Inspecting Mental Health: Depression, Surveillance and Care in Kerala

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Depression has become a major public health concern in Kerala, South India. Media and mental health professionals often attribute the rise of depression and suicide to a discontent around modern transformations and the flipside of the ‘‘Kerala model
           1 3 Culture, Medicine, and Psychiatry An International Journal of Cross-Cultural Health Research ISSN 0165-005XVolume 43Number 4 Cult Med Psychiatry (2019) 43:596-612DOI 10.1007/s11013-019-09656-3 Inspecting Mental Health: Depression,Surveillance and Care in Kerala, SouthIndia Claudia Lang            1 3 Your article is protected by copyright andall rights are held exclusively by SpringerScience+Business Media, LLC, part ofSpringer Nature. This e-offprint is for personaluse only and shall not be self-archived inelectronic repositories. If you wish to self-archive your article, please use the acceptedmanuscript version for posting on your ownwebsite. You may further deposit the acceptedmanuscript version in any repository,provided it is only made publicly available 12months after official publication or later andprovided acknowledgement is given to thesrcinal source of publication and a link isinserted to the published article on Springer'swebsite. The link must be accompanied bythe following text: "The final publication isavailable at”.  ORIGINAL PAPER Inspecting Mental Health: Depression, Surveillanceand Care in Kerala, South India Claudia Lang 1 Published online: 15 November 2019   Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract  Depression has become a major public health concern in Kerala, SouthIndia. Media and mental health professionals often attribute the rise of depressionand suicide to a discontent around modern transformations and the flipside of the‘‘Kerala model of development’’. Kerala’s primary health care system of healthgovernance, surveillance and care with its backbone of community and multi-pur-pose health workers is currently being expanded to target inner feelings, emotionalsuffering and existential despair, as a result of complex global, national and localprocesses of making visible and stabilizing depression as a public health category.Rather than relying on NGOs and foreign funding, mental health policy planners inKerala engage the state of Kerala. Using the case of a junior health inspector’scounseling, I argue that the reconfiguration of suffering from an existential part of life and symptom of adversity into a medical condition can also lead to mobilizationof (gendered) care in a context of familial marginalization and neglect. In thiscontext, individual bodies are healed by restoring social bodies. Medicalization doesnot necessarily silence social inequalities and marginalization but can becomeproductive in providing an idiom to critique a family’s moral economy. Keywords  Depression    Community mental health    Care    Elderly   South Asia &  Claudia 1 University of Leipzig, Leipzig, Germany  1 3 Cult Med Psychiatry (2019) 43:596–612  Introduction Depression has become a major public health concern in the South Indian state of Kerala. Depression has been made visible and stabilized as a public health categoryin the region as a result of complex global, national and local processes.Consequently, the scope of Kerala’s primary health care system—including healthgovernance, care, and the critical health mainstay community and multi-purposehealth workers—is today being expanded to address issues of inner feelings,emotional suffering and existential despair. Kerala aims to address the burden of depression in the state by using and strengthening the public primary health caresystem and integrating treatment and support for depression. Rather than relying onnon-governmental organizations (NGOs) and foreign funding, Kerala’s mentalhealth policy planners engage and address the state. Using the case of a multi-purpose health worker’s counseling and his ‘‘inspecting gaze’’, I argue that thereconfiguration of suffering from an existential part of life and symptom of adversity into a medical condition also leads to mobilization of (gendered) care in acontext of familial marginalization and neglect. Here, individual bodies are to behealed by restoring social bodies. Medicalization does not necessarily silence socialinequalities and marginalization but can become productive by providing an idiomof critique of a family’s moral economy and by care. A Case of Depression in the Elderly We entered the house of Umma, an elderly Muslim woman in her sixties, inPuttuvur panchayat 1 in rural Thiruvananthapuram. It was one of the wealthierhomes in Puttuvur, a distinction usually indicative of ‘Gulf money’. Ummawelcomed the junior health inspector (JHI) Sanjeev, my research assistant and me,arranged some chairs, and we sat down. Umma had been diagnosed with depressionat the mental health camp that the Thiruvanthapuram District Mental