Thank you all very much. Dr Webster, Dr Jenny, Dr G.
And all other friends, it's wonderful to be here.
Thank you for giving me the opportunity.
Now this the whole conference is called Mental Health in India Bridging the Gap and this particular session, the Mental Health Act in India.
What next? And what I propose to do and I'll try and be as brief as I can is.
When one talks about the mental health situation in India, one could start at different places depending on where one comes from,
you know, persons living with the illness would start somewhere. Caretakers and families would start somewhere.
Psychiatrists would start somewhere else.
But as I was saying earlier, I've spent most of my life in government and I look at this from the from policy, from the policy side.
And one very important thing which happened in India in recent years was the passing of the Mental Health Care Act of 2017.
It finally came into law in 2017, but work began on it in 2010.
And it's it's it's important. It's very significant. And I'd like to use that as the starting point.
And I'd like to say something about what were the dominant themes that we considered that went into the making of the act, important issues,
the act flags and where exactly we are now up because and I will say something about this that we were,
were the assumptions we made justified were the expectations we had.
Have they been borne out? And I think these are these are questions that we all need to talk about now.
Two very big teams dominated the the the framing of the Mental Health Care Act.
Of the first of these was visibility. And in fact,
the exercise itself came out as a fallout of the United Nations Convention on the
Rights of Persons with Disabilities RBD of 2007 and India having signed and ratified.
We may even have been the first country to have ratified it. We're very good at ratifying U.N. documents and having signed and ratified CERP,
it became incumbent on governments to see what the national legislation needed to be amended and.
Early in 2010 is when this exercise began looking at the country's mental health, the Mental Health Act of 1987,
to see what, what, how it needed to respond to our plea and what amendments I needed to be made.
It at that point of time, it was still thought that. A few amendments were all that was necessary to the act and that nothing very
much more needed to be done and we realised very quickly and I hope so on.
It's I won't say more about this when he speaks that this was this job was not going to get done with just a few amendments.
And as I said, the exercise began in January. Maybe by about June, we were clear that.
A new law had to be written if Typekit had to be not only CERP compliant,
but also more responsive to what by then were clear as the big issues facing persons living with mental illness.
Now, this dialogue or lack of dialogue with the disability sector remains and will continue because
there are huge issues with exactly the same time that we began this exercise the other day,
the concerned ministry and Government of India began amending the Persons with
Disabilities Act of 1995 because that also had to change in response to CRT.
And there were many fights and many of these disputes related really to the contentious Article 12 of the RBD,
which which basically states that all persons with disability at all times shall be assumed to have legal capacity.
And as you can imagine, this led to all sorts of disputes.
The whole nature of disability Indian laws to the current disabilities legislation also recognises mental illness as one of the types of disability.
But this is a very difficult question. Is mental illness disabling?
Do all people with mental illness regard themselves as disabled?
Some do. Many don't. Some regard themselves as disabled at some times, not at other times.
Parents, caregivers, families have a different take on whether the mental illness of someone they live with is disabling or not.
So this whole business of disability and mental illness will continue to remain with us and I
don't believe there is a there is no harmonious understanding of of where we are on this matter.
Let me also say here's something that I've said often in gatherings like this,
I've always believed the script was written draughted, negotiated and approved by people from the physical disability sector.
Because everything in that applies like beautifully to physical disabilities,
because the issue of building capacity is a non-issue when you're talking about physical disability.
And it doesn't seem to have occurred to very many people that it could become an issue
when you're talking about persons with disability arises out of mental illness.
So that is one big set of issues that dominated the discussion and continues to remain a big issue.
The other big issue, of course, was rights of the persons with illness and.
This is something I'm personally very glad about that I do believe that the Mental Health Care Act of 2017,
when it finally came out, did represent a very significant movement establishing the rights of persons with illness.
This is not something that Indian jurisprudence. Adopts as a matter, of course, the Mental Health Care Act of the Mental Health Act of 1987,
which was considered a very progressive and remarkable legislation for its time,
was remarkable only in that it was marginally better than the Lunacy Act of 1912 nigh than 1987.
Legislation did not think to establish the rights of persons with an illness and continue to take the broad line
that persons with the illness needed to be treated for their own good personal illness needed to be treated,
preferably in institutional surroundings, for their own good and in breaking this, this notion.
And setting out from the start, which is why really here we couldn't really amend the act.
We had to rewrite the act again was because our starting point changed that.
Every person with illness has rights.
And at all times, you must respect those rights, and those rights include the right to be not treated if that is what that person wants and to.
India does not have legislation which guarantees the rights to health care.
But we we have succeeded in putting in place legislation that guarantees you the rights to mental health get.
And we hope that this will become a significant landmark and that more and more
progressive legislation will come up that recognises the rights of persons affected.
One quick point also about again, the understanding of the rights of persons with the illness varies enormously.
Between sheeting between mental health professionals, which could include psychiatrists, psychiatric nurses, eye-catching social workers.
