Community Mental Health and Concepts of Mental Illness in the Sundarban Delta of West Bengal, India a. N

Anthropology amp Medicine Vol 8 No 1 2001

Community mental health and concepts of mentalillness in the Sundarban Delta of West Bengal India

(Accepted date 18 December 2000)

A N CHOWDHURY1 A K CHAKRABORTY2 amp MITCHELL GWEISS3

1Department of Psychiatry Institute of Postgraduate Medical Education amp Research Calcutta India2Diamond Harbour Subdivision South 24 Parganas West Bengal India 3Department of PublicHealth and Epidemiology Swiss Tropical Institute and University of Basel Basel Switzerland

ABSTRACT The Sundarban Delta of West Bengal is a remote rural region with poorinfrastructure and until recently without designated mental health services or a communitymental health programme To inform development of such a programme for the region and tocomplement epidemiological study of rates of suicide nonfatal deliberate self-harm and speci cpsychiatric disorders cultural epidemiological research was undertaken This research aimed toclarify the nature of broadly conceived mental health problems in the community (not justprofessionally de ned psychiatric disorders) and local concepts of mental illness clarifyingspeci c features perceived causes and help seeking for these problems Findings from ethno-graphic study of three villages of two Sundarban blocks (Sagar and Gosaba) are presented anddiscussed focusing on particular stresses and supports in the community local priority of mentalhealth concerns and concepts of mental illness This rst phase of research has been followedby a cultural epidemiological survey in phase 2 studying mental-illness-related experiencemeaning and behaviour among (1) patients coming for treatment with selected mentaldisorders (2) patients admitted after surviving an episode of deliberate self-harm (3)non-affected laypersons in the community and (4) health care providers with diverse orienta-tions and credentials serving the community As important as they are psychiatric epidemiolog-ical data alone are insuf cient to clarify the nature of needs and to specify the character ofservices This research shows how cultural epidemiology informs policy and action and howsimilar research in other settings may contribute to the mental health of populations

After more than ve decades of independence health services for the people ofIndia are lopsided favouring urban and neglecting rural areas Whatever may besaid about general health services the preponderance of mental health servicesin urban areas is even greater The more distant forested hilly and inaccessibleregions as expected are most neglected of all To some degree this re ects ageneral failure to invest in health and social services everywhere but other

Correspondence to Dr A N Chowdhury Institute of Psychiatry 7 D L Khan Road Calcutta700 025 India E-mail anccalvsnlnetin

ISSN 1364-8470printISSN 1469-2910online01010109-21 Oacute 2001 Taylor amp Francis LtdDOI 10108013648470120063924

110 A N Chowdhury et al

TABLE I Subdistrict administrative blocks of the Sundarban Region South 24 Parganas DistrictWest Bengal Indiaa

Number Population Number NumberAdministrative Area of of ofblocks in km2 islands Total Male Female Mouzasb villages

Basanti 2900 2 226974 116425 110549 65 75Canning I 2057 2 196295 100700 95595 67 62Canning II 2220 151635 77333 74302 62 108Gosaba 3325 11 200514 103286 97228 51 51Jaynagar I 1271 185271 95938 89333 75 75Jaynagar II 1752 177335 91327 86008 45 209Kakdweep 2611 190088 97563 92525 39 113Kultoli 2409 3 156450 80516 75934 43 90Mathurapur I 1484 141888 73264 68624 99 99Mathurapur II 2305 1 172982 90177 82805 28 175Namkhana 2271 1 134354 69018 65336 35 35Pathar-pratima 4695 13 245601 125904 119697 87 94Sagar 4708 4 154202 79242 74960 44 44

a Data from District Statistical Handbook Bureau of Applied Economics amp Statistics Government ofWest Bengal Calcutta T T Traders 1998b Mouza is the term for sub-block divisions which in Sagar and Gosaba blocks approximate villageboundaries

factors including inadequate models and information needed to guide popu-lation-based mental health services contribute to the relative dearth of servicesand needed programmes to prevent mental illness and promote mental health inrural areas

The Sundarban region of West Bengal south of Calcutta in the South 24Parganas District is an example of a neglected rural area The Sundarban is anactive delta region of the river Hooghly and other branches of the Ganges Riverat their con uence in the Bay of Bengal (Fig 1) It is the largest estuary on theglobe comprising 54 islands and including 4264 km2 of reserve forest for theprotection of wildlife primarily tigers in addition to populated areas (Table I)The total population of the region is approximately 23 million By all measuresof socioeconomic development the Sundarban region is poorly developed andunder-served Its inaccessibility poor agricultural output constantly shiftingland masses and ecological instability lack of industry and hostile climate havemade this area one of the most backward regions of the state of West BengalThe literacy level as well as the per capita income is far lower than the Stateaverage and 425 of the families subsist on earnings below the poverty line(De 1994) The transportation and communication systems are poor includingabout 280 km of paved road and 42 km of rail lines During the annualmonsoon much of the region becomes inaccessible

