Medical Anthropology

Cross-Cultural Studies in Health and Illness

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Task-Shifting in Community Mental Health in

Kerala: Tensions and Ruptures

Sudarshan R Kottai & Shubha Ranganathan

To cite this article: Sudarshan R Kottai & Shubha Ranganathan (2020) Task-Shifting in
Community Mental Health in Kerala: Tensions and Ruptures, Medical Anthropology, 39:6, 538-552,
DOI: 10.1080/01459740.2020.1722122

To link to this article: https://doi.org/10.1080/01459740.2020.1722122

Published online: 26 Feb 2020.

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MEDICAL ANTHROPOLOGY
2020, VOL. 39, NO. 6, 538–552
https://doi.org/10.1080/01459740.2020.1722122

Task-Shifting in Community Mental Health in Kerala: Tensions and

Ruptures
Sudarshan R Kottai and Shubha Ranganathan
Department of Liberal Arts, Indian Institute of Technology Hyderabad, Sangareddy, Hyderabad, India

ABSTRACT KEYWORDS
Based on an ethnography of community mental health programs run by two Biopolitics; community
NGOs in Kerala which have associated themselves with preexisting, locally mental health; globalization;
grown, community-based palliative clinics, this article explores how profes- Kerala; medicalization;
sional NGOs bring a new culture to volunteer-based programs. task-shifting
Professionalizing volunteers through task-shifting results in the transforma-
tion of their philosophy of community care, which constrains and narrows
understandings of mental health care. The state, in alliance with psychiatric
NGOs, front-stages development through aggressive task-shifting which we
argue is a socio-politico-moral process, disrupting the shared consciousness
between volunteers and their own communities with fatal consequences for
their most vulnerable citizens.

Task-shifting, “the process of training primary care and community health workers to assume some
health care responsibilities traditionally delivered by specialists” (Kohrt and Mendenhall 2015:255), has
become central to global mental health (hereafter GMH) policies and practices. The WHO Mental
Health Gap Intervention Guide (WHO 2010) supports non-mental health specialists to task-shift in
interventions in non-specialized health care settings so that mental health care is delivered to a larger
population. The Movement for GMH calls for the scaling up of mental health services through task-
shifting in order to bridge the “treatment gap” in mental health care in low and middle-income countries
(Lancet 2007; Patel 2012). The Movement emphasizes the need to train an array of community-based lay
health workers to augment government efforts to deliver mental health services (Patel 2009; Patel et al.
2009, 2011). Indian mental health systems have taken up these global innovations in mental health
practice, mainly through community mental health (hereafter CMH) programs.
However, critics have raised pressing questions about task-shifting in mental health care. Task-
shifting has the danger of becoming merely “task dumping of stigmatized health care activities on
persons who have less power to refuse these jobs” (Kohrt and Griffith 2015:585). Local people,
trained by professionals in biomedical models for task-shifting mental health practices, can experi-
ence a disruption of their selves as they feel incompetent to address issues from an expert’s vantage
point. Kohrt and Griffith (2015) illustrate in their description of a study in Uganda, where task-
shifting to identify psychosocial disability backfired as it increased numbers of referrals and the
consequent burden on mental health specialists. On the one hand, such unintended outcomes can
result in volunteers blaming and stigmatizing service-users and their family members as a result of
feelings of incompetence. On the other hand, task-shifting can steer local volunteer health workers
with limited experience in mental health care to “new ways of learning and observing,” with “ripple

CONTACT Sudarshan R Kottai la14resch11003@iith.ac.in Vineetha Bhavan, P.O. Pathirippatta, Via Kakkattil, Kozhikode
673507, Kerala, India
Media teaser: How aggressive task-shifting to scale up mental health services in Kerala replaces local systems of community care
with medicalized ‘mental health’ care?
Supplemental data for this article can be accessed on the publisher’s website.
© 2020 Taylor & Francis Group, LLC
 MEDICAL ANTHROPOLOGY 539

effects with regard to how others in the family and community understand mental illness” due to
volunteers’ impactful role in community (Kohrt and Griffith 2015:590). Kohrt and Griffith stress the
need for relational dialogue, creating spaces for learning and facilitating therapeutic alliance at
various levels; these could be stifled when mid-level health professionals are trained in what
Vincent Mujune, an Ugandan public health researcher, terms “software-only” training – training
with a “didactic approach with limited exposure to patients and health care facilities” akin to
teaching “someone a computer program without using a computer” (Kohrt and Griffith 2015:597).
Other scholars have argued that when non-experts apply the knowledge of experts, there are
dangers in missing signs and symptoms, and new tasks useful in promoting mental health or task
innovation (White and Sashidharan 2014). The highly structured, biomedical-oriented training given
to task-shifters in CMH settings in India further complicates the problem (as we discuss below in
relation to medicalization).
In India, task-shifting needs to be understood in the context of a biomedical model of care that
mental health care services predominantly follow. One study in north India found that
a government-run CMH program operated in isolation from local communities and their everyday
realities, with a narrow focus on biomedical aspects of patients’ lives based on western diagnostic
categories, leading the researchers to conclude that “psychotropic medication has become the
embodiment of India’s community mental health policy” (Jain and Jadhav 2009:61). While some
have reported on CMH programs that provide holistic psychosocial support by addressing social
determinants (e.g., van Ginneken et al. 2017), outcome measures in these studies have been based on
the perspectives of service providers. There is limited involvement of caregivers and users in the
planning and execution of mental health services in India, reflecting a need to shift from a provider-
centric to a user-centric model of care (Samudre et al. 2016). These studies all demonstrate the
complexity of task-shifting.
In addressing the lack of anthropological research on task-sharing in mental health services
(Kohrt and Mendenhall 2015:256), we undertook an ethnographic investigation of the practice of
task-shifting for psychiatric illnesses (including epilepsy) with two pioneering NGOs in Kerala, south
India. Both NGOs sought to reach underserved populations by collaborating with preexisting
community-based pain and palliative clinics (hereafter PPCs). We will describe the palliative care
system in Kerala and reflect on the association between palliative clinics and community mental
health. We look at the rhetoric and practices of task-shifting in these NGO-run CMH practices. We
argue that the induction of community volunteers in the language of formal mental health impedes
their freedom to work outside biomedical discourse, thereby taking away locally available and valued
solutions to human distress. Drawing from observations of clinical interactions between patients,
caregivers, volunteers, and mental health professionals, analysis of case records, home visits, and
practices of telepsychiatry, we illustratehow task-shifting takes unanticipated forms with unintended
consequences.