Persons with the illness themselves, families, caregivers, guardians and institutional authorities, and everyone has a different take.
I personally was most surprised by.
How vehemently the family caretaker Guardian group reacted to this notion that the person with the most has rights.
That and you see the argument always was, this is my child, this is my wife, this is my husband.
I mean, who knows? Who cares more than I do? And it's a difficult question.
Equally, there were persons with illness who who resisted the notion that family was the inevitable caretaker.
You know. Anyone except my mother, you know, what kind of response that many people to the list would come out with.
So it was interesting because and it was also interesting that the process we followed in draughting, the legislation was so public that,
you know, everything was repeatedly endless rounds of discussion, online discussion, face-to-face meetings where a lot of these issues came out.
So there are these two broad issues that you must always remember disability and the relationship between mental illness
and disability and the rights of persons with living with illness as teams that will continue to drive this whole debate.
Now, given that there are some specific points in the law which become important from the point of view of where we are going to be going from here.
Some important legal concepts that you built into the law and some important administrative steps that need to be taken now.
There are many things in this law and. But there are three aspects which I would like to call attention to which.
Because they were. Unknown in our in our in our lawmaking process, this one is given the given the given the.
Utmost importance of recognising the rights of persons with the illness we have built into the law.
Two concepts one of an advanced directive and one of a nominated representative, as I said, and these concepts don't exist in Indian law.
The Advance Directive basically says that any person, not necessarily a person with the most, any person, any time can leave.
Instructions and directive on how that person would like to be treated in the event
that the person was not in a position to express it so that if this person was say.
In the grips of mental illness and unable to express a view could leave a statement saying, I do not wish to be treated.
I do not wish to be taken to an institution. I do not wish to be given medication.
Or indeed, I please take me to an institution. Please give me medication.
So-and-so is my doctor. Now, this is important because it gives primacy to the fact that the wishes of the person are at all times
more important than the wishes of the treating doctor or the family or the caregiver or anybody else.
And finally, the notion of an advance directive is the notion of a nominated representative.
But if I, for whatever reason,
am not in a position to express a view so and so who need not be family is my nominated representative who will take all decisions on my behalf.
So that is to what I regard as very important legal provisions that we've built into the law.
The third, which is also very important, is. What what the law has to say on the matter of attempt to suicide.
Now many people say that the mental health laws criminalise suicide in India, which is not actually true.
Attempted suicide continues to remain a criminal offence under the Indian Penal Code.
We are one of a very sorry list of countries along with Malaysia, Nigeria,
Pakistan and somebody else where attempted suicide is still a criminal offence.
And that was not a law that we could do anything about from the Health Ministry.
But what we weren't able to do in this act was to say that attempted suicide.
Any person who attempts suicide should be regarded as being under severe stress and that before any other action is taken against this person,
this person should be taken to treatment. Now.
It is true that I don't believe anybody in India has ever been convicted in a court, but having attempted suicide.
But the probe, the provision that exists is enough to cause a lot of harassment.
And so therefore our law tries to say that.
Please think of this person as somebody who is under severe stress and see what needs to be done before you do anything else.
Now these three legal sort of constructs within the act, there are many administrative measures which the Act introduces.
Firstly, we the setting up of a central mental health authority.
Setting up a state mental health authorities and the setting up of district boards,
now why these are important is the district boards, if I can start with those.
These are the very, very important purpose because those boards are meant that, if any,
the law does not say that a person with illness will under no circumstances be institutionalised.
The law recognises that there will be some persons. Whose illness at some point of time is so acute as to need institutional care.
It has tried to temper this with the provision for advanced directive with the provision for a nominated representative,
but recognises that there may be a situation and it's quite strict.
I mean, you need.
The opinion of two distinct positions before and the conditions under which the person is kept constitutional saw a very severely restricted.
But the district board was created specifically for any person who has even given these safeguards who has been admitted to an institution.
Of a place where a person can go in a pill saying, I have been admitted.
Please explain to me why, please let me go.
And therefore it serves a very important purpose that even after some person has been taken into an institution facility for treatment,
that there is the option for that person to say, I want out of here.
And it's that district board itself, the way it is constituted, and the law includes the person with the illness.
Also on the board, who may be expected to understand the situation more a little more from the perspective of the person appealing to the board.
So there is the district board, there's the state authority, there's a central authority, the old teaching establishments,
whether the psychiatric wards and general hospitals, nursing homes are expected to be registered under these authority because it.
Now this law, there's more to the law, but I mean,
this is just the points I'd like to highlight the the the legal constructs in
the law and the various administrative measures that would allow this law,
despite the fact that parliament should debate and you can be very contentious.
This law actually won support across the floor.
It was originally moved in parliament by the previous government and was taken up for debate and passing by the Indian government.
But then there was actually very little opposition and many members of Parliament cutting across party lines spoke.
