may be, humane and kind treatment to them, a talk with them display due recognition to their dignities as if they are normal and responsible citizens, they leave a deep impression that in a “humane approach” to their minds, some definite solution to their problem is surely hidden. This is all the observation regarding the mental needs of the patients”
“Though the number of bath rooms, toilets including the latrines were said to have been increased, still, it must be mentioned that the number of toilets and latrines was not adequate. The hygienic conditions in the toilets were not found to be satisfactory. In none of the latrines, there appeared to be a plastic mug kept as a water container for hygienic use. Some of the taps in the latrines were noticed to be unserviceable. A whisper was heard that instances of removal or damages to the water taps were posing difficulty in the administration. None of the latrines were noticed to have regular wooden shutters. The explanation on the spot that was given by the attendants was that there did not exist since a long period. Swinging shutters without any latch was accepted to be a convenient mode to shut a latrine when it is under use. A shutter of some such quality seemed necessary from the point of view of decency. It was noticed that some of the patients were using the same plastic container of some irregular type, both for the purposes of drinking water and also for the purposes of their toileting and hygienic needs. This aspect was seen to be rather sorrowful.”
“In the isolated cells, meant for keeping violent or dangerous patients, the condition of the cells was not found satisfactory, inasmuch as, there was no carpet for a patient to sit or sleep. A Chapati was seen lying near the place where the patient was observed to be lying directly on the floor. A patient caged like any other living being was seen standing in the cell alone and moving in the small cell here and there showed his feet, particularly the bottom portion, to indicate that by constant standing and moving on the rough floor of the cell, there was a damage to the skin of his bare feet”.
“The patients on the whole, seemed to be needing some sort of humane and affectionate dialogue with them. The number of attendants or other officials to cover up this need of the patients was seen to be rather not adequate.”
“There did not appear to be a place for an attendant to sit with a view to keeping constant watch on the patients confined to the isolated cells in which one patient was confined to one cell, having iron bars with a door made of iron bars, which were duly locked. A patient was required to urinate in one corner of the small cell where an ordinary type of small outlet was kept to drive out the flow of urine, provided the patient were to make the use of such corner only. There appeared no guarantee where exactly such violent patient may urinate in the cell. In one cell, by the side of the place where the patient was seen lying, it appeared, that he had also vomited. This is how, was the general condition of the wards and the cells. The wards where the cots were kept seemed comparatively in a better condition, but the toilets and the latrines were found to be far from being clean. There appeared a need of cleaning the toilets from time to time, when the patients themselves do not have a due sense of decent use of the bath rooms, the toilets and the urinals.”
“The patients were given a bath twice in a week or on alternate days. No separate towels were provided to them. There appeared no daily use of soaps by the patients. Their clothes had the same appearance of the clothes used by patients in the general hospitals or in the jails. The clothes, which were made of a rough and a coarse cloth, did not seem to have adequately clean washing facilities. It appears that the patients had no facility of changing their clothes every day. In face of the routine hygienic conditions being not ideal or decent, it may be appropriate to consider need for daily changing the wearing clothes of the patients.”
“It seemed that many patients are confined to the hospital in respect of whom, neither their family members nor the Hospital authorities seemed to have any plan of early discharge. It is difficult to say that as a result of there being no proper rehabilitative methods employed or any results secured, there were instances of many patients who were once discharged, returning to the Hospital, as they could not do well with the members of their families. Perhaps, an improvement may need, a durable improvement in the routine habits of the patients, their behaviour in the family and their conditions being maintained in a manner requiring lesser and lesser treatment and more and more curative effects.”
“Human needs of the patients still require due attention by repeatedly arranging meetings with the relatives, facilitating deliberate maintenance of correspondence with the members of the family, special audio-visual films to educate them or to make provision for effective entertainment for the patients. This is mentioned because it may have a direct impact n wiping out the description of the Institute as ‘Mental Asylum’.”
“It may not be out of place to observe that for implementing the letters and the spirit of the recommendations, specially designed staff, with special mental approach towards the patients and perhaps, selection of right person for each job could matter for re-consideration in the context of the solemn statements made before the Court.”
(Source: District Judge’s Report (No.1301 OF1995, dated 10th October’1995).)
