The development of mental hospitals in West Bengal: A brief history and changing trends.

The communication between G. S Bose and Sigmund Freud is a well-documented fact, and philosophical blend of rich cultural experiences is unique to modification of traditional psychoanalysis in the context of development of psychiatry in West Bengal. The Calcutta lunatic asylum was established at Bhowanipore, and first general hospital psychiatric unit was formed at R. G. Kar Medical College, Calcutta. Prof. Ajita Chakraborty was a pioneer to describe her struggling days in the early career and shared her views with experiences in her autobiography. The volume and quality of research work, especially in the field of epidemiology led by Dr. D. N. Nandi is worth mentioning. A jail had been converted to mental hospital which is the largest in terms of bed strength (n = 350) at Berhampore, Murshidabad district where Kazi Nazrul Islam and Netaji Subhas Chandra Bose had spent some period as prisoner during British rules. Bankura was the first district in West Bengal to start District Mental Health program. The various nongovernmental organizations are working together in public-private partnership model or indigenous ways in tandem over years for the betterment of mental health services both at institutional and community level.

INTRODUCTION

The development of modern psychiatry in West Bengal has a long journey with rich cultural experiences, but not very well documented. The written communication between Girindra Sekhar Bose and Sigmund Freud has been well documented and highlighted. G. S. Bose had modified the practice of Freudian psychoanalysis, with his own modification in Indian perspective, through his innovative approach embalming philosophical concepts of the Hindu sacred text Gita in the purview of Descartian “mind-body dualism.”[1] His method of psychoanalysis was based on relief of psychic agony by virtue of resolution of two opposing forces or ambivalence. For example, “to hit” and “to be hit;” “to love” and “to be loved;” “to surrender” (femininity) and “to make surrender” (masculinity), etc., The patient's psyche can be reduced to the fight between two opposing ideas by the free association method or some other method by which resistance breaks down. G. S Bose showed with illustrative case studies that the patient's agony always reduced when he/she could tolerate the simultaneity of the oppositions. When the resistance breaks down the patient tends to be aware that his/her psyche harbors the opposing idea with respect to the initial idea that fastened him/her to the rigid position of producing psychiatric symptoms. Then, a see-saw mechanism ensues when the patient moves to and fro between two opposing ideas, being unable to accept both of them at a time. When the person becomes aware of one idea the opposite one becomes repressed. Finally, in the analytic procedure, a stage comes when the patient becomes aware of the two opposing ideas simultaneously. This unity of the opposing ideas brings the resolution of symptoms. The philosophical concepts such as perception (indriya), mind (manas), intellect (buddhi), ego (ahamkara), self (atman), joy (sukham), and sorrow (dukham) has been explained by him in his writings.[2]

In the proceedings of Calcutta Medical Board on April 3, 1787 the first mental hospital has been formed which marks the colonial influence on development of mental health services in India.[2] In Calcutta, the European Lunatic Asylum was established at Bhowanipore for European citizens, which was shutdown after the inauguration of European Hospital at Ranchi.[34] Indian Psychoanalytic Society had been formed by Girindra Shekhar Bose in 1922 in Kolkata and Berkeley-Hill initiated Indian Association for Mental Hygiene during the same period.[56] The first ever general hospital psychiatric unit (GHPU) had been formed at R. G. Kar Medical College, Calcutta, in 1933 by none other than G. S Bose.[7] In next 50 years, few other mental hospitals were added in Delhi, Jaipur, Kottayam, and in West Bengal.

