Role of Professional Societies and Whither IAPP? * Anirudh Kala**
I am sure many of you have read the story of Rip Van Winkle. He was a Dutch villager living in America in the eighteenth century during the colonial era. One day, as the story goes, he met some strangers carrying kegs of liquor and helped them in carrying their load to a mountain top. There, he shared their wine and fell asleep.
When he got up, he could not find the strangers whose booze he had shared. He was surprised to find he had a long beard. Infact, his sleep had lasted twenty years. When he came down the mountain, he realized it was a very different world. The village was much larger and more crowded, people were dressed differently. And a young man and a young woman who had an eery resemblance to him were introduced to him as his infant children from twenty years back.
And while he slept, the American revolution had happened, and the King of England was no longer the ruler of America.
I attended my last IAPP conference twelve years back. And to that extent I am that Rip van Winkle from the Washington Irving story.
But Rip Van Winkle also had an advantage. He could make out the changes in his village, far more readily, than the people who had been living through those changes on a day-to-day basis.
IAPP was conceptualised almost 23 years back, in January 2000, by a small group of people, who were attending the IPS conference held in Kochi that year. They were just 10 of them, sitting in one of the smallest rooms in the basement alloted to them, attending a symposium on problems being faced by private psychiatrists. It was, I remember, one of the eleven concurrent symposia.
At the end of the symposium, for some reason, I was the one, asked to start the process of cobbling up a new professional organisation which would focus on problems faced by private psychiatrists. The first task obviously was to start consulting with other colleagues across the country, to find out whether a significant number shared the conviction that such an organisation was in fact necessary. That was the easy part. They overwhelmingly did.
Just to recapitulate for you, those were the hey days of general hospital psychiatry. The Mental Health Act 1987 had been passed twelve years before, but its implementation was just gathering momentum. The Act among things required that all private psychiatric hospitals had to have a license. In addition, psychiatry wards in private general hospitals would also require a license while government general hospitals were exempted. The norms of care notified under the Act required one psychiatrist and one psychologist for every ten beds for the private sector. There was no such requirement for the government sector.
This generated among the private psychiatrists a feeling that the parent organisation, the Indian Psychiatric Society, had failed to look after their interests, and they needed a separate professional association to protect the interests of private psychiatry, which at that time was taking off in a big way.
Since private psychiatrists formed a major chunk of psychiatrists in the country, formation of IAPP was not looked upon a natural coming of age phenomenon like IASP or the Association of Child Psychiatry, both of which had already been formed by then, but as a rebellion of sorts.
However, we had with us a group of wise and pragmatic senior psychiatrists who could convey that the parent organisation was by its nature broad based and and could not be expected to look after the specific issues faced by private psychiatrists which task had become a full-time job. For that, they argued, a speciallised organisation was needed which would do things differently and in a focused manner.
And during the initial years, we did work differently and in a focused manner addressing the specific needs of private sector psychiatry. Just one year after the formation of the IAPP, India was witness to the horrific Erwaddy tragedy, in which 28 mentally ill patients who chained at a charitable asylum died in a fire at night.
There was an understandable anger throughout the country and the Supreme Court started a suo-moto public interest litigation to look into mental health system in the country in general and implementation of the Mental Health Act in particular. IAPP got itself involved as an interested party and we managed to convince the court about the need of uniform norms of care across all sectors whether government or private or charitable.
The Secretary Health, Government of India was asked by the Supreme Court to file an affidavit to the effect that the rules under the Act would be
amended and applied uniformly across all sectors whether government, private, NGO or religious. Such an affidavit was indeed filed by the Union Health Secreatary.
Three years later when the rules had still not been amended, the IAPP wrote to the union health ministry, that this amounted to contempt of court. This put the government in a quandry. If one psychiatrist for ten beds rule was enforced uniformly, the government would need three thousand psychiatrists for the thirty thosands beds in mental hospitals alone. The whole country then did not have that many psychiatrists.
Within days the central government issued a notification diluting the rules from one psychiatrist for ten beds to one psychiatrist for fifty beds. Likewise, the rules were rationalised for minimum required number of psychologists and nurses not because the government had suddenly developed a soft corner for private psychiatrists but because the government itself could not afford the unrealistic norms framed earlier for private sector. This ensured for all times that the minimum standards would be those which the government itself could afford to follow.
Let me divert briefly from the history of IAPP and dwell quickly on the usual functions of a professional society, any professional society.
Obviously a very important function of a professional society, particularly a society of medical men and women is the CME. Advances in medical sciences has been rapid, and it is important for all of us to keep up with the latest information. However, with rapid strides in the field of information technology and the ubiquitous reach of the internet, accessing information has never been easier.
The pandemic has honed our skills to not just mine information but also to interact with colleagues and even external experts through digital meeting platforms, without having to go anywhere. For CME or CPD alone, you no longer need to attend a conference or even be a member of any professional organisation.
In any case, as far as CME alone was concerned our parent organisation, the IPS was doing a fairly good job. CME was never the ‘raison-detre’ for IAPP. And fundamentals of treatment remain the same whether one is working in private or the public sector.
