As the general Outpatient Department (OPD) counter closes, the 61-year-old casts an anxious glance at his 25-year-old son staring blankly at the ground seemingly unaware of the fraught situation. Pariyar’s nervous hands clench in on the pink hospital card as a look of despair settles on his wrinkled face.[break]
“My son has been suffering from psychosis due to which he doesn’t respond well and either stays lost in his thoughts or goes around speaking senseless things. I hurried here with a hope that poor and needy people like us would get free checkup and medicine at minimum costs,” says Pariyar who arrived with his son from Sindhuli about a month back. “I needed to get my son’s medicine and leave for my village tomorrow but I might have to wait two more days for his turn of checkup.”
As Pariyar calculates the cost of extended paying OPD service for which he would have to pay Rs 250 besides the medicine cost and his traveling expenses, he shakes his head and decides to request some people he knows in the city to let them stay the extra two days.
“My son had his initial checkup here but because the hospital beds were full at the time, we had to take him to Kathmandu Medical Hospital in Sinamangal and we’ve spent all we had. He’s still not fully recovered from his illness but we can no longer afford to stay here,” says Pariyar.
He decides to give it another shot at the OPD department where checkups are still going on. Distracted by a woman sobbing in a corner of the dark hallway, he pauses and frets for a moment. He then goes on pleading in his subdued voice from one desk to another, only to be scoffed at and asked to leave.
Back in the compound again, he stands squirming; chewing the inside of his cheeks as his droopy eyes start glistening. “I guess I’ll just come back the day after,” he whispers to himself and slowly walks away, guiding his son by the hand.
Over at the pharmacy counter, people line up to get medicines but one after another, many return empty-handed. “The stock of medicine is very limited here,” says Mani Raj Shrestha, the in-house pharmacist, “The amount of medicines we get yearly, if properly distributed, will not even last three months.”
Past the second gate, as you enter the hospital lawn, many patients and their family members and caretakers are seen scattered around. While some wander around aimlessly, some lay stretched sunbathing and some engrossed in their conversations.
At a corner, Punya Ram Shilpakar and Hari Bhatta sit beside each other talking softly. One – a patient and another – caretaker, they have become close acquaintances and share a hospital cabin.
“My son has been here for a week receiving his treatment for depression,” says Bhatta, “But the state of hygiene here makes me worry about his health and mine.”
He shares that most of the toilets near the wards in the hospital don’t have water and proper doors, letting off an awful stench all day long.
For many patients and the caretakers who come from villages all over Nepal and have to stay there for a long period of time, taking baths and washing clothes also become a grave challenge due to the acute shortage of water.
A look around the hospital building and you’ll immediately notice that most of the windows are broken. The glass has been replaced by flimsy plastic materials that would give away to the slightest of windy weather.
Jagat Shrestha, from Dolakha, whose 17-year-old daughter Swostika Shrestha has been in the hospital for a month undergoing treatment for her manic episode, shares, “I came here to visit my daughter and my wife who’s staying here as her caretaker. It’s depressing to see that even my wife looks like she’ll need treatment after staying here so long.”
His wife Dhan Kumari Shrestha sitting beside her feverish sleeping daughter, however, says with a sigh, “It’s definitely difficult to stay here but I’m fine. I need my daughter to get well and she’s recovering slowly, I think.”
With a daily inflow of more than 200 patients, the hospital in Lagankhel is Nepal’s only public mental health facility.
This is where most people from far off villages travel for days with their disturbed loved ones suffering from mental illnesses in hopes that they will be cured and will be able to return to normal.
But the lack of proper infrastructure, adequate medical and counseling services often leave them disheartened.
Dr Surendra Sherchan, the hospital director, shares that the hospital has faced several challenges throughout its history.
“Firstly, mental health has never received as much priority for the possible reason that morbidity from mental diseases isn’t as much as in other diseases,” says Sherchan. “The budget allocated for mental health is less than 1 percent of the total health budget and so the hospital also has to function with very limited resources.”
With an annual budget of Rs 16 million Sherchan says more than 90 % is spent on administrative costs that include salaries and infrastructure maintenance while 5 percent is allocated for medicines.
Hospital staffs complain that due to inadequate manpower – both technical and administrative – the facility has not been able to run smoothly.
There is only one shift of general OPD and no emergency care, so most patients have no option than to have themselves checked at the paying OPD which runs like a private clinic in a government hospital, they say.
There is no reception or inquiry area, lab assistants are being engaged in the ticket counters, many of the tenders for medicines are not followed up on. So most of the times the hospital does not have the full stock of medicines that should be in its quota, which is already too insufficient in itself.