LIFE AND WORK OF PROF. AJITA CHAKRABORTY

Prof. Chakraborty described her personal life experience with transformation of development of psychiatry over decades. India, over centuries, is enriched with highly developed theories of the mind and techniques of intervention in human consciousness. In her book she wrote, “We are now left with predominantly de-cultured, asocial, overtly medicalised psychological disciplines studying subjectivities in this part of the world.” The critics said, unlike Ronald Laing and his anti-psychiatry group, she did not attempt to differentiate between normality and abnormality. “She retains the difference as a therapeutic reality and a tool of social criticism” as adjudged by her critics.[9]

She described in the book, her early career in psychiatry, her views and experiences in transcultural psychiatry, deconstructing and analyzing hypothesis and individual characteristics of people, her attachment with Indian Psychiatric Society (IPS) and the antipsychiatry movement. Her struggle with anticolonial politics, struggle of refugees, and trauma of partition made herself strong enough to join as a volunteer of Indian Ambulance Corps as a volunteer probably as altruism of struggling childhood and adolescence following parental break up. She was influenced by Dr. R. B. Davis after attending the national conference of the IPS at Ranchi in 1952. She worked in the UK, and then joined Nethrone Hospital in Surrey and met Dr. V. N. Bagadia and Dr. N. B. Jethmalani who inspired her a lot. Then, she went to Springfield Hospital and joined the courses at Maudsley. After completing DPM and MRCPsy in Edinburgh, she already had become famous in intellectual class of England at that time of male dominating society and at the time when tranquillizers were preferred to electroconvulsive therapy. She believed in the concept that Indian school of psychiatry should be developed in its own way not just as “Western variants.” In 1966, she got elected as the general secretary, and in 1976, the president of the IPS. Over two decades, she played a pivotal role with her active participation in IPS.[10]

EPIDEMIOLOGICAL STUDIES

The epidemiological studies were primarily concentrated in West Bengal (40%) and Uttar Pradesh (10%), which cannot be generalized across the nation. The senior citizen aged 60 years and above, which contributes to 7.5% of the total national population are at-risk mental health population.[1112] In a community sample, 61% of geriatric population has been found to need help from psychiatric services. The psychiatric morbidity has been found high in village population in West Bengal across tribes and castes.[13] The Rutter's B scale had been applied on rural 460 preadolescent children where cutoff score 17/18 had been used by Banerjee et al. Approximately 27% children (n = 125) scored above this cutoff level clinically diagnosed by International Classification of Diseases-9 criteria and parental interview had been done.[141516]

The legend of epidemiological research in Bengal, Dr. Nandi and his team in a longitudinal follow-up after 20 years in the same geographic cluster (1972 and 1992) has found that the prevalence of depression has been alarmingly increased 67.5% from 49.93 cases/1000 population to 73.97 cases/1000 population, the similar finding has been replicated in Suttur study (1992 and 2012 comparison).[171819] The psychiatric researches were predominantly concentrated in certain geographical territory, for example, in West Bengal (40%) and Uttar Pradesh (10%). It's very difficult to extrapolate the findings across India.[20]

Due to stigma and ignorance, the mentally ill person has been viewed with negativistic attitude with lots of stigma and prejudices. The institutional mental health care (used to be called asylums), had been provided by Government at own expenses which initially only meant to provide curative care, now both preventive and rehabilitative care has been provided by these institutions.

PSYCHIATRIC CARE INITIATED BY THE GOVERNMENT

The first lunatic asylum in India was established in Bombay (Mumbai) in the year 1745, followed by Calcutta (Kolkata) in 1784.[21] Subsequently, number of such asylums increased significantly and by the year 1947, there were 31 mental hospitals in India.[2223] By the end of 1914, it was recognized that the lunatic asylums at Bhowanipore and Berhampore in Bengal were in bad shape, overcrowded with European patients.[24] According to the report of National Human Rights Commission in 1999, there are 59 mental hospitals are functioning in our country. A study by the National Human Rights Commission has found that most Indian government-run mental hospitals are in jail-like and subhuman conditions.[25] The report based on investigations by the National Institute of Mental Health and Neurosciences, Bengaluru, India, examined 37 public hospitals, with 18024 beds, and found that 14 hospitals had custodial systems that had not changed since their inception. They have mentioned that a jail in Berhampore was converted into a mental hospital in 1980 without any structural change. As per the World Health Organization recommendations for Mental Health Policy, the psychiatric care can be provided through GHPU and community care services in a cost-effective manner.