Methods
An ethnographic study of CMH services run by two prominent mental health NGOs in Kerala was
conducted in three phases over nonconsecutive 11 months between 2015 and 2017. Each NGO was
established by a psychiatrist specifically to care for persons with mental illness, using existing
palliative care infrastructure (buildings, vehicles, and the human capital of community volunteers)
to access patients. Fieldwork was conducted at CMH clinics serviced by these NGOs in PPCs in five
districts of Kerala, viz., Kozhikode, Malappuram, Wayanad, Ernakulam, and Alappuzha. Sudarshan
(first author) is a native of Kerala and speaks the local language, Malayalam. Both researchers are
psychologists with prior experience working with mental health training institutions and CMH
settings. We attended out-patient clinics and training programs, and interviewed various stake-
holders of these programs. We interviewed a total of 94 patients, and followed up 53 among these at
clinics during subsequent field visits; we also interviewed 21 mental health professionals, 32 palliative
540 S. R KOTTAI AND S. RANGANATHAN

care volunteers, and 59 caregivers. We observed 143 clinical interactions, and 47 case records were
analyzed. Clinical ethnography was extended beyond clinics by paying visits to 47 homes employing
“mobile go-along” interviews (Castrodale 2017) to understand socio-spatial situated environments of
distress. This was carried out in response to our realization that clinical ethnographies restricted to
clinics produce empty and repetitive ‘clinical’ talk because of the spatial demarcation of clinics as
medical spaces. To protect identities, we employ pseudonyms in this article.

Kerala’s palliative care movement

Kerala is touted as the most progressive state in India with democratic and community health
institutions, high literacy, decentralized governance, and public engagement.1 It is also adjudged to
be one of the best performing states in CMH (Goel 2011).
The pain and palliative care movement in Kerala was the first community-based palliative care
movement in the world. Palliative clinics extended across north Kerala in the 1990s as a social
revolution, attracting thousands of ordinary citizens across social spheres to work together to care
for bedridden and terminally ill people with small donations from local residents. The program is
considered to be the best example of a locally sustainable and culturally appropriate health care
system in the developing world (Kumar 2007; Shabeer and Kumar 2005). Ninety percent of all
palliative care programs in India is located in Kerala, although only three percent of the country’s
population lives there (Kumar 2013). Community participation in the management of cancer and
other terminal illnesses, referred to as the Neighborhood Network in Palliative Care, is a volunteer-
led movement in which doctors and other health professionals have a minimal role. In the “Kerala
model” of palliative care.2 The focus is on homecare and community involvement, and includes
other illnesses that emerge from sufferers’ needs and volunteers’ experiences.
Community volunteers form the soul of this movement. They visit patients’ homes and provide
drugs, wheelchairs, groceries, books, school fees, and clothes to those who are needy, sit with patients
and family members, and listen to their stories. They also help in nursing tasks and train caregivers
in the same. The backgrounds of volunteers are cross-cutting: shopkeepers, taxi-drivers, school-
children, and police donate to palliative clinics and serve the community. A woman in her fifties, one
of the first volunteers of a community-based palliative care system, explained this as follows:
Palliative care strives to improve quality of life. It is not about curing; it is all about caring and offering dignity
in life and death. When we visited homes, we realised that it is not physical pain that bothers many of them; it
is the lack of a secure home for their children, lack of food at home, etc. Here is where we intervened. It is
terribly wrong to undermine non-medical aspects which may appear less important to us. Sharing becomes very
important here.

Because PPCs have evolved bottom-up, community volunteers have a genuine interest in helping
people in distress. Open to new ideas and interventions, they think beyond the band of possibilities,3
and their synergy becomes a melting pot of varied views, skills, and knowledge bases bridging the
divide between the medical and the social.

Emergence of CMH NGOs in Kerala

From the 2000s, PPCs moved beyond cancer care to provide mental health care to people with severe
mental illness from the poorest sections of the population. In 2008 two psychiatrists came together to
form one NGO to provide stand-alone psychiatric services through the palliative clinics. One of the
volunteers at a palliative clinic explained the evolution of the clinics:
The idea of extending the scope of intervention beyond cancer came with the realization that all illnesses
involve suffering and pain in the context of poverty and other social incapacities. That was the reason to include
mental illnesses also under the fold of palliative care.
 MEDICAL ANTHROPOLOGY 541

The NGOs envisioned palliative clinics as the most viable route to reach the community because of
the vast network of volunteers anchored to their localities. Psychiatric medicines are given for free by
PPCs and the services of the mental health NGOs are paid for by PPCs. Most PPCs raise funds from
the community, although some also get funds from (nonresident) Keralites working in Gulf
countries. The NGOs seek funds globally through competitive awards. The malleability and adapt-
ability of lay community volunteers enabled their “transformation” as extended arms of community
health practices prioritized by the NGOs. The director of one of the NGOs noted:
Palliative care volunteers exhibit more openness and readiness to learn as they are not bound by any particular
professional boundary. Non-professionals are doing much better work than [mental health] professionals
because of their motivation, versatility and voluntariness. Palliative clinics are great learning grounds for us
and form the bedrock of our CMH program.

