by Sushovan Patnaik 11 November 2021
Earlier this year in February, as India stumbled into a deadly second wave of the coronavirus pandemic, fatally more so for her underpaid, systemically oppressed, and underacknowledged sanitation workers, a heart-wrenching detail emerged in the lower-house of the parliament. The Social Justice and Empowerment Ministry revealed that in the preceding five years up until December 2020, a total of 340 manual scavengers had succumbed to the tortures of their profession.
Manual scavenging, a caste-based profession embedded into India’s social framework, has been the subject of an immense repertoire of academic and journalistic coverage over the years. With India’s central government teasing and then denying interest in amending the deeply flawed Prohibition of Employment as Manual Scavengers and Their Rehabilitation Act, 2013 from last year through to March of this year, policy interest in the subject has been rekindled to some extent. When the fatality numbers were declared, therefore, they became an emotive, assertive rallying point to bring back manual scavenging into mainstream policy discourse. At the same time, however, centralising the discourse on creating a special protective regime for manual scavengers around numbers and statistics sidelines certain vital, underexplored aspects of the problem – mental health occupying foremost among those.
Basically, these statistics reflect only the direct deaths from onsite asphyxiation accidents associated with manual scavenging. On the other hand, indirect fatalities associated with the profession have received only haphazard and arbitrary coverage, with no existing standard statistical analyses dedicated to the deaths peripherally related to the profession, either by the government or NGOs. Within this category of ‘indirect deaths’, suicides occupy a prominent position.
Most recently, in February 2021, a 37-year-old manual scavenger in Mysuru, Karnataka, took his own life after months of harassment and humiliation doled out by his boss. In a harrowing suicide note, he wrote that he had been forced to enter into a manhole without any protective gear, and later coerced by his superiors to put thumb impressions testifying that he had entered the manhole with bare hands voluntarily. Numbers and laws fail to account for stories such as this.
In India, sincere literature surrounding the mental health-related impacts of manual scavenging, both as an occupation as well as a social condition, is minimal. A comprehensive and novel understanding of the psychological dimensions of scavenging, therefore, must be carefully foregrounded in a detailed understanding of how discrimination and mental health interact.
Structural violence and intergenerational trauma
Norwegian sociologist Johan Galtung, in 1996, wrote about forms of violence that are culturally legitimised, or as he wrote, “violence that was frozen into structures”. Despite Western origins, Shaima Ahammed noted that the terminology of ‘structural violence’ can be immensely helpful in understanding the operation of the caste system in India. Caste oppression and its persistence hinges itself upon the structural legitimation of violence in an already repressive society. As Chugh et al note, even though the specific terminology of structural violence may not have germinated by Dr. Ambedkar’s time, it is clear that because Dr. Ambedkar perceived caste discrimination as structural violence, could he innovate upon methods of foundationally challenging concretised cultural systems to annihilate caste.
Thus, while the narrative of ‘structural violence’ has always played a significant role in understanding the Dalit-Bahujan-Adivasi conditioning in India, only recently has there emerged a mainstream discourse surrounding how this structural violence is closely associated with intergenerational trauma and the mental health of marginalised populations. In the language of Tessa Evans-Campbell, intergenerational or historical trauma within African-American populations explains the critical connection between a succession of historically traumatic events faced by any marginalised community, and the contemporary stressors that affect modern individuals and families coming from those communities.
It is fair to acknowledge that Dalit communities in India host this intergenerational trauma, and this trauma plays a notable role in constructing the identity of the Dalit individual and the community. As Ruchita Chandrashekhar insightfully notes, this inheritance of trauma occurs due to cycles of “secondary traumatisation”, caused by violence within the community, somatic stressors, and emotional dysregulation. Because caste violence is structural violence, and because most Dalit communities are deeply socially and politically downtrodden, they have no means of escaping these vicious cycles of traumatisation. Manual scavenging is restricted to Dalit communities which are most extraordinarily marginalised, and most immensely lacking in agency and healthcare access. What further contributes to this, is how the nature of the stigma associated with manual scavengers is itself intergenerational. The resultant of this intergenerational discrimination are vicious cycles of limited opportunities and sanitary work faced by children of manual scavengers, and thus vicious cycles of trauma.
Societal exclusion:
Social exclusion of entire communities is itself a form of structural violence, and similarly is an intrinsic driver of debilitating mental health of both the individual and community level. In an empirical study from Ghazipur district, Singh and Ziyauddin noted that families from Mehtar caste communities (engaged in manual scavenging) resided in houses that were situated outside the main residential area and dwelled in extremely unsanitary conditions. As such, they were also prohibited from interacting or dining with people of higher-caste communities. According to Chugh et al, the caste system transfixes economic rights of caste communities, immune to any forms of change or flexibility, and thus results in the “forced exclusion” of manual scavengers. Further, manual scavenging communities experience systemic forms of educational exclusion, as children of manual scavengers, vulnerable to discrimination in schools, are often forced to do scavenging work which undermines their educational ambitions, forcing them to drop out frequently.
Manual scavenging communities, therefore, experience not only geographical alienation and housing-based discrimination, but also deeper forms of social exclusion through obstructions upon human interaction and educational progression. As Lilavati Krishnan notes, there exists a bilateral relationship between exclusionary factors such as stigmatisation and mental health/ill health, and the ‘othering’ of communities and individuals can lead to gross forms of psychological deprivation and injustice.
Acknowledging silenced trauma
Structural violence against oppressed caste communities has historically manifested as public humiliation, forced labour, exploitation of children, denial of access to water, public lynching, assaults and rapes among other forms. This violence has been simultaneously accompanied by an absence of viable, and socially acceptable media for the expression of grievances, traumas, dissent, and protests. What this results in, is the intensification and perpetuation of the marginalised individual’s trauma and disempowerment.
