Emergency hospital services for homeless women and men with psychosocial disabilities.

The Emergency Response Unit is a project which provides emergency care and allied services to homeless persons with psychosocial disabilities within the Kolkata metropolitan area in West Bengal.

Iswar Sankalpa’s flagship project, Naya Daur (Outreach) was initiated in 2007 to provide care and service to a population which is invisible to the rest of the city and the State – the homeless persons with psychosocial disabilities. Our team of mental health professionals work towards providing services, countering stigma and discrimination and bringing together agencies which can provide sustainable intervention.

The Outreach team is however unable to deal with the cases which are referred to as ‘emergency cases’.

These are people who – because of their acute psychosocial disability and distress – are highly agitated, hostile, often causing a disturbance in the neighbourhood, and in the absence of immediate medical and psychological intervention, are a danger to themselves and to others.

Many such persons are also in a deplorable physical condition; with open sores, wounds and other communicable diseases. Such emergency cases need –

  • A medical crisis response team to assess their condition and provide emergency care.
  • The permission of appropriate medical and legal authorities for custody, and
  • Immediate hospitalization / medical care

Project Arogya deals with such emergency cases, and commenced in March 2010. It is the convergence of efforts between state agencies on the one hand – the Kolkata Police and state-run psychiatric and general hospitals, and Iswar Sankalpa and private in-patient health care facilities on the other.

The key players in this project are the Kolkata Police and Iswar Sankalpa, and the beneficiary stakeholders are emergency cases of homeless persons with psychosocial disabilities who, in legal terms is a person ‘causing a law-and-order problem – that is, likely to harm self/others’.

Project Arogya however, does not deal with people with chemical dependence.

PHILOSOPHY

Prior to Iswar Sankalpa’s partnership with the Kolkata Police, the latter did not have the wherewithal to deal with aggressive or traumatised people with psychosocial disabilities on the streets in need of emergency care. Periodically, the Kolkata Police would, under the Vagrancy Act, 1943, round up these homeless persons to be produced before a Magistrate.

All such ‘vagrants’ – including people with severe psychosocial disabilities, would be detained indefinitely in the Vagrants Home until they were classified either as lepers, the ‘insane or mentally deficient’, and/or suffering from communicable diseases or children.

The persons declared by the Magistrate to be ‘insane or mentally deficient’ were then transferred to the Vagrants Home in Murshidabad – the only one in West Bengal earmarked for people with psychosocial disabilities, where they would languish practically unattended because of the dearth of state employed psychiatrists.

Later, when Iswar Sankalpa began working in Kolkata in 2007, an informal partnership grew between the two organizations. Each time the organization’s social workers located a homeless person with psychosocial disabilities who needed hospitalization; the matter was reported to the local police station as a matter of course before hospitalizing the person.

The collaboration grew through sustained advocacy on the part of Iswar Sankalpa and a high degree of receptiveness on the part of the Kolkata Police, and as an increasing number of police stations became aware of the existence of an organization that took care of a hitherto ignored population, some began regularly coordinating with Iswar Sankalpa as soon as they came across such persons. Through their extensive networks, the Police also worked to identify the homes and families of such rescued persons, many of who come from distant states. Their involvement further increased with the setting up of a Drop-In-Centre at the Hastings Police Station as a rehabilitation space for recovering persons.

Given such a background, this relationship was formalized under Project Arogya – an Emergency Response Unit which maps the technical and medical capabilities of Iswar Sankalpa with the duties and capabilities of the Kolkata Police to:

  • Identify persons with psychosocial disabilities on the streets who are, because of their mental health condition, at risk of causing harm to themselves or to others.
  • Deliver emergency response services to such persons, which include assessment of the person’s mental and physical condition, and if the person needs further medical treatment, procurement of a medical certificate and producing such a person before a magistrate for custody orders.
  • Make provision for such persons in state hospitals, and refer them to private care in the event that state facilities are not available
  • Take medical and financial responsibility for the recovering client.
  • Locate the families of recovering clients and repatriate them to their homes. If families cannot be located, or refuse to take the person back, make other provisions for the safety and future of such cases.