The collaboration between palliative clinics and NGOs involved the merger of two polarized
philosophies about health and health care, as the following narratives show. A senior palliative
care physician in Kerala described the vision of palliative care as follows:
The crux of palliative care constitutes community volunteers because they mobilize resources in their locality to
provide interventions. Medicine was essentially care-based until the introduction of antibiotics after which it
became cure-based. In certain conditions, there is no cure; only care is possible. This very recognition of reality
fuels palliative care. Some doctors would ask patient to take medicine post-dinner, but many don’t even have
food to eat.

In striking contrast, the chief psychiatrist of one of the NGOs described how the concept of
psychosocial disability is taught to community volunteers, through courses on psychopathology
that form part of the training of volunteers in mental health.
Mental illness is just like any other non-communicable disease. It is a brain disease – that is how we look at it.
We medicalize it to destigmatize it. We portray it [mental illness] as a neurological disease. It is a fact.
Psychiatry is nothing but neurology. Even after awareness classes, many women complain that it is because
of the fight with the mother-in-law that they got depression. However, this is not the case. It [depression] is an
internal physiological problem which is wrongly attributed to external factors.

This notion of psychosocial disability as equivalent to a brain disorder is percolated to the popula-
tion by volunteers. Thus, when people report distress stemming from domestic violence, sexual
abuse, inequality, and so on, volunteers typically displace attention to ongoing structural violence
with medical treatment. There are two main reasons for this.
Firstly, volunteers strive to be “scientific” in their efforts to mimic mental health professionals.
Hence, field-based innovations in care recede while medicine compliance management assumes
priority as they bend their energies toward NGO goals. The palliative care volunteers provide
material support through monetary help, help to construct homes, paying school fees of children,
and providing food each week for families which struggle to meet basic needs. Unfortunately, these
interventions are seen as a means of achieving medicine compliance by NGOs. The clinical
psychologist in charge of rehabilitation services explained:
Poverty is the basic problem that patients present with. Most of them (85%) lack even food, proper shelter and
clothes. The coastal area of Ponnani is really terrific that the patients are extremely poor. Women are not
allowed to go to work for cultural reasons, forcing the family to live in penury. All suffer from stress. The
majority of patients suffer from depression, anxiety, schizophrenia, which are rooted in the lack of primary
needs such as food. Many lack a secure home to live in. We started Mindfulness-based Stress Reduction
(MBSR) therapy for them. Palliative volunteers even construct shelters and provide food for free, which
increases treatment adherence. When such help is provided, patients will not resist taking [psychiatric]
medicines.

As the NGOs prioritize medicine as the primary line of treatment, psychosocial interventions tend to
recede into the background. Crises such as seeping roofs cease to be seen as an emergency as these
slip into the “normal,” while the “abnormal” brain stirs the conscience of the volunteers. Further, the
deployment of therapies such as MBSR individualizes distress and gives the NGO power to exercise
542 S. R KOTTAI AND S. RANGANATHAN

professional authority over volunteers, who are actually already providing ecologically valid solutions
to the complex problem of poverty. Reporting on NGO’s community care work amongst persons
affected by HIV/AIDS in Malawi, Rosenthal (2012) states that “the common use of buzzwords such
as “psychosocial support” and “holism” is a key element in the power dynamic” to separate the NGO
from the community on the basis of professional expertise. In Kerala, psychosocial care (in the form
of family psychoeducation, peer support meetings, home care, etc.) is reduced to a supplementary
effort to ensure medicine compliance. This overmedicalization of poverty not only labels everyday
sadness as a treatable disorder, but also deflects attention from severe mental disorders which are
most responsive to psychopharmaceuticals. Scholars have spoken of the danger of disservice to
people with severe mental disorders when mental health resources are allocated to treat natural
reactions to traumatic life contexts by framing them as anxiety and depression. “Treating” social
problems with pill distribution in “pharmerging countries” (LMICs like India) creates “psychophar-
maceutical globalisation” (Applbaum 2015).
The second reason comes from a new meaning that volunteers find in mental health care delivery.
Volunteers who so far had dealt with palliative care for terminal illnesses find greater satisfaction in
working with psychosocial disability. They experience a greater sense of control because the medical
intervention is still possible. One volunteer remarked:
Psychiatry is not that difficult. In general home care [for physical illnesses] we have a lot of emotionally taxing
work to be done: wound dressing, catheterization, bathing, taking care of bedsores, to name a few. However,
after all that, the person’s (health) is ultimately out of our hands.

With mental health issues, tangible outcomes are observable: people who complained of sleeplessness
now sleep; those previously hearing voices now don’t. Trained under the biomedical paradigm by the
NGOs, volunteers stick to supplying medicines as a tangible, concrete act of care. They also increasingly
come to define outcomes in terms established by the NGO, asking whether the man who didn’t work is
now “employed” or if the woman who didn’t cook for the family is now “duty-bound.”
Thus, volunteers fall in line with the NGO’s definition of the problem and its solution; at the same
time, the provision of free medicines creates a complex sense of affiliation, subjugation, and
dependence in the minds of patients and families, which leads to “reciprocity anxiety.” While
psychiatric medicines are typically not dispensed without seeing the patient in person in the clinics,
medicines may be provided by proxy to those who report on behalf of patients. All of these practices
are based on the idea that volunteers are truly engaging in a noble act of care through medicine-
dispensing.