In addition to CME, there is the valuble networking among members of a professional society that happens at conferences. Not just inside but outside
the halls too. Networking results in cross germination of ideas which sometimes progresses to research projects.
Conferences are crucial. Conferences validate our existence. But if the scientific program of an IAPP conference can not be distinguished from scientific programme of a conference of any other psychiatric society, then it becomes an existential dilemma. I have gone through the programme of this conference. We have eminent speakers. We just heard two very significant presentations of stirling quality. And nothing less was expected from them. Infact all the presentations in the programme promise to be of a very high calibre, and I plan to sit through as many as I can.
The quality is not an issue at all. The issue is this.
There are more than 50 topics listed in the programme. However, just one paper is specific to concerns of private sector psychiatry. It is about difficulties in managing rehabilitation services in a private set up. One out of fifty plus papers is less than 2% of the scientific programme.
During my flight yesterday, I went through the latest issue of the IAPP journal, and I must complement the editor for a great job being done. The lay out is appealing as is the quality of papers. Journals are not easy to bring out. And new journals provide a welcome opportunity for young professionals to publish. I particularly liked the article about the usage pattern of MHCA website and the one about the peep into society through the kitchen. The paper about Code of Conduct rules drafted by the NMC earlier this year is without doubt, a very important paper but I am more interested in knowing whether the IAPP discussed these NMC draft rules in any of its NAB meetings and did it submit any official feedback to the NMC on behalf of IAPP.
However, surprisingly the latest issue of ‘The Indian Journal of Private Psychiatry’, has no paper specific to private psychiatry. Not one. If you hide the cover page, it could be passed off as journal of any psychiatric society.
Here is my question. Will it be too much to ask that 25% of the content in a conference and 25% of papers in the journal must be about problems and situations faced in the field of Private Psychiatry. Just one fourth.
A look at the scientific programme also informed me that the IAPP is once again busy making “Expert Consensus Guidelines” for treatment of
different psychiatric disorders. It has been a regular exercise I am told. And I ask myself, why are we spending time, effort and money framing these expert consensus guidelines? Treatment guidelines are evidence driven, time consuming activity and must be updated regularly. And treatment guidelines cannot be different for members of IAPP.
As far as treatment guidelines are concerned, we are a consumer organisation. IPS is better equipped to do it. Infact if our treatment guidelines are different from IPS treatment guidelines, it would be difficult to explain why. Particularly in a court of law, in a hypothetical case.
And if the treatment guidelines are going to be the same, why bother.
As the ever wise and pragmatic one of the founders, Dr. Neelam Bohra, would have said, “Bhai, agar yahi sab karna tha, to alag banane ki kya zaroorat thi?”
And we will also open ourselves to the criticism of being the B team of a particular society. Because, let us face it, they have been doing it for much longer, seventy-five years to be precise and they have a larger talent pool. And being members in good standing, all of you any way attend their conferences and get their journal.
The moot question is if the IAPP is skirting the regulatory mine field and not doing anything to improve access to treatment for our patients, what is it that it is doing differently. Let me be very clear.
I have no problem with the organization to be generic and continue in the same way as it is at present. But in that case, why restrict the membership to those in private practice. Why not open up?
Let us now look at just a few specific events of seminal importance in the country in just the last decade which have impacted mental health services to a great extent or have the potential to do so. And examine the role IAPP played or should have played.
The Mental Health Care Act has transformed the practice of psychiatry particularly the indoor treatment component. It is true that a vast majority of patients suffering from mental illness can be treated as outpatients and would never need admission. But it is also true that the minority who need admission are often also the patients who lack capacity and refuse treatment. That is the reason they need admission to start with.
For the first time in India, the correctness or otherwise of the decision to treat a patient, who is harmful to himself or to his family members, is subject to a judicial review. And that too within a week of admission. Review boards have been formed at the district level in most states. The reviews are not yet happening at all the places, but they soon will.
The moot question is during the four years long run up to the Act, where was IAPP? Did the IAPP hold any in house meetings, and I do not mean academic sessions or symposia, but brain storming sessions by its National Board or the Executive Council?
If it did, did it then engage with the government, the parliamentarians, the press? Did it ask its office bearers to appear on TV, record videos and post on you tube espousing its views about the draft. Did we engage with people on social media?
Did IAPP as an organization attend the multiple consultations that were held in those crucial years between 2012-15? Were any memoranda submitted? That the IAPP was not specifically invited is not enough reason. As far as I know no organization was invited but these were open consultations and people did attend and made a didderence.
Did the existence of IAPP even make a 5% difference to the final shaping up of the MHCA?
I know that no other psychiatric organisation did anything constructive, either. But we were the ones who had appointed ourselves the guardian angels of private psychiatrists, not them.
The organization which came into existence as a reaction to the parent organization not making its presence felt during the formation of earlier Mental Health Act, did not make its presence felt when it came to the formation of the next mental health act.
