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30 March 2017 Editorial


30 MARCH 2017 

The modern way

Mental health law can be used to strengthen primary care

The passage of the Mental Healthcare Bill in the Lok Sabha, putting it on course to become law and repealing the Mental Health Act of 1987, will potentially help India catch up with the advances made in the field by other countries. India urgently needs to make a transition from old-fashioned approaches to providing care for those suffering from mental illnesses, something that China, for example, has achieved through state-led policy reform. Even the sketchy studies on the nature of care available to Indians indicate that in terms of population coverage the new law faces a big challenge. The country's grossly inadequate base of professional resources is evident from its ratio of 0.3 psychiatrists for 100,000 people (with marginally higher numbers taking independent private practitioners into account), compared to China's 1.7. Then there are massive deficiencies in the availability of trained clinical psychologists and psychiatric social workers. Evidently, the National Mental Health Programme has not been sufficiently funded within the health budget; neither has capability been built in most States to absorb the meagre allocation. Delayed though it is, the new legislation can bring about change with its positive features. The important provisions relate to the recognition of the right to medical treatment, decriminalisation of attempted suicide, explicit acceptance of agency of people with mental illness and their freedom to choose treatments, prohibition of discrimination and regulation of establishments working in the field.

Raising effective primary and district-level coverage of mental health services for the general population, without requiring people to travel long distances to see a specialist and get medicines, should be a priority. Since the base of psychiatrists is low in relation to the need, the use of trained general practitioners as the first line of contact assumes importance. Some studies show many of them are not confident enough with their training to detect, diagnose and manage mental illnesses. With a concerted effort, primary care physicians can be trained to help people with mild and severe problems, ranging from anxiety disorders to depression, psychoses and conditions arising from alcohol and substance abuse. Being able to get professional counselling will reduce the complications arising from extreme stress, often the trigger for suicide. Extending health insurance cover is also a step forward, since out-of-pocket expenditure has risen along with the expansion of the private sector in this sphere, just as for other ailments. The provision in the new legislation prohibiting seclusion of patients, something that is frequently resorted to in asylums, and the general use of electro-convulsive therapy must be welcomed. Modern treatment approaches rely more on family and community support. The new Central and State regulatory authorities should speedily weed out shady non-governmental rehabilitation organisations in this field.

Back to square one

Egypt's restive politics

For most of those who hit Cairo's Tahrir Square in 2011 demanding democracy and a freer society, President Hosni Mubarak was a symbol of repression. After his ouster, the dictator was tried for corruption and causing the death of hundreds of protesters. Still, his release last week, after six years of detention at Cairo's military hospital, was received by Egyptians as just a routine development. There were no major protests against his release, nor were there any rallies in support - an indication of what Egypt's state and society have become six years after the Arab Spring. The release was long expected. Most of his associates and family members, who also faced serious charges, were already released. His sons, Alaa and Gamal, accused of embezzlement of public funds, were released in October 2015. Corruption charges against Mr. Mubarak were overturned in January 2015. Earlier this month, he was acquitted by Egypt's highest appeals court of conspiring to kill protesters, paving the way for his release.

It may appear ironic that Mr. Mubarak, who ruled the country with an iron fist for almost 30 years and was toppled by public protests in which hundreds were killed, is now a free man, while Mohamed Morsi, Egypt's first democratically elected President, is in prison. But this irony also symbolises Egypt's complex contemporary politics. Though the government of Abdel Fattah al-Sisi claims the legacy of the 2011 revolution, it took a lenient view of Mubarak-era crimes while cracking down on Mr. Morsi's Muslim Brotherhood. It is difficult to gauge the political mood in Egypt. Despite large-scale concentration of power in the hands of the military, the Sisi regime doesn't face any existential threats. For ordinary Egyptians, who went through the instability and chaos of the post-Mubarak months and the threats of Islamisation and economic miseries during the Muslim Brotherhood rule, General Sisi at least provided stability and order. The belief is that compared to other countries that were hit by popular protests in 2011 such as Libya, Yemen and Syria, Egypt is doing better, thanks to the army's intervention. Tunisia is the only country that internally transformed itself into a democracy after protests. Gen. Sisi projects himself as a guarantor of order and enjoys support among the minorities and secular sections. But the question is if the status quo is sustainable. Order was restored at a brutal cost. Hundreds were killed when security personnel forcibly removed Islamist protesters from Cairo. There is no substantive political opposition. Personal freedoms are being curbed again, while media groups and journalists are targeted. In effect, what hundreds of protesters at Tahrir Square risked their lives for was never achieved. Gen. Sisi has taken the country back to square one.

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