MENTAL HOSPITAL BERHAMPORE

In the year 1971, Government of West Bengal had sanctioned establishment of Mental Hospital at Berhampore in the premises of defunct Borstal (young offenders reform) school with 350 beds in the indoor, the largest in terms of bed strength, for treatment of mental diseases (vide GO No H7/787/7H-36/70 dated May 31, 1971). But in view of law and order, state government subsequently decided building a special jail for extremist prisoners (Naxalite) temporarily. According to hearsay, the prisoners who were given death sentences used to be hanged at the topmost floor and the dead bodies used to be handed over to the relatives on the other side (now where the Matri Sadan or the maternity ward of Murshidabad Medical College is situated). The main gate of the entrance of the Hospital used to be the main gate of the Central Jail. The relatives used to come and talk with the prisoners from the other side of the gate. The premises of (land and buildings) the mental hospital was taken over from Home (jail) department in 1971. Initially, it was planned to have 350 beds with free and paying beds. The proposed rate of paying beds in the ward was Rs. 4/diem/paying bed, and for cabin, it was prefixed as Rs. 8/diem/cabin. Outpatient department (OPD) services were rendered free except for investigations such as electrocardiograph and X-ray. The sanctioned posts were as follows and that to be filled up gradually. With the endeavor of former MLA of Revolutionary Socialist Party, Sri Debabrata Bandyopadhyay, the former Health Minister of West Bengal, Sri Nani Bhattacharyya had opened the Hospital on June 12, 1980. Electroconvulsive therapy used to be given here till 1996. At present, there are 150 beds running currently with the construction of new building work is almost complete and the number of beds is expected to be increased very soon.

Unfortunately, the previous literature does not give us true picture. True evaluation of institutional care at Mental Hospital; Berhampore, had not been done by the previous authors. It's true that the central jail had been changed to mental hospital with the same constructional work, but the building is satisfactory and spacious, and not at all uncomfortable. This was agreed by various officials and reputed mental health-care professionals from time to time during their visit to Mental Hospital, Berhampore. Converting a jail into a mental hospital for the administrative convenience does not necessarily mean that human rights being violated and that the patients are treated as prisoners. Rather, the patients do voluntarily participate in various activities such as singing, gardening, painting, and handicrafts.

A BRUSH WITH POLITICS AND LITERATURE

The place is also very important for its historical point of view. During the days of struggle for independence, the British government had arrested many freedom fighters. The two great sons of our nation Netaji Subhas Chandra Bose and Kazi Nazrul Islam spent some of their prison day's here. While in prison, Nazrul wrote the “Rajbandir Jabanbandi” (“Deposition of a Political Prisoner”). Wrong information that had been cited in the literature is that Indians in the Berhampore asylum suffered less frequently from depression than inpatients in European asylums without any systematic study and statistical comparison.[8] Charuchandra Chakraborty, born in 1901, is an M. A of Calcutta University. Charuchandra in his service life worked as a jailor in several district jails of West Bengal including the Berhampore central jail and retired as Superintendent, Alipur Central Jail, Calcutta. His pen name is Jarasandha. The wide experiences he thus gained of jail life in his direct daily contacts with prisoners, convicts, and criminals of all sorts, he put to good use as a writer; and in his four volumes Louha Kapat The Iron Gate, his maiden venture in 1953, Tamasa (1958), Nyaydanda (The Sceptre of justice, 1961), and other novels he practically built up a whole world with them. Bimal Roy had been awarded as the Filmfare Best Director in 1963 for the Bandini, based on the story by Jarasandha.

The two storied indoor building comprises one female ward situated in the ground floor and two male wards the new male ward in the first floor and one old male ward in the second floor. There are three observation rooms in each floor for the agitated patients or those who requires isolation and close observation. The day starts with prayer and gardening followed by breakfast. The morning dose of medicines is given next. The consultants give their morning round. Some of the patients then visit District Hospital for liaison consultation. Some patients participate in vocational activities regularly and cultural programs from time to time. The lunch is provided in the dining hall by 12:30, and the patients are encouraged to maintain adequate cleanliness. In the afternoon and evening, the patients take a walk, and some remain busy in the indoor games.