The pivotal role of task-shifting

In scaling up CMH programs, the tasks of psychiatrists are shifted to psychologists, social workers,
a homeopath, and a psychiatric nurse. Once a week, these task-shifters run clinics as if they were
psychiatrists. The patients address them as “small doctors” as they are mistaken as junior doctors.
They see patients once a week and prescribe medicines. A trained psychiatrist comes to the clinics
rarely, and because of his seniority and perceived authority, patients address him as “big doctor.”
Volunteers are given training in basic psychopathology, social skills training, psychoeducation,
family communication, relapse prevention strategies, and medicine compliance management. In
the following sections, we discuss how care has become medicalized in the palliative clinics and the
consequences of this medicalization.

Medicalization of distress
Following the NGO-PPC collaboration, volunteers display particular attention to the role of med-
icines as a panacea for all sufferings. We see medicalization at work in three different respects: in
terms of awareness; in terms of therapeutics; and in terms of clinicians’ practices.
 MEDICAL ANTHROPOLOGY 543

In terms of awareness: “change in thoughts is disease”

Even though mental health professionals and volunteers point out various reasons for mental health
issues ranging from sexual abuse, domestic violence, discrimination, sex trafficking, gender-based
violence, and social exclusion due to non-heteronormative sexual orientation, awareness programs
emphasize mental illnesses as brain diseases and stress the importance of medicines in addressing
them. For example, when a volunteer once brought up the family issues of a patient, the psychologist
cautioned: “It is not our work to get involved in family issues. We need leadership which will enable
regular supply of medicines.” At a two-day training program for ASHAs (An Accredited Social
Health Activist (ASHA) is a trained female community health activist. Selected from the community
and accountable to itself, they act as an interface between community and public health systems) to
be inducted for its CMH program, the director-psychiatrist of one of the NGOs explained mental
illnesses with a PowerPoint presentation.
A mentally healthy individual is a person who can think clearly, solve problems in life, work produc-
tively, enjoy good relationships with other people, feel spiritually at ease and make a contribution to the
community. This is a normal person. When it becomes illness, there are symptoms. There are different
symptoms of depression, anxiety, psychosis. In psychosis, the person lives differently. It is not an
ordinary life. The main thing that you need to ask is whether they are sitting alone and laughing.
We live in a society with certain rules. These people live in a different world altogether without
following these rules.

Everybody has a pattern of thinking, which is normal. Change in thoughts is disease. Negative thoughts, having
no happiness, no meaning in life, is seen in depression.

The day after the training, we accompanied volunteers on their home visits. For the volunteers, now,
every possible deviance, difference, or distress appeared to be a sign of an untreated mental illness
rooted inside the person, as revealed in the following conversation between the social worker,
a woman aged 65 and the volunteer:

Social worker: These medicines need to be taken continuously, and you should not
stop them without consulting the doctor. This is a disease of the brain.
Volunteer: Is it that you are extremely clean?
Housewife: No. I am having tension, extreme tension. I was given sleep medicines
on which I was utterly dependent. I can’t sleep without medicines. My
brother and sister are bedridden due to stroke. When I see them or
think about them, I become very tense. I am a smart woman and used
to do all the work at home, but now I have tension. When I see my
brother and sister bedridden, I feel very upset, and I cry.
Social worker to housewife: you need to continue the medicines. consult the doctor once more.
medicines are taken to prevent recurrence of [mental] illness.
Social worker to volunteer: you need to also educate them that this is a brain disease and that it
will be cured with medicines. Also, tell them about the symptoms of
common mental disorders.
The professionally trained social worker teaches lay ASHA women how to communicate health
information, preventing them from engaging with genuine life concerns and limiting them to
medicines. It is useful here to consider Holland’s (2018) discussion of biocommunicability which
instills specific roles for different actors to adopt concerning health knowledge. News media rarely
bring out controversial aspects of people’s experiences that undermine psychiatric authority, and
thus are complicit with biomedical authority in promoting a biomedical model of mental illness. In
this context, they sideline the role of social forces and neoliberal governments in causing and
addressing mental health issues.
544 S. R KOTTAI AND S. RANGANATHAN

In terms of therapeutics: “who is not taking medicines? who is not taking bath, who is not
working?”
Volunteers become normalizing and moralizing inspectors during home visits. Community volun-
teers are tasked with identifying symptoms and ensuring medicine compliance, transforming them
into check-box psychiatrists where checklists of signs and symptoms are employed, while they must
decontextualize suffering from its socio-political contexts. In this process, they reduce “the complex-
ity of mental life to a manageable and readily communicable numerical form” (Young 2017:34).
While returning from a home visit, Sneha (60), a community volunteer, said that she becomes very
anxious when her only son travels far to attend university. She reported her “diagnosis” of anxiety
disorder to the psychiatrist, who prescribed anxiolytics. In many cases, volunteers diagnose people
around them loosely just because they happen to act differently.
Instructed by the doctor to ensure medicine compliance, the first thing that volunteers do
during home visits is to verify medicines. Family members and patients are told to store the used
medicine strips for verification. Afraid of being reprimanded for medicine noncompliance by the
clinical team, volunteers resort to persuasion and threat to ensure compliance. Here, the effect of
medical hierarchization is at play, mirroring caste-entrenched Indian society (Jadhav et al. 2016).
The volunteer is intimidated by the psychiatrist into action, and the patient, in turn, is intimidated
by the volunteer. This top-down approach is grounded in the fear of being penalized for not
delivering and meeting targets. It can also be linked to the professional training and practice in
psychiatry in India, that operate chiefly in an instrumental fashion, focusing on the patient and
his/her social world as the site of pathology (Bayetti et al. 2017). Overcoming this cultural barrier
between clinician and patient is necessary for establishing a therapeutic alliance through dialogical
practices, which forms the core of effective interpersonal healing practices (Kohrt and Griffith
2015).
A social worker spoke of the purpose of home visits:
Other than providing emotional support to the family, an important aim of home care is to see whether
medicines are regular. We also check the medicine strips to ensure regular intake of medicines. If they are not
taking medicines, we compel them and the family caregivers. If nothing works, medicines are given covertly in
food; liquid medicines dissolve quickly.

