Homeless persons with mental illness and COVID pandemic: Collective efforts from India.

COVID-19 pandemic had made an unprecedented impact worldwide. India has entered into a total lockdown by invoking the special provision of Epidemic Diseases Act of 1897 and Disaster Management Act, 2015. The complete lockdown policy has a direct and indirect impact on Homeless Persons with Mental Illness (HPMI) concerning shelter, basic needs and access to health care, besides the transmission of COVID infection. In this manuscript, we highlight the collective efforts undertaken by both the Government and Civil Society in providing care and protection to HPMI against COVID during the lockdown in India.

Introduction

The unprecedented impact of COVID- 19 on public health and the society worldwide, led on to the lockdown initially in Bhilwara, Rajasthan, on March 21, 2020. Subsequently, on March 22, 2020, on the call of Prime Minister of India underwent a self-imposed – Janata curfew, as a test of resolve & preparedness. Later on, the official countrywide lockdown was imposed from March 25, 2020, and has been continuing till date with few restrictions (“India Lockdown news: India to be under complete lockdown for 21 days starting midnight: Narendra Modi, 2020). Several legal and policy measures were invoked through the special provisions of Epidemic Disease Act of 1897 and Disaster Management Act, 2015 (Awasthi, 2020). Under this, all the non-essential services like shopping malls, social gatherings were closed to ensure adequate physical distancing. Also, the Ministry of Health and Family Welfare, Government of India (Uday Foundation, 2020) implemented and promoted the strategic measures like personal hygiene, physical distancing and isolation of confirmed cases and quarantine of suspected cases as advocated by the World Health Organization (“Advice for public, 2020). The total lockdown has both direct and indirect impact on every citizen of India and more so with double marginalized Homeless Persons and HPMI. Tandon, 2020 has rightly pointed out the relevance of psychiatry and COVID-19, differing mental health challenges faced in different parts of Asia, in the context of homeless people, refugees, economic and political crisis (Tandon, 2020). With relevance to the above, this manuscript focusses on the challenges faced and collective efforts from India towards HPMI during COVID-19 lockdown period to provide shelter, basic needs and health care interventions.

Homeless persons with mental illness and COVID-19

In India, a homeless person is defined as a person who “does not live in census houses” (i.e. persons live in places other than a house with a roof). According to the 2011 census, India has around 1.77 million homeless people (“Census of India Website: Office of the Registrar General and Census Commissioner, India, ” n.d.). The National Mental Health Survey (NMHS) estimates range from “nearly nil” or “almost minimal” to “1%" persons with mental illness to be homeless, which translates into about one million individuals. Majority of HPMI’s are often found near the railway stations, bus stations, pilgrimages, beggar’s homes and in the street corners of metro cities of India (National Mental Health Survey (NMHS, 2015; Singh, 2016; Math et al., 2019). They are considered as the highly marginalized and neglected population in India and worldwide (Gowda et al., 2017a, 2017b). The HPMI are more vulnerable to acquire and spread the SARS-CoV 2 virus infection than the general public (Bartholomew, n.d.; Mumbai, n.d.) due to multiple factors like poor self-care, inadequate sanitation, comorbid physical conditions, overcrowding, poor awareness about COVID 19, low level of immunity & nutrition and lack of access to adequate healthcare services (Kar et al., 2020; Housing and Land Rights Network (HLRN, 2020a; Kim, 2020; “Surviving COVID-19,” 2020). In addition to that, they may not be aware or may not practice the respiratory, hand hygiene and physical distancing measures advocated by the MoHFW, GOI (Uday Foundation, 2020). Hence, the Government and society have challenges to provide shelter, essential basic needs and health care services (Avenue et al., 2020).

Collective efforts towards the care of HPMI during COVID-19 lockdown period

Housing and food

In India, during COVID-19 lockdown period, migrant population and homeless population-related issues have become a major problem. Housing becomes prime importance during the current Public Health Emergency of COVID pandemic (Farha, 2020; Bartholomew, 2020). The United Nations Human Rights Commission has proposed necessary measures to be provided during pandemic for homeless persons in shelter homes like a) sufficient and functional community toilets, b) clean drinking water, c) adequate water and sanitation facilities for bathing, d) regular cleaning, disinfecting toilets and bathrooms, e) clean and hygienic living spaces, f) clean blankets, mattresses & other shared utilities, g) providing food thrice daily. (Farha, 2020; HLRN, 2020a; CDC, 2020b).To address these issues, the Government agencies like Delhi Urban Shelter Improvement Board, Centre for Urban and Rural Development Authority have taken initiatives to open emergency temporary night shelters by hiring Chatras, (Choultry/marriage ceremony hall), Community Halls, buildings and unoccupied residential facilities or accommodating them in centres like ‘Nirashritha Parihara Kendras’ (designated public places for the homeless in Karnataka State, India). Through these centres, they are providing accommodation to HPMI along with homeless persons and other migrating population (Jayasimha, 2020). These informal emergency temporary shelters ensure a secure place to live, but have challenges with regards to adequate spacing, privacy, special needs and ventilation. Instead of punishing HPMI under the Epidemic Disease Act of 1897 for not following lockdown, it is commendable and sensible that public as well as the policemen have been identifying such persons and have placed them in such shelter homes. It is a form of community integration of mentally ill persons without discrimination and this move supports the existing legal measures for HPMI (Mental Health Care Act (MHCA, 2017). In the shelter homes, HPMI are provided with food thrice daily without discrimination (“Locked down India struggles as workers flee cities, 2020; “Donate to COVID-19 Relief Fund in India | Donate to COVID-19 Feeding Programme,” n.d. 2020). Besides that, the local authorities had to bring out policy measures to ensure adequate physical distancing, hand hygiene and respiratory hygiene to prevent the COVID-19 infection.