And the Mental Health Care Act is not ‘all bad’. Not at all. For one it categorically lays down that insurance companies cannot refuse to insure mental illnesses. Mental illnesses must be insured at par with physical illnesses and the expenses on treatment paid for. Not just mental illnesses but also the substance use disorders because the latter are specifically included in the definition of mental illness.
In our discussions and writings over the years, all of us have been lamenting
the fact that India has so few psychiatrists. We used to compare ratio of psychiatrists per hundred thousand population of India as given in a WHO reports and rue the fact that we were so few as compared to Western countries.
Some years back I stopped counting the number of psychiatrists in the country because I found the exercise to be irrelevant.
Although the number of psychiatrists and psychologists has doubled in the last 10-15 years and even small towns now have a psychiatrist or two, but the patients and the families still cannot access them.
Because most of the treatment expenses are out of pocket and majority of people cannot afford it. The insurance companies have always been refusing to pay for treatment of mental illnesses, with a few exceptions. Some even had mental illness as an exclusion clause.
This is the treatment gap that the Mental Health Care Act tried to partly address through two measures. The government is now legally required to provide mental health services at the district level for those who can neither afford private treatment nor insurance.
And for those who can pay for health insurance directly or indirectly the insurance companies were asked to step up.
It has been four years after the MHCA, and the insurance companies are still dragging their feet. The Regulatory Authority is aware of the problem and has issued at least four orders the latest on 1st November,2022 ordering companies to start falling in line. The impression one gets is that not withstanding the orders, the insurance companies are planning to obfuscate the issue rather than comply.
They say they will not refuse to pay any claims, but they will not have psychiatric hospitals on their panels for cashless treatment. That they say is their discretion. Most families do not have spare cash and if cashless facility is not available, the treatment gets postponed. This step by companies amounts to blocking access to treatment of mental illnesses. The law is on our side, the regulator is amenable, but we too as an organisation are prominent by our absence from the whole scene. Rather than us waiting for another four years, the issue should be taken to the Supreme Court as a public interest litigation. The IAPP should have been in the front on this issue, and it is not even present in the vicinity. And this is an issue which would not just have helped the patients and the families but private psychiatrists themselves too.
The third major issue that has rankled the membership of IAPP not just in my state but in several others as well, is the utter apathy of IAPP about governments taking coercive legal action against psychiatrists who are treating substance use disorders. Some of them were arrested and are still fighting their legal battles. It was reported widely in the media. But nobody from IAPP has officially reached out to them, neither the National body nor the state branches. To the best of my knowledge the issue was not even discussed in any meeting of the NAB or the Executive body.
While this was exactly another of the situations IAPP was supposed to help with.
Twenty-two years later, ladies and gentlemen, it is a good time to ask some introspective questions. We need to make some radical changes in the way we function. One would be to accept that most of the useful work that professional organisations do, is done in between the conferences.
What I call the inter-ictal activity because the conference itself is like a seizure. Many things happen during it but most of these are ephemeral.
This activity inbetween the conferences that I am talking about would involve engaging with the government, both state and the central. Yes, governments are opaque and not very welcoming. But a constant engagement is the key, and most changes in rules require feedback from all stakeholders. Even if not statutorily required, written feedback from professional stakeholders cannot be ignored. The key officers in relevant government should know that something like IAPP exists, right now they do not.
A small group of members, a dedicated cell if you want to call it, at both state and central levels would serve this purpose. In addition, professional organisations which deal with governments often hire consultants. Another similar focussed cell can be there for reaching out to civil society through media including the social media. If the organisation has visibility, people will listen to you. If they do not know you, they wont’. Right now, the IAPP does not have a face book profile and the only IAPP on twitter is Indian Association of Privacy Professionals.
Let me give you one example of an organisation which is doing what it is supposed to be doing. Palliative Care Society of India does the very difficult job of convincing the central government of making narcotic analgesics available
to patients suffering from terminal and painful conditions. And they are managing to do this rather well, although the government as usual is obstinate every step of the way.
To conclude, the IAPP was created by its founders to be a niche organisation, with a special purpose.
Twenty-two years later, we are not niche. We are generic, a poor copy of the parent organisation we grew out from.
That is not a very comforting thought.
It is a pity that there are no questions after an oration. Because a fair question from you to me would have been, where was I for these ten years myself. To which I would have glibly answered, people who create organisations are not good at running them. That requires a different skill set.
And I would have pointed you again to the story of Rip van Winkle. Those who have read the story, know that Rip was a lazy man. Following is from the story: –
“He avoided working on his farm, his fence was falling to pieces, and he would often walk into the forest with his dog Wolf.”
That is when not going up the mountains and sleeping for years.
So may be that.
But both the answers would have been well, glib.
- Awarded Amit Bohra Oration by the IAPP and read at its 23rd Annual Conference at Varanasi, November 24-27, 2022.
** Founder President, Indian Association of Private Psychiatry and Clinical Director, Mind Plus Health Care, Ludhiana. Punjab.