CARE DELIVERY MODEL

Under Section 25 of the Mental Health Act, 1987, the Officer-in-Charge of a police station is duty bound to take into protective custody any wandering person with mental illness who is not able to take care of him or herself or is dangerous because of such illness.

This person must then be produced by the Officer-in-Charge of the concerned police station before the nearest magistrate within 24 hours for further orders.

Due to Iswar Sankalpa and Kolkata Police’s partnership, in an order dated 22nd February 2010, Sri Bani Brata Basu, Special Commissioner of Police II, with the permission of the Commissioner of Police, Sri Goutam Mohan Chakraborty, issued instructions to all Divisional Deputy Commissioners reminding them of their duties towards the homeless persons with psychosocial disabilities under the Mental Health Act of 1987 and advised them of the procedures and protocol to be followed towards such persons.

Since March 2010, our team began providing technical assistance to police stations within the Kolkata metropolitan area under Project Arogya.

  • The process begins when a police station contacts Iswar Sankalpa about a person who is creating a law-and-order problem on the streets and appears to be psychologically disturbed
  • Iswar Sankalpa then sends an Emergency Response Unit consisting of a fully equipped ambulance and a trained social worker to assess the case, and if their assessment confirms that the person needs psychiatric intervention (and in addition, sometimes urgent physical health care intervention)
  • Once the magistrate assigns the person to Iswar Sankalpa’s care, the organization takes complete responsibility for follow-up and support to the person until his/her release from the hospital. Often the person’s physical condition needs to be treated first, and given the lack of space and facilities in public hospitals, as well as their reluctance to deal with psychiatric cases, Iswar Sankalpa is usually forced to admit him/her in a private nursing home.
  • After the person is released from the hospital, Iswar Sankalpa takes care of them, either by placing them at shelters or homes, or back into the community, and provides them with rehabilitation services for as long as necessary.
  • In cases where the person is able to divulge their names and addresses, the Kolkata Police and Iswar Sankalpa work together to restore them to their families – including paying for all costs.

The process flow of responsibilities between the Kolkata Police and Iswar Sankalpa is given below –

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OUTCOMES

The following highlight some statistics which have resulted from Project Arogya (Emergency Response Unit) –

April 2009 to March 2010
Reached out to: Women – 4, Men – 1

April 2010 to March 2011
Reached out to: Women – 37, Men – 7

April 2011 to March 2012
Reached out to: Women – 34, Men – 2

April 2012 to March 2013
Reached out to: Women – 49, Men – 1

April 2013 to March 2014
Reached out to: Women – 43

April 2014 to September 2014
Reached out to: Women – 16

GRAPHICAL REPRESENTATION:

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CHALLENGES

The collaboration between Iswar Sankalpa and the Kolkata Police has resulted in significant movements in the service delivery to a population which for the longest time has remained ‘invisible’. The project has provided an opportunity for the Kolkata Police to abide by its legal obligations under the Mental Health Act of 1987 alongside displaying humane aspect to the work done by them, which often goes unnoticed and unseen.

However, certain challenges continue to persist –

  • Training of Police Personnel

Some amount of training in the provisions of the Mental Health Act 1987, orientation on the needs of homeless persons with psychosocial disabilities, and training in court procedures is necessary for the police personnel to better handle the process of procuring court orders.

  • Need for a Blanket Reception Order

Under the existing system, the time taken with which an emergency client is identified and hospitalized depends on how quickly the police can produce the person before the Court, and how fast the Court gives an order in the case. Often, people have to be kept overnight in shelters and nursing homes and full-fledged medical care is delayed till this official process is completed. It would be very beneficial for persons who are in urgent need of medical attention, if the Commissioner of Police could, within the purview of the various legislations involved, issue a blanket Order of Reception in lieu of the court process.

It is important to work on these challenges by aiming at a change in the policy and top-down processes in order that the transfers and changes in the important posts do not lead to a waste of the efforts made collectively by both Iswar Sankalpa and the Kolkata Police.