“If anything goes wrong, like a patient slips or runs away from the hospital, it’s all blamed on the guards or the peons or the nursing staff, but with the number of people here, it’s impossible to handle all the patients properly,” says a hospital staff who didn’t want to be named.
Sherchan too admits that weak infrastructure and lack on manpower has been a major challenge at the hospital but he says he says there’s not much he can do with the limited budget.
He emphasizes that over the years the situation has improved for people to at least acknowledge their mental illnesses and come out despite the taboos and stigmas.
They have extended services such as Hotline telephone services, oral substitution therapy for drug and alcohol abuse and community mental health programs.
Despite the government’s lack of interest in the sector, mental health workers have been constantly pushing for the Nepal Mental Health policy and its implementation to guarantee primary mental health facilities to all and fight for the unvoiced rights of mental-health patients.
“For a public hospital as this, it’s always hard to attract and retain technical staff who are always looking for better opportunities. Moreover, the mental health field in our country is already too limited, with less than 60 psychiatrists, a handful of psychologists or counselors and no social workers nationwide,” says Sherchan.
“Besides, due to the taboos associated with mental health, there aren’t many people who want to work in this field.”
According to various researches, at any given time, 10 to 15 percent of the total population will have mental problems; in the developing countries, the percentage often reaches 25 percent. According to the 2006 WHO data, Nepal has only 18 hospitals that treat mental illnesses.
The number of medical practitioners at these facilities stands at 51 psychiatric doctors, 11 psychologists and 48 nurses and almost 75 percent of the services being Kathmandu-centric, this leaves a huge treatment gap in the country.
Dr Saroj Prasad Ojha, Associate Professor at Tribhuvan University Teaching Hospital (TUTH), says that many times mental problems in Nepal are often under-diagnosed. Due to the misconception that mental illness is all about what we call “insanity” in general terms, people don’t realize the gravity of the situation.
“Even medical staff and doctors within the hospital are still ignorant that mental health consist of a lot more than cases of insanity,” Ojha says. “Our studies have shown 20 percent of patients who come in for general checkup in the hospital have psychiatric problems.”
He says that out of 60 patients that the psychiatry department at the hospital receives everyday, almost 80 percent suffer from different forms of depression and anxiety disorders and only the rest will have severe psychosis diseases like schizophrenia, bipolar disorders which too can be cured with proper medication and treatments.
“Mental illnesses are also like any other body disease – either caused by chemical disturbance or outer environmental factors. Say you have a fracture. If you leave it untreated, it will remain broken and get worse but proper treatment can fix it. It’s the same with mental illnesses,” says Ojha.
Reports of mental patients being neglected in confinement due to lack of treatment or social taboo and mentally ill people cast out from their family and society roaming around the city in pitiable conditions are common sights every person has seen or heard about.
Many mental patients are also in jail or asylums that keep them confined due to their violent and impulsive actions as a result of their illness.
“You can see there are people receiving treatment for severe mental problems like schizophrenia and together with patients suffering from less severe diseases, and with proper care, they can be normal,” says Ojha.
“But if you leave them untreated for a long time, they can develop chronic illnesses like you see in the patients living in jails or confinements and there’s less point of return.”
Early diagnosis therefore becomes crucial, experts say. But because of the social taboo associated with mental diseases, lack of awareness and health professional and the treatment gap, many of the mental health cases remain ignored.
Dr Bal Krishna Subedi, spokesperson at the Ministry of Health and Population (MoHP), shares that the Nepal Health Sector Program Implementation Plan II 2010-2015 does put a greater emphasis on mental health, and the government is trying to tackle the situation with expansive coverage from the grassroots level.
“We are focusing on the preventive aspect and integrating mental health in primary healthcare,” says Subedi. “The plan is still in its initial phase. It will focus on training health workers in primary healthcare centers in pilot districts on the basis of mental health so that there can be correct diagnosis, treatment, counseling and referrals to specialists.”
But Jagannath Lamichhane, mental health rights activist, feels that even at policy level a lot has to be done to ensure not just proper treatment and facilities for mental health patients but to ensure protection against human rights violations as well.
He adds that mental health issues have to come out from just the medical framework into a broader social framework due to its crosscutting nature.
“Increasing suicide rate and violence due to frustrations are also indicators of mental problems in people,” says Lamichhane, “So mental health has to be integrated in not just the Health Ministry programs but in gender-based programs, economic welfare programs and other sectors as well.”
For people like Pariyar and his son who desperately cling on to the hopes of having a normal life again, lack of and inaccessibility to primary mental health facilities pose as grave obstacles.
Disregarding the mental health issues despite the knowledge that it is omnipresent in every society and will only worsen if not addressed earlier would stub out the prospects of a healthy society.
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