HealthProgram (DMHP) team had conducted at the nearby primary health center someweeks prior to our visit in 2016. She had been prescribed Amitriptyline (25 mg) andLorazepam (2 mg), the usual anti-depressant medication prescribed by thepsychiatrist to elderly patients diagnosed with a depressive disorder. Since nobodyhad accompanied Umma, the community health worker (an Accredited SocialHealth Activist, or ASHA) who was responsible for the earlier identification of hermental distress served as the obligatory bystander [attendant] required for a patientvisiting the camp. That a family member did not fulfill this role pointed to asituation of isolation and familial neglect. The DMHP psychiatrist treats patientsonly in the presence of a bystander whose important role includes not onlyproviding reliable information but also ensuring care and family attention for the 1 Grama [village] panchayats are a South Asian form of local self-governance or participatory localdemocracy that gained new political power in Kerala when the People’s Campaign for DecentralizedPlanning launched in 1996 with its emphasis on participatory, community-based sustainable development(Isaac and Franke 2002). Under the new system, primary health centers and sub-centers have beenbrought under the responsibility of the panchayats.Cult Med Psychiatry (2019) 43:596–612 597  1 3  patient. At the camp, Umma complained about aching in her lower back,nonspecific pain, and lack of sleep. The psychiatrist identified these as somaticsymptoms of depressive disorder.We had come to visit Umma to understand more about her situation. The juniorhealth inspector began by asking her about her three adult children and theirfamilies and how she came to live alone in this big house. In spite of transformationsfrom extended to nuclear families in the recent decades, it is still normative for the‘good’ Kerala family that elderly parents live with the family of one of theirchildren and are cared for either by their daughters-in-law or their own daughters.At first, Umma was reluctant to answer Sanjeev’s questions about feelings of loneliness, sadness, tension and lack of care. In Kerala, talking about sadness anddespair is often seen as a sign of weakness, and revealing family problems canswiftly jeopardize a family’s reputation. Sanjeev requested that she open up andspeak frankly with him. Since he was a representative of the state, this request wasas much an expression of authority as it was a therapeutic intervention. Umma andmany others understand that following the instructions of a representative of thestate is part of their duty as citizen as much as inspecting mental health had becomea duty for the junior health inspector. Citizens are expected to comply withcommunity health workers and doctors just as panchayats are expected to complywith state programs, and governments with global mental health agendas.As our conversation progressed, it revealed deep loneliness and the impact of broken relationships of care on Umma’s life. Her husband had died some years ago,and her two grown sons had moved to Kuwait as labor migrants ten years ago wherethey worked in the travel business and earned enough money to build a house forUmma. They had then lost their jobs due to visa problems and were now barely ableto provide the material forms of care and evidence of affection that otherwise serveas the tangible proof of kinship relations in Kerala. Although they had returned fromtime to time in order to marry, father children and see their mother, a court caserelated to their political activity in a communist organization in Kerala preventedthem from returning now. They remain stranded and unemployed in Kuwait, neitherable to earn money nor come home. Umma’s daughter lived in Saudi Arabia withher husband and children and could not return to her mother either. Umma’s twodaughters-in-law lived about half an hour away by bus, and Sanjeev’s questioningaimed to inspect the ties of affection in the family and the care provided by thedaughters-in-law. Though her sons and daughter showed concern by telephoningseveral times a day, Umma told us, her daughters-in-law rarely visited, telephoned,cooked for her or gave her money. Sanjeev identified Umma’s sons’ lack of controlover their wives as the key problem: ‘‘The husbands have lost their voice. So thewives do whatever they want. If husbands have no money, then they are treated likedogs.’’Umma went on to tell Sanjeev that the in-laws of her younger son had tried toarrange a divorce, a factor that further increased the tension she experienced. The junior health inspector tried to comfort her by pointing to the phone calls as forms of care (for ICT in transnational intergenerational care see Ahlin 2018) and signs of affections from her children. In conversation with Umma’s younger son by phoneand with her eldest son’s wife, who happened to drop by while we were there, 598 Cult Med Psychiatry (2019) 43:596–612  1 3
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