In favour of the law and it got passed.
Now we have got the law, we have got not much rejoicing amongst some of us because what seemed what began in January 2010 finally ended in July 2017,
seven years and a bit of which for reasons we don't have to go into now.
Two years were completely wasted. But seven years we got the law through.
Now where are we now? I mean, this just becomes very important for us now.
Some of the big debates continue, the disability debate continues,
the rights debate continues because it's not just there are some persons within limits who believe very strongly that.
At no stage down under no circumstances will they accept any kind of treatment.
We're not talking just about institutional treatment, no treatment.
And that comes up again and again and again that it is my rights not to be treated.
That is an issue that we need to remember. But it is on these.
The legal constructs and the administrative mechanisms we put in that the situation is all very, very unclear now.
I personally would like to see. The provisions regarding advance directives nominate a representative and a person
attempting suicide to be treated is under stress to be challenged in court.
Right.
You should go to court and we do need to see a court ruling on them because it is only through precedents and you know that the case is built up.
If somebody has left lays down an advance directive and if the family or caregiver objects saying that not all this is wrong
and this should not be followed if the treating doctor wants to use advance directive because that's what the law says.
If the family says no, the negative was written under pressure or whatever and the matter goes to court.
I would like to see what the court rules because until such time as we have precedents being built up.
Likewise, for a nominated representative,
if a person with illness nominates Person X as the winner and then this person's relative says, No, I should be.
This is an important issue because quite often there are issues of property, all sorts of things involved.
Somebody challenges this art, and I am the only person I am the next of kin,
I should be the person taking these decisions, and I would like to see the court rule on that.
Likewise, in the suicide situation,
if somebody is taken for treatment because the law says this person should be regarded as being under severe stress.
I'd like to see another wing of the police department saying, no, no, no,
this person needs to be booked under three zero nine of the IPC because it is only through this that there will that opinion public not public option,
legal opinion will change, public opinion will change that.
The notion that these are inbuilt rights promised by the law will be established and that is something that,
to my knowledge, has not yet begun to happen.
I, I I would like to think that quietly, these things are happening that people are leaving are writing down advanced directives,
that people are nominating representatives and that these documents are being upheld normally.
As for the law, whenever it's come up, but I'm not sure that that is actually the case.
So we need to see where these things go. The administrative side is a little more difficult because.
The sentimental letter has been set up. It's hopeless.
It has been set up and we have luxury from the Banyan and London to set up the Banyan is a member of the CMJ and their tour,
the one which is perhaps about the only reasonable person there is on that.
So they have followed that word for word in how it is to be constituted.
And they have created a body that just it's been created, so the boxes have been ticked off.
But it's not doing anything, it is not doing what it was supposed to do now.
So Mr. just tells me the 19 states have set up state authorities.
Some are better, some are not so good. But we have to wait and see. The law very clearly sets out what their duties are, what they should be doing.
Then are a lot of times they should be aware of where the treatment of persons with mental illness is taking place.
What is happening? Are there qualified persons and things like this?
Because these are all jobs, which this is a different story, not the Medical Council of India failed to do.
But the state misled authorities under this law are empowered to ensure that there is.
Well-functioning system in place for the treatment of personal illness,
very little is known so far, it's taken them a while two years to set up the authorities.
And. We don't actually know what's happening, we know even less about the constitution of the district boards,
which are from the point of view of persons with list of the most crucial.
Those are the boards that the person on the list has recourse to in the event of an issue.
And underlying all of this is that all this takes government funding.
Have the central and state governments shown in their budgetary papers a significant increase in the funding available to do these various things?
And the answer is no, we have not seen this. It is true that there has not been a significant increase in funding for the health sector as a whole,
but there certainly hasn't been increased for funding in the mental health sector.
So these authorities, which are to be set up, these district boards, which are to be set up.
In fact, without these structures, the functioning of the act itself,
howsoever progressive and wholesome and forward looking at is the implementation is not going to happen unless
investments are made in setting up these bodies and training the persons who are required to work with these body.
That I think we have to wait and watch. Is this going to happen?
If so, when is it going to happen? So these are all big questions.
So. I can insure all I'd like to say is.
I think India did well in putting in place the legislation that it has done.
But it's almost as though we have run out of steam. But all our all our efforts, our energies went into.
Framing a law with the view that, look, this is the long term requires the positioning of a well framed,
progressive, people oriented, rights oriented law. But now everyone in the system has to pick up this law and run with it.
The not not too many signs of that is happening, so we need to see more civil society groups getting involved.
You know? Awareness taking the law, taking to citizens groups, talking about making people aware of what the law says,
what the law promises them, more stuff, going to court my rights to mental health treatment,
which the law promises to be, to be taken to court and for the court to rule, saying that yes,
the law gives this person the right to treatment and directs the concerned state government to provide the treatment.
So these are the sorts of things we keep we need to see happening and inshallah, these things will happen.
Thank you.