11. Court’s Response
The district judge has responded as a human being naturally shocked when exposed to the raw nature of mental hospital life. It is evident from these excerpts, that even a layperson could understand the dire needs felt by the patients, just within a two-day’s visit. Though the District-Judge made several important recommendations, the Supreme Court overlooked them, saying that it was not necessary to refer to the report in great detail, as several of the directions had been complied with, although there were several deficiencies. The following excerpts reveal the apathy of the judicial system towards the very basic rights of persons labelled with mental illness:
“The Superintendent, Regional Mental Hospital, Yerawada, Pune, has filed a detailed affidavit dated 22nd September 1995 with several annexures. Annexure ‘A’ tabulates all 68 directions as contained in the order dated 10th of November 1989 and as against each of them, statements are made showing how and in what manner they are complied with, though not all. It is candidly accepted that some of the directions could not be complied with, but however, attempts are going on to improve and ameliorate the conditions prevailing at the Institute. (page 7)
“We propose not to expand controversy and in our view, it is not necessary. As mentioned earlier, large numbers of directions were already given and several of them have been implemented. It is true that something always more is required and desired to be done, but one must also not forget the several constraints that exist and which cannot be removed without necessary resource and man power. It is common ground that the strength of the Institute at Yerawada is 1200, but at the moment, there are in all 2450 mental ill patients, out of whom 1400 are males and 1050 females. There are in all 30 doctors and 1150 employees attached to this hospital. In other words, the Institute has to cater to double the strength. (page 8)
“In the meantime, the Parliament made a new Act known as “The Mental Health Act, 1987″ Section 37 of that Act provides for appointment of Visitors.”
“We are told that this Act was brought into force by the State of Maharashtra on 11th of November 1993 and the rules made there under gave two years time to implement some provisions of the Act.”(page 5 and 6)
These excerpts make one feel that the MHA was being religiously implied by all the mental hospitals, though there was ample evidence to the fact that these provisions were rendered a mere paper-exercise.
The most glaring example of the Court’s apathy is evidenced by the complacency with which the case was closed:
“Though these patients are confined like prisoners, it is necessary that such patients ought not to have feeling as expressed by Oscar Wilde in one of his poems:
“All that we know who lie in gaol’
Is that the wall is strong;
And that each day is like a year.
A year whose days are long.”
On the contrary, they must have the feeling that one day they will return to their sweet homes minus disease.” (Page13)
(Source: The High Court of Bombay, Writ Petition No.3128 Of 1995.)
12. The Final Disposal
Even though the petition was disposed off, Malati Ranade presented substantial evidence to the fact that the “State Mental Authority and Inspector’s Board” was a total myth, and that the Government had failed to do its duty towards the mental hospitals, during her letters dated 25.7.95 and 26.2.96. She wrote letters and sent out circulars, and privately circulated several papers to peers and others. She questioned the inability of the State Government to implement the MHA [Mental Health Act, 1987] within the given time period of two years, thereby proving the invalidity of statements made in the Judgment -No.3128 of Dec. 1995(pages 5 and 6}. She monitored the process by which the mental health authorities were managing the issue by keeping article clippings, official letters, etc. She pointed out the errors, inaccuracies, denials and contradictions in the government response and follow up actions. She pointed out how the Visitor’s book never reflected their visits for so many years. The Visitor’s committee was not even aware of their mandate.
On 7/5/90 there was a news item in Indian Express. The Director of Health Services, S.M. Bhadkamkar said as per recommendations of the Committee a Standing Committee under the Chairmanship of the State Programme Officer has been constituted to monitor the progress of the 4 mental Hospitals.” Malatitai noted that nothing was heard of this Committee or its working.
On 13/9/93 a further Committee was constituted for the evaluation of the implementations of the recommendations. There is no mention of the implementation committee and the results that it came up with. The committee members visited the Yeravada Mental Hospital on 14/1/94, did their evaluation in one day and gave the report – 53 rec. were implemented, 7 were being implemented and 8 were to be implemented by the government.
A glaring example cited by the Committee Report is “absence of doors to the lavatories, numbering approximately 100″. When the Mahajan Committee gave several visits to the Yeravada Mental Hospital in 1989 there was not a single lavatory whose door was missing. When the District Judge visited the Yeravada Mental Hospital (Sept. 1995), there was not a single lavatory with a door. The statement that Authorities in the past had an experience that the patient’s have a tendency to lock them-selves in the toilet” could easily be proved to be far from the truth. The truth is that, no one bothered when patient’s rights were violated and they were not kept in a humane & pleasing environment, wherein they could live with dignity as human beings. No one bothered when the Hon. High Courts’ Order to implement recommendations including rec. 1 & 68 was disobeyed. No one bothered when about 100 doors of lavatories were stolen from the Hospital and so Govt. property was lost. No one bothered to look after the comforts and basic human needs of the patients, despite eleven hundred Govt. employees in the Mental Hospital employed by the Govt. to do this job.”
Recommendation 1 states “the patients should be kept in a more human and pleasing environment, where in they can live with dignity as human beings.” Malatitai noted that this recommendation is blatantly flouted by the Govt. by outraging the dignity of mental patients. Until she passed on, she lamented the fact that Rehabilitation and individual care was not provided by the hospital to the patients.
The Government as well as the Court remained deaf, in spite off constant appeals and reminders. Though Malati Ranade urged instruments viz. WHO, to look into the matters, nothing changed. Government and the Court ‘closed’ the matter by delivering the final judgement in 1998, which disposed off the case.
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