In seeking to reinforce medicine compliance, caregivers, volunteers, and NGO all work in tandem, as
the following anecdote from a home visit to a 50-year-old-female patient, with her husband, nurse,
and volunteer, illustrates.
Husband: She doesn’t take medicines correctly.
Patient: I forgot to take medicine only for one day.
Nurse: You cannot skip medicines. Show me your medicines. We will shift you to a shelter
home if you don’t take medicines.
Volunteer: Do you know how costly the medicines are? Forget about the cost; you have two
daughters – you need to take care of them, right?
Patient: I do take care of both of them. I wash their clothes; I make food for them.
I help my husband in his work also. Sometimes I forget; everyone forgets, right?
I don’t feel any difference even if I don’t take medicine. I don’t have any
problem now.
Social worker: If you don’t take medicines, we will bring the vehicle for sure and place you in
a shelter where you will be given medicines on time.

On one home visit, when Jousheera (45, F) informed the volunteer and a social worker that the
medication made her tired, the social worker and volunteer rallied together to justify the use of
medicines.
 MEDICAL ANTHROPOLOGY 545

Social worker: Do you know which medicines you are on? Do you know people who take more
medicines than you? We need to change mind’s sadness, right?
Volunteer: The pounding of heart, burning in the stomach are all due to disease. Because there
is no strength of mind, your body is affected. We can start our medicines. Why
should you suffer? We all have problems in life. When sadness interferes with our
functioning, we require medicines.
Social worker: Don’t feel bad that you are starting medicines again. You need to move forward in
life. You need to look after your children. Taking all these into consideration, you
need to take medicines. Medicines will make your mind strong.
Volunteer: Do you want medicines, or do you want to sit and brood?
The volunteer insists that the patient’s son go to the clinic the same day to fetch medicines and he
does so under compulsion.
When we reached a male patient’s (aged 28) home, he was demoralized by the volunteers and
social worker who sought to bring him in line with existing social customs and practices.
Aren’t you ashamed of living off the income of your younger brother? Learn from your brother – he makes Rs.
900 per day. Like others of your age, you need to go for work. Why didn’t you shave your beard? Last time
I had told you to shave. If I see you with a beard again, I will shave it for sure. Don’t invite shame on yourself.

When a 32-year-old woman staying in the rehabilitation home expressed her desire for a partner to
the speech therapist-cum-volunteer, the latter was unequivocal in providing “moral therapy.”
See, here you can stay safe. Even if you are in a relative’s home, it may not be safe [for a woman]. If you are
married, a sexual relationship is imperative, and the children you give birth to will not be normal as you are on
medicines. Why do you want to trouble another family, a husband and a child? Think about it. You lack the
capacity to care for a family. You say that you feel tired. Can you look after a family with this tiredness?

The above narratives illustrate how moral injunctions and social norms are reinforced through
psychiatric advice, where “scientific medical assessments” translate into social judgments. These
observations about moral therapy also show that the process of medicalization of volunteers is not
complete as they make moral rather than medical recommendations, but the moral is used to justify
the medical (take medicines so that you will be a good son, mother, etc.).
A senior palliative volunteer from Malappuram, the heartland of palliative care in Kerala,
remarked on the importance of paying attention to nuances of suffering during home visits, in
contrast to the ideas held by new generation volunteers trained by the mental health NGOs.
Everyone will definitely have depression if they don’t have food or money to educate their child. Will medicines
help them in such a case? When we visit the home, we have seen that many don’t have food or a proper house.
The first thing we do is to provide them with basic amenities. Only after that do medicines come in the picture.

Despite the recognition of the importance of a holistic perspective to mental health in palliative care
philosophy, in practice, home visits often did not consider these factors but focused instead on the
powers of medicine.

In terms of clinicians: the “big” doctors and the “small” doctors

The clinical panel of NGOs includes diverse professionals including a psychiatric nurse,
a homeopathic physician, and recent postgraduates in social work and psychology. However, in
the name of task-shifting, all “perform” as psychiatrists in prescribing medicines. The director of the
NGO was straightforward:
Task-shifting is a medium through which the goal of universal coverage can be achieved in LMICs. For
a massive population like India, task-shifting becomes essential. Our vision is to expand services geographically,
and task-shifting is one way to achieve this.
546 S. R KOTTAI AND S. RANGANATHAN

At palliative clinics, non-medical professionals perform the role of psychiatrists, dispensing medi-
cines. They are commonly referred to as cheriya doctors (“small doctors”); an older, senior doctor is
called “big doctor” and younger, junior doctors are called “small doctors.” The same term “small
doctor” is used in the clinics for the social workers and psychologists who see patients and prescribe
medicines, just as psychiatrists do. Typically, if no new complaints are reported, they prescribe
a repetition of the same medicines by writing “repeat.” If clarification seems required by them, they
talk to a doctor over the telephone. During such “tele-psychiatry” consultations, patients and
caregivers sit outside the consultation room so that their real identity remain concealed.
Jyothirmayi’s (22, F) father shared his experience with tele-psychiatry.
We didn’t meet the big doctor [director-psychiatrist] for two years. They (non-medical professionals) ask us to
sit outside for some time, and they talk over the computer. We cannot see doctor [online]. My daughter used to
drool too much. I requested them to stop medicines or to reduce the dose of medicines. The volunteer at the
palliative clinic also asked me to press the small doctors (psychologists and social workers) to reduce medica-
tion when they saw her sad plight.

