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Inspecting Mental Health: Depression, Surveillance and Care in Kerala, South India

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Abstract

Depression has become a major public health concern in Kerala, South India. Media and mental health professionals often attribute the rise of depression and suicide to a discontent around modern transformations and the flipside of the “Kerala model of development”. Kerala’s primary health care system of health governance, surveillance and care with its backbone of community and multi-purpose health workers is currently being expanded to target inner feelings, emotional suffering and existential despair, as a result of complex global, national and local processes of making visible and stabilizing depression as a public health category. Rather than relying on NGOs and foreign funding, mental health policy planners in Kerala engage the state of Kerala. Using the case of a junior health inspector’s counseling, I argue that the reconfiguration of suffering from an existential part of life and symptom of adversity into a medical condition can also lead to mobilization of (gendered) care in a context of familial marginalization and neglect. In this context, individual bodies are healed by restoring social bodies. Medicalization does not necessarily silence social inequalities and marginalization but can become productive in providing an idiom to critique a family’s moral economy.

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Notes

  1. Grama [village] panchayats are a South Asian form of local self-governance or participatory local democracy that gained new political power in Kerala when the People’s Campaign for Decentralized Planning launched in 1996 with its emphasis on participatory, community-based sustainable development (Isaac and Franke 2002). Under the new system, primary health centers and sub-centers have been brought under the responsibility of the panchayats.

  2. These joint one- to three-hour home visits lasted much longer than the few minutes Sanjeev usually spent in one household. The state guidelines for multi-purpose health workers require him to cover approximately 250 people, or 60 households, per day, which would amount to 8 to 10 houses per hour. In practice, he picked out certain homes and left the rest of the work to the ASHAs.

  3. The people of Kerala are called Malayalis, derived from their language Malayalam.

  4. With the Ashwasam program, Kerala launched a specific action plan to include depression in primary health care. As part of the Ashwasam program, medical officers and staff nurses in primary health centers are trained to identify people suffering from depression during PHC visits, screen specific vulnerable groups and provide pharmacological treatment and basic psychosocial counseling. Criticism of the Ashwasam program largely revolves around the focus on psychopharmaceuticals to the neglect of psychosocial interventions. Although the latter are built into the conceptualization program, they have not yet been put into practice. Community health workers such as Sanjeev have not been involved in the Ashwasam program so far, but they have been involved identifying patients with mental health problems in the community as part of the mental health for all program.

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Acknowledgements

I wish to thank Anne Lovell, Ursula Read, Andrew McDowell and the other participants of the workshop “Historical and Ethnographic Perspectives on the Emergence of Global Mental Health,” Florence, June 13–15, 2017 and an anonymous reviewer for providing helpful suggestions and comments on earlier versions of this paper. I also thank Jemima John for helping me with translations.

Funding

This research has been conducted as part of European Research Council (ERC) (340510)-funded project “GLOBHEALTH – From International Public Health to Global Health”.

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  1. University of Leipzig, Leipzig, Germany

    Claudia Lang

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Correspondence to Claudia Lang.

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Lang, C. Inspecting Mental Health: Depression, Surveillance and Care in Kerala, South India. Cult Med Psychiatry 43, 596–612 (2019). https://doi.org/10.1007/s11013-019-09656-3

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