Gender and the cultural context of urban mental health in Mumbai

By 2015 it is expected there will be 23 megacities, and all but four will be in developing countries. Mumbai, which now has a population in its metropolitan area of 16.4 million (Census of India, 2001), will then be the world’s second largest city after Tokyo. Three other cities in India (Kolkata, Delhi, and Hyderabad) and two more in South Asia (Dhaka and Karachi) will also join the ranks of these megacities. In Asia and Africa such demographic shifts into cities have been especially challenging, and the environmental and social impact of unbridled urban expansion on infrastructures affecting health status has become a priority for public health. It is recognised that the urban poor are especially vulnerable to these adverse effects of urbanisation, but the topics of culture and gender have attracted far too little interest, especially in mental health research and policymaking. Various accounts of international health agencies concerning the needs and approaches to the mental health of populations highlight the broader social, cultural, and economic contexts, for which clinical experience alone is an inadequate guide. Changing social values and the influence of globalisation require timely consideration of the role of gender. Mainstream psychiatric priorities advocate a model of mental disorders that has become less attentive to the impact of social conditions than many aspects of clinical practice and effective community mental health programmes require. Such considerations indicate the need to re-establish the balance between these interests and current research priorities in psychiatry, which emphasize the biological basis of mental disorders and criteria-based definitions based on clinical, rather than community, experience and research. Informed policy, which is attentive to the local contexts of needed mental health actions, requires more relevant research as a guide, responsive to recommendations of major policy reviews reported in the World Mental Health Report (Desjarlais et al.,
1995) and the WHO’s (2001) world health report on mental health.
The field of cultural psychiatry has long been grappling with a tension between
needs to pursue psychiatric epidemiological study of mental disorders in Asia and
Africa, which have long motivated developments in transcultural psychiatry, and
questions about the limitations of dominant paradigms of psychiatry, which motivated
subsequent rethinking of the new cross-cultural psychiatry. Questions about
interactions between gender and culture, however, have been for the most part
subordinate among priorities in the field. Research is needed on mental health
problems to examine explain interrelationships among gender and culture as a
complement and integral feature of psychiatric epidemiology—addressing questions
of why, how, and what to do—and to make languages and priorities of patients,
communities and professionals more mutually comprehensible.
A common theme links the various studies that comprise this thesis. It is a
focus on local representations of various mental health problems in both clinic and
community settings in urban Mumbai, with particular attention to questions of gender.
Formulating these studies in both clinical and community settings provided valuable
opportunities to consider a broader agenda of mental health interventions rooted in,
and aiming to restore, a more contextual formulation of a biopsychosocial model.
The research reported in this thesis has been motivated by the clinical professional
and personal experience of the author in Mumbai, focussing the work on particular
themes of cultural context, gender and common mental health problems. These
studies highlight the concept of common mental health problems because the nature
of the problems that arise in the course of evaluating deliberate self harm (DSH) and
the mental health-related issues that arise in dealing with both clinic patients and community residents are not restricted to the formal professional concepts of
psychiatric disorder. Our studies of DSH have examined underlying sociocultural and
psychiatric problems and identified triggers of suicidal actions. Expected genderspecific
contexts were identified, such as alcohol and other substance dependence
disorders among men and victimisation among women. Furthermore, a number of
individuals also described their problems in terms that contradicted the gender
stereotypes. For some conditions, such as substance use disorders, mental health
problems had substantial impact on people living with affected person, indicating a
hidden burden.
The research has been especially attentive to the influence of social and
cultural factors in Mumbai that affect mental health—factors such as economy,
unemployment, poverty, and the gendered dynamics of family interactions. The
nature and formulation of categories of distress, perceived causes, and health
seeking were clarified in community dialogues through ethnographic community
study, clinical interactions and clinical cultural epidemiological study using locally
adapted EMIC interviews. Our cultural epidemiology provides an account of the
distribution of the categories of experience, meaning and behaviour, which constitute
locally valid representations of mental health problems. These studies proceeded at
two different sites in Mumbai. The ethnographic community study was undertaken in
the Malavani slum, 35 kms north of central Mumbai in a western suburb. The study
of DSH was based at the second site in the KEM Hospital, which is the largest
hospital in Mumbai. It proceeded in cooperation with colleagues in the emergency
medical department to ensure systematic referrals of all patients who met criteria for
study. The research reported in this thesis demonstrated how cultural epidemiology
supported by ethnography may complement psychiatric epidemiology to guide
clinical practice and mental health policy. Collectively, the studies in this volume
suggest the value of ethnographic data for identifying categories of experience,
meaning, and behavior, which clarify locally important features of common mental
health problems. The research on DSH examined the relationship between clinical
diagnoses based on DSM-IV criteria and patient-perceived determinants of suicidal
behavior ascertained in EMIC interviews. This perspectivism has guided
complementary psychiatric and cultural epidemiological assessments of suicidal
behavior. Locally relevant features, attentive to the impact on suicidal behavior of
psychopathology, underlying problems patients relate to their DSH, and stressors
that constitute triggers of suicidal behavior should all inform suicide prevention,
community mental health interventions, and clinical practice.
The research reported in this thesis contributes to a novel approach that
provides gender-sensitive information of practical significance for designing services
and programmes in urban settings of low-income countries. Individually and
collectively, these studies are addressing practical and highly relevant issues that
mental health policy must address in India’s cities, both in communities and clinics of
slums and in middle-class neighbourhoods. In addition to their contribution to mental
health at these sites, it is hoped that the example of these studies will also clarify an
approach to cultural epidemiological research that will be useful in other settings.