Very often, the psychiatrist is unavailable over these digital mental health platforms, leading to
several “repeat” sessions until the “big doctor” appears on the scene. The pharmacological manage-
ment of the tribal population in Wayanad district is carried out solely by a psychiatric social worker
without even employing psychiatric telephone consultations. Another social worker prescribed
medicines for a 65-year-old woman patient while on a home visit. She advised her daughter-in-
law:
If sleep is less, then it will be a problem. If you have Quetiapine with you, it can be given in any dose. Oleanz
will create side effects. See for another two days and if she doesn’t sleep, give her Quetiapine.

There is clearly an imperative to project an image of being a doctor to gain respect and credibility.4
One of the community volunteers was critical of this:
Here they (social workers and psychologists) are doing the work of the psychiatrist, and they are not doing the
work that they are supposed to do. After having taken on the role of the psychiatrist in prescribing medicines,
they are not willing to part with that role as it commands respect and offers comfort within the four walls of the
clinic.

Reviewing GMH praxis from a cultural psychiatry perspective, Kohrt and Griffith (2015) cautioned
that task-shifting may result in unintended consequences. When evidence-based practices developed
in the cultural context of high-income countries are exported to LMICs, the role of family may be
limited, leading to individualized interventions. Also, assigning specific roles in task-shifting influ-
ences the conceptualization of mental health and illness. In India, psychologists and social workers
share similar worldviews to those of psychiatrists because all are trained in a biomedical model at
a mental health institution. Hence, the transmogrification of these non-medical professionals into
psychiatrists for task-shifting is smooth and easy.

The power of “free medicines” from “small doctors”

While we have tried to show the medicalization process at work, we also want to add that for many
informants, medicines are very powerful things, both symbolically and biochemically. For patients,
the fact that the clinic supplied “free” medicines was a major attraction, and many sought
medicines in some form or another (as injections or tonics, for example). In addition to the
symbolic value, the biochemical value of medicines cannot be underestimated in dealing with
extreme states of distress or confusion, and with epilepsy. Judicious use of medicines by sensitive
psychiatrists can improve the socioeconomic engagement of the person, reducing symptoms,
stigma, and social exclusion. However, our home visits found many patients drifting into greater
poverty as serious side effects incapacitated their capacity to work, thereby increasing their
dependence on NGOs.
 MEDICAL ANTHROPOLOGY 547

Some patients did experience relief and satisfaction with medicines. Thus, Shantha (51, F), whose
four-acre paddy field had become submerged after the construction of a dam, was reassured after her
first week of consultation:
The doctor talked to me for half a minute. He asked me to take medicine (one tablet at night). He told me everything
would be ok. Now I am all right. The effect [of medicine] was felt the next day itself. I was not talking much the day
you met me last week, right? Look at me now; I can go out alone without fear. Previously I was reluctant to go out
alone. I came alone today [to the clinic]. Now I have energy to work. My appetite has increased.

Shantha’s narrative illustrates her faith in medicines, illuminating the vital role of medicines as material
substances mediating people’s relationships with clinics. Clara Han’s work (2013) on CMH in the context
of labor instability and extreme poverty in Chile showed how people took psychiatric medicines when
hungry, to derive energy to work and to feel relieved when parents quarreled. People also gifted
antidepressants to help their friends sleep and feel better which, she argues, “sits in awkward tension
with GMH’s call for the treatment of common mental disorders through packages of care” (Han
2013:299). Likewise, hunger in drought-stricken villages of Brazil became so normalized that medicines
began to replace food for the starving poor (Scheper-Hughes 1992). As a concrete material substance,
medicines render treatment actionable for providers, offering a sense of concreteness and control for
people beset by structural violence and social suffering, producing new subjectivities.
Medicines in different forms also signify different things for patients. People demand tonics, vitamins
and other drugs instead of taking steps to change the political economy of health (Petryna et al. 2006;
Whyte et al. 2002). In the Indian context, injections are seen simultaneously as powerful, fast-acting and
draining, while the “tonic” is viewed as providing strength. Thus, while families requested a reduction in
dosage of the medicine, which was seen as depleting energy from the patient, they might request the
provision of tonic to strengthen the body. The following clinical interaction occurred between a 70-year-
old mother of two male patients and the psychiatric social worker.
Mother: He [son] is not taking food or tea. Is there any tonic you can prescribe?
Psychiatric social worker: For tonic, you need to see the doctor of the body (shareerathinte doctor)
who comes in the morning.
Mother: You, please write the tonic.
Psychiatric social worker: I don’t know about tonic. Any other issue?
Mother: He is not taking food – that is the problem. I think you need to decrease
medicines; he is drained.
Psychiatric social worker: If he is having problem we cannot decrease the medicine, let it continue
as it is. We will see after three weeks.
The mother looks at the psychiatric social worker with a hopeless sigh coupled with anger, goes out,
and leans on the rails of the veranda.
Bewildered by the “doctor’s” response, as she neither prescribed tonic for tiredness nor reduced
medicines, the heaviness in her heart was palpable:
He is not taking food since two weeks. He gets up only by 11 a.m. He had epilepsy since he was four and he is
on treatment since 1993. He is exhausted nowadays. Can’t we give tonic for that? The other son sleeps after an
injection; there is not much of a relief. Now there is an injection every week. I requested them to reduce
injection to once a fortnight but for the doctor, the time is not yet ripe to do so [whines].