Health care, COVID-19 screening and referrals

Many shelter homes have made arrangements to screen HPMI for communicable diseases and COVID and provide primary health care as there is a higher risk for transmission. The basic health care services can be enabled based on a centre to centre basis by looking at existing health care services and human resources. In Karnataka, mental health professionals and psychiatrists from the District Mental Health Programme across the state are visiting the emergency shelters and are screening for mental illness among the homeless persons. Along with this, it may be wise to assess the severity of mental disorders and substance withdrawal states. There is a need for identification of such individuals and initiation of immediate mental health care services by the psychiatrists and to tie-up with the Mental Health Establishments within the city to provide inpatient and emergency psychiatry services. Few districts across the country have taken such initiatives, where HPMI are screened and provided mental health services on emergency or inpatient basis or tele based services (Kar et al., 2020).

Special population with HPMI

The needs of special population like pregnant and and lactating women, elderly and children, who are homeless are complex. There is a need for separate female shelter homes with special attention given to privacy, safety and sanitation. They pose different challenges as they require special care and individual support along with regular care. Interventions can be planned on case to case basis based on the individual needs.

Preventive measures and recommendations against spreading COVID-19 at shelter homes

Homeless persons with mental illness

The Centre for Disease Control (CDC, 2020a) laid down precautionary measures to prevent COVID spread. The same recommendation can be ensured and educated at the individual level like a) by providing tents/sleeping area with at least 12 feet x 12 feet of space per individual, b) by providing the restroom facilities with functional water taps and hand hygiene measures, c) by ensuring adequate water and sanitation facilities for bathing, d) by ensuring their living area, toilets and bathrooms are cleaned regularly, d) by providing blankets, mattresses and other shared utilities in the shelter home that are cleaned and disinfected periodically, e) by promoting adequate physical distancing, hand hygiene and respiratory hygiene measures among co-inmates in the homeless shelter (HLRN, 2020b; CDC, 2020a).

Outreach staffs who provide services to HPMI

Outreach staffs who provide services for HPMI must take precautionary measures like a) ensuring adequate physical distancing, b) ensuring adequate hand hygiene by using hand sanitizers or soap with water, c) use masks to ensure respiratory hygiene, d) to follow the Centre for Disease Control standards while providing care and thereby facilitating the health care to suspected COVID-19 cases (CDC, 2020b).

HPMI admissions in mental health establishments

Non-availability of alcohol, other substances and stress can exacerbate preexisting psychiatric illness (Das, 2020; Grover et al., 2020) or present with severe substance withdrawal state to the emergency care (Das, 2020). It is often difficult to get proper COVID histories in such cases due to inadequate information or severe altered mental state. Sometimes, the clinical condition of alcohol withdrawal state presenting with diaphoresis, tachycardia, autonomic fluctuation and delirium can mimic COVID 19 infection. It is necessary to have separate standard operating procedures for screening and testing of COVID 19 during emergency care and admission, which is in line with guidelines laid down by MoHFW, Government of India (GOI) (admin, 2020). It is better to screen for COVID and admit after COVID results turn negative, as there is a high risk of spread to co-inmates and health care workers. So, soon after the admission, it is better to keep them in a designated possible risk zone for the next 14 days. Later on, patients can be shifted to a regular ward, where there is no risk of COVID. When the COVID 19 test results are positive, HPMI can be isolated and admitted in COVID 19 designated General Hospitals, where he/she can be provided both mental health and supportive care for COVID 19 infection.

Role of psychiatrist / mental health professional in care of HPMI during the lockdown

The COVID 19 pandemic led to negative mental health consequences worldwide. (Grover et al., 2020) In this context, there is a need for preparedness and simple community based psychosocial management to address the mental health issues of HPMI(Banerjee and Nair, 2020). The role of a mental health professional (MHP) /psychiatrist is essential in this crucial period for the identification, diagnosis, treatment and rehabilitation of HPMI (Tandon, 2020). Based on the need of settings, to provide care to HPMI, MHPs can act as ascholar, a researcher, a good communicator, collaborator, a manager, a supervisor, a leader and a health advocate (Grover, 2011). As there is scarcity of MHPs / psychiatrists (Math et al., 2019), tele psychiatric services can be an option to provide care to HPMI.

Challenges in providing services to the HPMI during Lockdown

Stakeholders face many challenges while providing the needed services to the HPMI during the lockdown(Tandon, 2020; Seidi et al., 2020). These include a) safety, b) privacy, c) risk of spread of communicable diseases including COVID -19 infection, d) external contact with visitors, NGOs and public officials and e) complex needs of HPMI including pregnant, lactating women, children and elderly. Few of these issues can be handled by providing sanitizers and soaps for handwashing to maintain hand hygiene and ensuring adequate respiratory hygiene by providing masks and adequate physical distancing.

What after lockdown for HPMI?

All HPMI are getting shelter, basic needs, food and health care without discrimination at the shelter homes in India. After lockdown, care of HPMI in temporary shelter homes becomes non-existent. There is a need for measures to be in place to provide care and rehabilitation of HPMI, post lockdown. All stakeholders need to deliberate upon this issue and shift them to safer long term shelters keeping in mind the provisions of the MHCA, 2017. The Government, Central and State Mental Health Authorities should act proactively to convert the lockdown challenge into an opportunity and work towards protecting rights of PMI given under MHCA, 2017.

Conclusion

Even though the Public authority, outreach staffs and NGOs face many challenges during lockdown, they have taken the best possible measures to provide shelter, basic needs and health care for the HPMI during COVID-19 pandemic in India.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

Nil.