According to Anandhi and Kapadia, the lack of mechanisms of grievance expression also results in the repression of anger and the motivation to protest. As Nilan Yu notes, this results most directly in the internalisation of worthlessness, self-defeating beliefs, and lack of agency. Denial of expression, integration, and healing devastates an individual’s functional capacity, deepens sensations of loss, and intensifies their shame. van der Merwe and Gobodo-Madikizela note that repression of anger and trauma also leads to humiliation and fundamental breakdown of the self. While this ‘breakdown of the self’ can and often does result in clinical depression, it also manifests in various expressions of violence, directed towards both other people (including family members as domestic violence), as well as the self. As best put into words by Evans-Campbell, trauma, like energy cannot be self-contained, and seeks a way out in one or the other way, if denied agency and expression.
We understand therefore that trauma when silenced has harmful potential implications in the forms of domestic abuse, marital rape, child abuse, and overwhelmingly, suicide. Dalit communities associated with manual scavenging are deeply deprived of political participation, and therefore are worse affected in terms of having their trauma silenced, and the narrative of their suffering dissolved. Predictably, this kickstarts vicious cycles of traumatisation, in the forms of high instances of domestic abuse in manual scavenging communities, but also increasing instances of suicides, self-harming attempts, and severe mental illnesses.
Acknowledging the ceiling of India’s economic reform model:
Rehabilitative schemes in India surrounding manual scavenging communities have expectedly and routinely circumvented psychosocial rehabilitative goals. The existing schemes that are in place, initiated under the Prohibition of Employment As Manual Scavengers And Their Rehabilitation Act, 2013, have a rather narrow scope of operation, transfixed more singularly upon financial and educational upliftment goals. §13 of the scheme lays out a plan for providing for cash assistance to the member of the household of the manual scavenger, voluntary skill development training, concessional loans, scholarships for children of manual scavengers, and capital subsidy. Keeping aside the fact that these schemes themselves suffer immensely in terms of implementation and funding, in purely practical terms, they are also insufficient for holistic rehabilitation of scavenging communities, since financial rehabilitation rarely translates to actual psychosocial rehabilitation.
According to a study conducted by Gupta and Coffey on the analysis of how caste and religion shape mental health, the authors noted that in India, efforts relating to wealth redistribution, and education of Scheduled Caste and Muslim communities has negligible impact on reducing gaps in mental health. This is explained by previous findings by Thorat and Joshi, who note that a large fraction of people still admit discriminatory behaviour towards scheduled castes, a resultant of which observable characteristics such as education and household economic status become irrelevant. Evidently, thus there is a need to imagine a rehabilitative system in India better suited to the complex mental health needs of manual scavenging communities.
Bolstering psychosocial rehabilitation in India
Psychosocial rehabilitation broadly refers to a reformative system that hopes to facilitate opportunities for persons with chronic mental illnesses to reach their optimal level of independent functioning in society. The objective remains the improvement of the emotional, social, and intellectual skills of the persons such that they are able to learn, live and work within the community with the least amount of professional support.
The aspect of minimal dependence on professional support is especially important in the Indian context since fiscally mental health remains perhaps the least prioritised component of healthcare allocations. As of 2020, the Indian government spent just 33 paise per mental health sufferer in the country. Where professionals across the organised sector struggle to find priority as beneficiaries of mental health funding, manual scavengers and other communities engaged in unorganised work remain cosmically estranged from the discussion.
As the practicality of professional support wanes, community-based mental health rehabilitative (‘CMHR’) programs exhibit immense promise. Evidence shows that community-based psychosocial rehabilitation is a feasible option in low and middle-income countries since they can be delivered effectively by trained lay health workers under supervision of mental health specialists. Further, in the specific context of marginalised populations, delivery of mental health support and care, psychoeducation, and narrative therapies by laypersons, community-based primary care practitioners, and shared mental healthcare workers can be greatly effective.
CMHR programs for manual scavenging communities can be based on two successful experimental programs deployed in India.
The first is the Atmiyata intervention employed in Maharashtra, a village-level CMHR initiative aimed at tapping into the pool of village-level community members who have the time and inclination to provide support to other members in their community. The intervention was designed to build informal community care for people in distress and with symptoms of depression and anxiety, as well as facilitate access to social benefits, a core strategy for improving mental health and social outcomes for rural populations with poor access to formal mental health services. Joag et al noted that the program was successful at the ground level – community therapists were able to identify people with emotional distress and in need of psychological support, and patients experienced reduced symptoms of depression, domestic violence, alcohol use, and severe mental illness.
Similar to Atmiyata, the Vidarbha Stress and Health Programme (VISHRAM) in Maharashtra employed a successful CMHR model, shifting focus away from hiring psychiatrists and psychologists far away from villages, and towards building a body of “lay counsellors” who could check on fellow villagers daily. VISHRAM had highly positive impacts on reduced farmer suicides in the region, and also led to increased awareness regarding superstitions and stigma. The prevalence of depression fell from 14.6 to 11.3 percent, and the prevalence of suicidal thoughts in the previous 12 months went down from 5.2 to 2.5 percent.
If the successful models of Atmiyata and VISHRAM were to be replicated within manual scavenging communities in urban setups, in such a way that the best practices of both the programmes are incorporated, such as qualitative training of lay workers, it could lead to decreased instances of domestic abuse and suicide. While existing economic and educational rehabilitative programs need to be further developed, such development must occur in consonance with increased scholarly and policy investment in CMHR programs for the specific mental health needs of scavenging communities, such as coping with silenced trauma and structural violence. To construct a CMHR friendly framework through a harmonious functioning of India’s social justice and mental healthcare policies is perhaps the only acceptable way forward.