FROM THE PAST TO THE PRESENT

In an order dated November 08, 2013, West Bengal Government declared Calcutta Pavlov Mental Hospital as second campus of Calcutta National Medical College for better patient care, medical education and research with formation of Unit I and Unit II for the mutually exclusive but collectively exhaustive West Bengal Health Services and West Bengal Medical Education Services cadre, respectively. The units will have 150 and 30 inpatient beds, respectively.[25]

The Government mental health-care system in West Bengal has been critically appraised 10 years back for many reasons, for example, it is inaccessible to a large section of the community, growing psychiatric morbidity and widening the gap between need and existing infrastructure and facilities, ineffective mobilization of existing resources, overcrowding, unfavorable doctor-patient, patient-counselor, beds per thousand population ratio, etc. The quality of mental health care in West Bengal has improved significantly with the inclusion of voluntary agencies and nongovernmental organizations (NGOs). Some of them are running outpatient care, day care, and inpatient care in PPP model.

Bankura is the first district which implemented District Mental Health Programme in West Bengal. In a survey, among all cases of hospitalization in government set up, mental and behavioral disorders ranked 15th sharing 2.4% among all admitted patients.[26] With growing peer pressure, career ambitions and changes in lifestyle, breakdown of joint family structure, nuclear family and working parents, and the adolescent mental health problems are growing day by day. Surprisingly, in West Bengal, indoor bed occupancy of mentally ill patients is 15.93% (including reserve bed for Central Institute of Psychiatry [CIP], Ranchi) which is adequate in comparison to other inpatient specialized care. Previously, Mankundu Mental Hospital and CIP), Ranchi (with reserve beds for patients of West Bengal) was also operating.[27]

Institute of Psychiatry, Kolkata, is the 3rd oldest surviving Mental Hospital in the Country. In 1817, it was started as a private asylum, namely, European Lunatic Asylum, Bhowanipore. British-Bengal Government changed its name to mental observation ward. In postindependence era, Dr. Bidhan Chandra Roy, 2nd Chief Minister of West Bengal, upgraded the full-scale Mental Hospital with 30 beds including 10 observation beds. In 1963, Prof. Ajita Chakraborty started the first OPD here.[2829]

CONCLUSIONS

There are lots of rooms for improvement. The regular use of modified electroconvulsive therapy, more availability of essential psychotropic drugs in outpatient and more equipped 24-h emergency services should get the top priority in government mental health institutions. Establishment of drug de-addiction center is very demanding in these days of changing lifestyles as more people are abusing psychoactive substances. The human rights of mentally ill patients need to be protected by all means. The budget allocation for the National Mental Health programme in the current 12th 5 years Plan of the Government of India (2012–2017) has emphasized on issues such as stigma attached to the mental illnesses and the protection of rights of mentally ill people in the society. Despite the limitation of budgetary provision, a careful financial allotment on prioritization model can be very effective for improving the present status of various Mental hospitals in the state of West Bengal.

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Conflicts of interest

There are no conflicts of interest.

The essay provides snippets of the intellectual history, as well a peep into the political events that shaped some of the contemporary services in Bengal. It mentions the rapid changes in Asylums in Bengal, which shift and move all the time in the 19th–20th centuries. Interestingly, the mental hospital at Berhampore works as a Jail, a reform school for young offenders, a prison and interrogation center during the Naxalbari violence, and then finally an Asylum. It also has links to a significant political and literary legacy. In addition, the contributions of two eminent psychiatrists, Dr. G.S. Bose, who was reputed to be one of the richest private practitioners in his time, and a contributor to psychoanalysis, as well as Dr. Ajita Chakraborty, whose contributions and dissensions within psychiatry are also remarkable. Dr. Bose has been a subject of much historical research, and a museum is being curated in his memory, while the Ambedkar University, Delhi is trying to put his works online. At the time, however, he was dismissed by some of the more opinionated reviewers as "the greatest danger to psychiatry." Dr. Ajita Chakraborty was emphatic in her call to develop services for the marginalized and poor, and the need to develop a different model for psychiatry. It ends with a call for further reform, and improvement, and integration of the Mental Hospital with community care and outpatient services.