Mental health for the grassroots
Matunga resident Seema Uplekar translates a WHO guide for primary care of mental health disorders into Marathi, allowing it to become a resource for Maharashtra's primary health centres
Seema Uplekar was a 40-year-old trailing spouse when she accompanied her husband Dr Mukund Uplekar, a senior medical officer working in Geneva for WHO's Global TB Program in 1999. She had no idea that 17 years later, a little before her husband's retirement and return to Mumbai, she would be placed with an opportunity to translate WHO's Intervention Guide for mental, neurological and substance use disorders in non-specialised health settings. She has rendered the guide in Marathi, the fourth most spoken Indian language.
The guide aims to fill the gaps in the provision of the much-needed mental healthcare to the poor and vulnerable section of her home state, especially in setups where medical personnel are not trained to handle matters of the mind. Apart from English, the guide (mhGAP Intervention Guide, 2016 updated version) is available only in Russian and Spanish. Uplekar's version was launched in the form of an e-book, but is intended for circulation in Primary Health Centers (PHCs). It is directed at bringing evidence-based and high-quality mental health care within the ambit of Marathi speaking personnel of the third-largest Indian state.
Considering the paucity of mental health professionals in Maharashtra, the availability of a translation makes sense for the Accredited Social Health Activists, doctors, nurses and paramedical staff, who do not necessarily comprehend an English manual written in UN-mandated medicalese. They will not appreciate terms like Pruritus (severe itching/ khaj yene) or Eclampsia (seizures during pregnancy/ garodarpanatil zatkyancha ajar) or Agranulocytosis (low white blood cell count/ pandhrya rakta peshinchi kamtarta) — which are nonetheless symptoms of mental disorders. As is acknowledged by many, medical terms need to be conveyed in a lay person's vocabulary; English or otherwise. A handbook in the local language will further help in demystifying the scary jargon.
WHO has stated that mental health is going to be the highest burden among non-communicable diseases by 2030
It will increase the quality of communication between the care giver (who has not studied psychology) and the patient who is either struck by suicidal thoughts or suffers from post-partum depression or is a victim of post-traumatic stress. According to WHO, one out of four persons in India needs mental health care, especially in metros where fast-paced lifestyles cause acute stress. Maharashtra is sadly marked by farmer suicides and gender-based harassment. WHO has stated that mental health is going to be the highest burden among non-communicable diseases by 2030.
The step-by-step graphical guide at the PHC level reminds the medical care system to factor in mental disorders — be it sedative overdose, job-related anxiety, or acute adolescent aggression. Fortunately, the guide is not limited to mere assessment of prevalent medical conditions, but it details the management in terms of dosage, caution and side-effects. For instance, mood stabilisers are a no-no for breastfeeding women, or children below 12 years should not prescribed pharmacological treatment but monthly follow-ups with school-level counsellors.
Uplekar's Marathi rendering of the WHO guide has an interesting backdrop, one that makes her a suitable candidate for taking on the self-assigned translation. Born and raised in Mumbai, her initial years were rooted in the quaint Maheshwari Udyan vicinity (central Matunga) minus flyovers and traffic blocks. School (King George) and college (Ruia) were at a walkable distance. There was always Amba Bhuwan and Madras Café when mom allowed after-hours Udupi snacks; Aurora talkies for the kids' day out; most needs taken care of by dad's automobile workshop!
But life took a 360 degree turn in 1976 when the family, on its way to Baroda in a car, met with a fatal accident near Vapi. The 16-year-old Seema was the least physically hurt in the mishap, but the most-mentally affected — she lost two siblings and her parents were hospitalised for 45 days. She did not realise what had hit her. She was advised by doctors not to disclose the death of the siblings to her convalescing mother, which involved immense pressure on the teenager. If at all there was someone who could have alleviated the pressure, it was a shrink. But no one recommended therapy.
"We could have easily afforded it. But, as a family, (and as a society), we didn't even perceive the mental damage. It was not seen as life-threatening; the physical bandaged injury mattered the most," laments Uplekar, who narrates a string of instances in her life when she could have emerged stronger by letting out the bottled feelings. After delivering her second daughter, she suffered the thyroid condition known as exophthalmos causing bulging of eyes.
"I remember whenever I travelled in public transport, people stared at my eyes or whispered about it. I would approach them gently and tell them about the disorder. This was my way of fighting the stigma and seclusion that follows any rare medical condition in India." She says she should have been referred to a counsellor at that point because she felt threatened as a mother and a wife; similarly when she lost her mother, she felt the need for respite, because a caregiver too, requires a mental break. "Seeing a loved one die is a dreadful situation," she recalls. Incidentally, respite care has been addressed in the intervention guide.
Uplekar laments that not much has changed in the Indian attitude towards mental trauma over the years. That's precisely why she volunteered to translate a 164-page manual meant for those who can make life a bit easier for victims of mental illness. By the sheer virtue of being in Geneva, she was close to a group of public health experts. As a UN employee's spouse, she was part of the UN Women's Guild which aids children in vulnerable situations and sponsors mother-child care programmes. As the UN representative for the International Alliance of Women, which advocates women's rights, she presented several statements at World Health Assemblies.
"I felt that all that exposure made sense only if I could make a dent in my country. With that sentiment in mind, I asked the then WHO director, if I could bring the mental health guide in a prominent Indian language." This was her debut project, having earlier translated a few verses from English, Hindi, Marathi and French. She completed the translation in one and a half years, seeking insights and technical accuracy from numerous mental health professionals, practicing therapists and psychology professors. Uplekar also plans to translate the training manuals for the users of the Intervention Guide. She has also approached the Maharashtra Government for dissemination at the local level. There is another distinct impulse behind the translation — researched papers and other literature produced by the UN and WHO and other global bodies don't reach the intended audience. "It pains me to think that much of the documents lie unread," she says. We can call ourselves globally connected citizens only when we share and benefit from the guidance material available to us. Her guide is a small step in that direction.
No. of persons out of every four in India, needs mental health care
Salient points of the guidebook
. Do not discriminate against people with mental, neurological, and substance use (MNS) conditions
. Do not ignore the priorities or wishes of people with MNS conditions
. Do not make decisions for, on behalf of, or instead of the person with MNS conditions
. Do not use overly technical language in explaining proposed treatment
Sumedha Raikar-Mhatre is a culture columnist in search of the sub-text. You can reach her at firstname.lastname@example.org
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