Side effects of “care”

A severe consequence of medicalized treatment is the side effects that patients suffer. In palliative
clinics, when patients complain about side effects, their voices are often silenced by the non-medical
professionals who have no expertise in psychopharmacology. Instead, patients are often blamed for
the disabling side effects by attributing these to noncompliance. Side effects are sometimes written
off as part of the disease process.
548 S. R KOTTAI AND S. RANGANATHAN

While most patients given psychotropic medicines were not even seen by a general physician for
years, many also expressed their anguish about not meeting the “big doctor” (psychiatrist). With the
rise in popularity of the NGO and the consequent proliferation of psychiatry units, a psychiatrist has
become a rare visitor to the clinics. Many patients struggled with the disabling consequences of
unmonitored psychiatric polypharmacy. For instance, a 22-year-old patient started experiencing
epileptic seizures while on a high dose of antipsychotics. The “small doctors” added antiepileptic
drugs to the patient’s regimen, and he soon became robot-like. Upon consulting at the government
medical college, they learned that seizures were the result of side effects caused by unmonitored
psychiatric polypharmacy. We learned that many patients were admitted to referral centers due to
serious side effects. We have been noticing intense tremors in Lipesh (22, M), who was from a poor
family, from the time we first met him in 2015. When we met again in September 2017, his condition
was pathetic. He spoke with a slurry voice:
I suffer from severe tiredness, and I can’t go anywhere. I had told all these to the doctor [psychiatric social
worker]. For two or three months, I experience severe tremors. When I sleep at night also, there is tremor. I am
not going for work because of intense hand tremors for the past three months. The big doctor saw me one year
ago; the small doctor is seeing me now. An injection is given once a fortnight. I am very tired. Now I don’t go to
play cricket also.

Similarly, when we met Shaji (51, M) at his home for the second time in 3 years, we were given
a warm welcome while he struggled with a slurry voice, swaying gait, and drooling. His condition
had progressively deteriorated. His speech was hardly comprehensible.
Severe tiredness – I am not able to do any work. I used to go to work sometimes, but I’m unable to go
nowadays. Since two months the small doctors are giving injections. I’m not able to speak correctly as my
tongue curls up. I have not told this till now because I’m not comfortable in telling them. Tongue becomes too
dry. I’m not able to speak correctly. I’m afraid that I will die soon. Sodium Valproate has been increased to
500 mg from 300.

We gathered from the palliative volunteers that because Shaji had skipped medicines for some time,
he was being administered injections to ensure compliance, indicating the symbolic value5 which the
injection holds for the palliative clinic. Moideen (53, M) looked around to ensure that nobody in the
clinic heard what he said:
Due to injections, I cannot go for any work as I have severe fatigue. There is difficulty in walking as I have lost
strength in my legs. They (palliative clinic) have given me two injections now. Now I am getting tremors. I have
not told this to the clinicians. When I sit near them, I don’t feel like telling all this. I pass urine without my
knowledge sometimes nowadays. Please tell this to the doctors. I don’t have anyone, you know.

Applbaum (2015) found that doctors often fail to distinguish between symptoms of illness and side
effects of medicines. He added that side effects and withdrawal syndromes had not received
sufficient clinical research. Navas (38, M) requested us to convey his side effects to the doctors
and volunteers on his behalf. When asked why he did not tell them himself, he exclaimed: “How can
I tell them? Even if I do, they will not value me at all.” When we asked clinicians why routine blood
tests mandated while administering certain antipsychotics like Clozapine were not carried out, they
evasively said that it was not a practice at the clinics. Yet, Clozapine is not recommended by mhGAP
for routine administration without monitoring (WHO mhGAP Guideline Update 2015).
For the director-psychiatrist, however, the issue of non-medical practitioners prescribing psychiatric
drugs was not seen as a violation of legal protocol but as a perfect example of task-shifting, as he elucidated:
This is how our system of CMH operates, based on decentralization, demedicalization and deprofessionaliza-
tion through task-shifting. We didn’t do anything wrong. Medicines are written (by non-medical professionals)
after discussions with the doctor. The details are shared and monitored on Dropbox.

For this psychiatrist, the NGO was only following textbook prescriptions of CMH. In turn, volunteers
knew of no other way to work than to prescribe, particularly in a context where people placed their trust
in the palliative volunteers who were familiar to them. This raises important questions about what task-
 MEDICAL ANTHROPOLOGY 549

shifting actually means in this context. Although task-shifting is stated to be an effective strategy, many of
these studies measure effectiveness based on the range and scale of outreach (Balagopal and Kapanee
2019; Nimgaonkar and Menon 2015) rather than the quality of services delivered. In the context of
a severe shortage of mental health specialists in India, rather than resulting in deprofessionalization and
demedicalization, task-shifting often results in professionalizing and medicalizing non-medical profes-
sionals, lay health workers, and community volunteers.

