Over the years, the ‘accommodation-based’ definition of ‘home’ has expanded to a multidimensional angle to include concepts of autonomy, personal space, dignity, a sense of belonging, trust and security. And there are umpteen western definitions of homelessness, but it is not just the lack of a ‘place to live’. It’s a social deficiency and a concerning human rights crisis.
According to a World Economic Forum report (2021), there are 150 million homeless people in the world. The Indian Census 2011 says there are 1.77 million homeless individuals in India, nearly 0.15% of the country’s total population. Needless to say, it must have significantly increased by now. These numbers are also rarely ‘true’ since the big burden of homelessness is hidden. The missing numbers mostly reside in inadequate settlements, slums, temporary shelters, and relocate frequently.
Estimates suggest that one in five Indians suffers from a mental health condition. Besides, among those affected, only 15% receive the required treatment. Certain sections of the population are particularly vulnerable, and homeless individuals are one of them. The vicious cycle of poverty, homelessness, and ill health can cause and aggravate physical and mental illnesses. The epidemiological studies conducted among the homeless mentally ill people in India show that psychosis (encompassing schizophrenia and related illnesses) is most common, followed by mood disorders, addiction disorders and intellectual disabilities. A significant majority is unable to seek help due to the lack of social support, impaired self-care and judgement, high stigma, limited literacy, poverty, lack of employment and rapid urbanisation. The social inertia towards their complaints also interferes with providing medical care to them.
How often have you seen people ridiculing and laughing at individuals with mental health conditions on the roads? They are typically depicted as ‘dishevelled’, ‘disorganised’, ‘untidy’ and ‘aggressive’ in popular media. What is not shown, however, are their voices, how the illness has affected them, why they get aggressive, and how well they respond to treatment.
Homeless people with mental illnesses have the double burden of lack of self-care and security. They often suffer from paranoia. In that context, making fun of them can trigger agitation and violent behavior. This can change as many of them regain their identities after successful treatment.
I remember Mr. Manish. I regularly used to see him on the streets of Jayanagar in Bengaluru, either muttering to himself or chasing kids away with a cane. He looked self-absorbed, at times begged for money and food, had extremely poor hygiene, and was resistant to being brought for treatment. It took us a lot of will, planning and many challenges to bring him to NIMHANS, Bengaluru, where I used to work back then. The efforts towards tackling the initial difficulties—including the provision of medicines and counselling in the hospital—started reaping rewards when his diet, nutrition, sleep and self-care improved. He recalled his name, details of his identity and workplace. It was indeed sad—his elder brother had allegedly usurped his property, ignored his symptoms, and when his condition worsened, left him on the streets.
He expressed a desire not to go back to his own family and chose to be rehabilitated in one of the rehabilitation houses. Today, Manish runs a small grocery shop of his own, is better on medicines, and helps bring others like him for treatment.
But such narratives are changing. The Mental Healthcare Act, 2017 (MHCA), has brought several provisions for the homeless mentally ill, defining the responsibilities of law enforcement individuals, psychiatrists and society.
NGOs comprise a major part of the support infrastructure that helps out with the homeless mentally ill in India. The Richmond Fellowship Society (Karnataka), Iswar Sankalpa (Kolkata), The Banyan (Chennai), Ashadeep (Guwahati), Aashray Adhikar Abhiyan (New Delhi), to name a few, work extensively in psychosocial rehabilitation of mentally ill homeless individuals. These institutes have worked consistently for their social recovery, empowerment and social reintegration.
India is socio-culturally diverse and the poverty-mental health nexus is evident in research. As stated by Reetinder Kaur and R K Pathak in Homelessness and mental health in India (The Lancet Psychiatry), “There is an urgent need to redefine the term ‘homelessness’ in the Indian context.”
Traditional Census methodologies may not optimally collect data on homeless people; policy provisions can only be formulated based on data from the ground. The voices of those suffering from mental health conditions and those who are homeless need to be reflected in research and media. Few national programmes target their unmet needs: even the MHCA needs further improvisation. Gaps in their overall healthcare need to be addressed.
Regular national surveys, screening and identification of mental health conditions in homeless individuals, systematic attempts at rehabilitation, re-establishing their social identities (tracing family members, facilitating Aadhaar cards, enabling healthcare access, among others). Community sensitisation helps in reducing stigma and involves the public in their care.
Many such homeless mentally ill people are met with hostility and abuse, which is a gross violation of their dignity and human rights. Government-NGO collaborations, the media playing a role in sensitisation, training of psychiatrists and physicians to empower and treat homeless mentally ill individuals, and fresh policies in this regard to improve their general healthcare—will ultimately help in their rehabilitation, therefore ensuring their human rights and dignity. Their ‘voices’ must be listened to and reflected in the programmes and policies designed for them. Only then can we proudly proclaim the world is one family: “Vasudhaiva Kutumbakam”.
Dr Debanjan Banerjee
Consultant Neuropsychiatrist, APOLLO Multispecialty Hospitals, Kolkata
(dr.djan88@gmail.com)