Conclusion
The community led-palliative centers have the virility, vigor, and vitality to be “counter-clinics”
(Davis 2018) or potential alternative spaces outside, alongside or oppositional to mainstream
psychiatric settings. However, with the redefinition of the community care into CMH care, plural,
rights-based, dialogical, and ecological approaches in health interventions are giving way to
a singular discourse and practice in mental health where trained community volunteers pitch for
a large tent of “patients” in need of “treatment.” The illegitimization of local healing practices (Sood
2016) is now jointly propagated by volunteers and NGOs vouching for “scientific” treatment for all
daily hassles, leading to ascendance of global categories in local contexts (Halliburton 2005). Here,
task-shifting appears to work smoothly only because the program targets the poorest sectors of
society and tribal populations from whom resistance is unexpected. Here, free medicines become
a Hobson’s choice for the underprivileged.
Reporting from the frontlines of community psychiatry in the USA, Brodwin (2011) demonstrated
how a moral logic of care in health care is a culturally driven process where the social organization of
work silently shapes clinicians’ actions. Factors antithetical to values of community care such as lack of
political will among politicians for complex social interventions, oligarchic and top-down approaches
of biomedically oriented leaders, and tensions between mental health professional groups have been
cited as reasons for mental health policies in India choosing the biomedical model (van Ginneken et al.
2017). Medical hierarchization and excessive reverence for doctors nested in an Indian cultural milieu,
and the anxiety of patients for the material and emotional support received from palliative clinics,
result in psychiatric pharmaceuticalization where sufferings are reshaped as “brain diseases.”
The fact that unanticipated consequences of task-shifting are happening in Kerala, where health
care systems are the best in India, raises important questions about the role of the state in
accelerating “care” in the name of development. David Mosse (2013) traces ethnographies that
point toward the loss of state power in the government of development due to its dispersal to NGOs,
donors, informal institutions, social entrepreneurs, and the private sector. He notes: “In the age of
neoliberal reform, the terms weak state, fragile state, crisis state, and collapsed state are especially
prominent in the development policy lexicon” (Mosse 2013:236). Reminding us that recovery
approaches in India are still based on clinical recovery rather than personal recovery models,
Sharma (2019a) states that people in India are offered the tokenistic presence of “peer support
volunteers” by psychiatry-led enterprises to fulfill their agenda of scaling-up services. The National
Mental Health Policy 2014 talks about provisioning trained lay health workers to achieve clinical
recovery – controlling symptoms, improving social function and making the patient “normal” –
without a focus on personal recovery – a unique personal journey to develop new meaning and
purpose in life despite suffering from psychosocial disability. Sharma has criticized this as a watered-
down version of the peer support model of Indian psychiatrists. “[T]his seems to be a case of dual
marginalization by a socially powerful and dominant group (psychiatrists) of another group (current
patients) in the name of employing them in low paying ‘jobs’” (Sharma 2019a:28). Sharma has also
noted that “[t]he realization that often people cannot move beyond psychiatric understandings of
their experience is at the heart of [her] struggles” (2019b:9).
In response to the evolution of the new mental health care act, Davar (2012) has warned of the
political economic interests that lie behind modernizing mental health care through the right to care, by
facilitating the growth of private psychiatric facilities to provide access to treatment. Saiba Varma showed
550 S. R KOTTAI AND S. RANGANATHAN

how the goal of modernization of mental health care in India, aimed at deinstitutionalization, works at
the expense of neglecting stigmatized, chronically ill, long-term destitute patients with few resources
(Varma 2016). Similarly, the developmental goals of NGOs in Kerala cast the burden of development on
the most vulnerable citizens. Taken together, these issues raise critical questions about what is meant by
mental health “care” and what kinds of “care” are included in this term.

Acknowledgments
We thank all participants who spent their time and shared their stories which form the bulk of this research. We are
grateful to three anonymous reviewers for their helpful comments and Lenore Manderson, editor, and Victoria Team,
Editorial Assistant, for timely editorial guidance.

Funding
This research was funded by the Ministry of Human Resource Development, Government of India, New Delhi
[LA14RESCH11003].

Notes
1. For a detailed analysis of density of associational life in Kerala, see Chathukulam and John (2002) and Heller
(1996).
2. Kerala was the first government in Asia to roll out a palliative care policy in 2008. The pioneer of the palliative
movement in Kerala, Dr. M R Rajagopal, was nominated for the 2018 Nobel Peace Prize.
3. Systems of day care, home care, volunteer meets, family (caregiver) meets and vocational training to make
umbrella, soap, etc., imparted to bedridden patients are locally grown systems of care of palliative clinics.
4. Saiba Varma (2012) describes a similar process where counselors act as doctors in the context of violence in
Indian-administered Kashmir.
5. People even demand injections from doctors for fast and effective relief. Halliburton (2010) evidences how
people in Kerala regard allopathy or “English medicine” as an occasionally painful method of healing, while
indigenous Ayurveda as an esthetically pleasant method of therapy.

Notes on contributors
Sudarshan R Kottai is a PhD candidate in Department of Liberal Arts, Indian Institute of Technology, Hyderabad,
India. His broad interests include mental health in the context of gender, disabilities and sexualities, and intersections
in mental health all taking a multidisciplinary perspective.

Shubha Ranganathan is an Associate Professor in Department of Liberal Arts, Indian Institute of Technology,
Hyderabad, India. Her research is interdisciplinary, drawing on the fields of medical anthropology, gender studies, and
alternate paradigms within psychology such as critical psychology.

ORCID
Sudarshan R Kottai http://orcid.org/0000-0002-2564-4879
Shubha Ranganathan http://orcid.org/0000-0002-6954-2727

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