Inaccessibility travel hazards on land and water and the distances people

Community mental health and concepts of mental illness 111

FIG 1 Sundarban region West Bengal India

must travel for clinical care compromise the adequacy of health services for theentire region Furthermore poverty illiteracy and cultural ideas about healthand illness in the context of available services in uence the help-seekingbehaviour of the local population and many of these people depend on localtraditional means of healing for all of their health problems including mentalhealth problems and health care needs arising from exposure to local environ-mental hazards such as tiger attacks for those who survive and snakebites theyrely less on the allopathic services of government hospitals In recent years


however more patients with serious mental disorders have been making the tripto metropolitan Calcutta for psychiatric care Seeing such patients coming so farfor help indicated the needs in the region and it was recognition of these needsthat motivated eld visits interactions with the community assessment ofmental health problems in the existing primary health clinics and eventuallyselection of the region for developing a need-based sustainable communitymental health programme (Chowdhury et al 1999)

The need for epidemiological data to inform mental health policy anddevelopment of services is widely appreciated Psychiatric epidemiology helps toestablish the burden of disease relative needs and to determine priorities andresource allocations It also provides a means of assessing the impact of healthsystem interventions (Jenkins 2001) Some epidemiologists however have alsoemphasized the need to attend more carefully to country-speci c features ofhelp-seeking and local barriers to recognition and treatment of mental disordersat the national level (Wittchen 2000) Local considerations within large coun-tries like India however may also vary widely suggesting the need to link notonly global and national perspectives but also national and local perspectives(Weiss et al 2001a) Psychiatric epidemiology is primarily concerned withquantitative methods to account for the occurrence of professionally de nedpsychiatric disorders (Kraemer et al 1986) but ethnographic approaches alsohave their value and distinct advantages for dealing with some questions(Weisner 1997) Cultural epidemiology provides an integrative interdisci-plinary approach to assessing mental health problems making use of epidemio-logical methods and anthropological frameworks that are particularly well suitedfor considering the local social and cultural features of the community andwhich require attention in formulating strategies for programmes responsive tolocally perceived needs The importance of balancing psychiatric epidemiologi-cal and cultural epidemiological considerations for mental health has become arecognized priority for international health (Weiss et al 2001b)

Cultural epidemiological research was undertaken to guide the developmentof services and a community mental health programme for the Sundarbanregion Because access to the community by outsider professionals is a compli-cated matter it was clear that an assessment had to consider not just pro-fessional priorities but also local priorities if a programme was to have anychance of acceptance It would be important to identify the particular mentalhealth-related concerns among the people of the region to characterize theirexperience of these problems the ways in which they interpreted these problemsfor themselves and explained them to others and characteristic behaviours thateither put them at risk for such problems or which they pursued to get helpClinical psychiatric epidemiological monitoring of mental health problems anddeliberate self-harm in the primary health centres was also recognized as anecessary activity to help assess needs This approach balanced these comple-mentary interests in both diagnosis and the cultural and social basis of mentalhealth problems in the community considering local preferences for help-seeking with reference to available options in the complex pluralistic health


system Although it is recognized that instruments for research in psychiatricepidemiology may be cumbersome and unwieldy (Ommeren et al 2000) andhence a concern for working in these Sundarban communities it was antici-pated that the cultural epidemiological approach would focus on concerns andconcepts that were understandable and acceptable within the community It wasanticipated and hoped that by including a cultural component establishing therelevance of mental health concerns this might also facilitate psychiatric epi-demiological study

Aims and approach

The primary objective of this study was to examine locally identi ed mentalhealth problems in the community and the experience and meaning of speci cmental health problems Research aimed to clarify these issues in the context ofthe local health system with reference to speci c interests in developing acommunity mental health programme Concepts of mental health problemswere to be examined with ethnographic research in the community and speci cmental health problems of particular interest in planning a mental healthprogramme were to be examined in a clinical cultural epidemiological study ofpatients and a community survey of laypersons in the community and healthcare providers

The research aimed to use ndings to develop a culturally appropriate mentalhealth service system in the Sundarban region beginning with a monthly mentalhealth clinic on Sagar Island which was established during the course of theresearch Inasmuch as a full analysis of the rst phase of research is not yetcomplete and the second phase of research with the EMIC is still underway thepurpose of this report is not to discuss details of the ndings but rather toprovide an overview of experience in the ethnographic phase and to show howthe ethnographic phase relates to the local adaptation of the EMIC in develop-ing a comprehensive cultural epidemiological study (Weiss 2001)

Ethnographic research in three villages of two development blocks in theSundarban regionmdash Sagar Island and Gosaba Island blocksmdash examined thevarious aspects of the social and cultural context of life in these communitiesthe nature of cultural and community stressors environmental factors genderroles recreational use of drugs and alcohol and concepts of health and illnessIn addition to mental health problems broadly conceived it also inquired aboutthe experience and meaning of mental illnesses identi ed in these communitiesand behaviour related to risk and help-seeking with reference to local socialsupports and complex health care networks At the outset it was recognized thatgovernment services and allopathic clinicians constituted only a small compo-nent of the existing local health system

A second phase aimed to adapt and use the EMIC a research instrument forcultural epidemiology to study categories and narrative accounts of illnessexperience (patterns of distress) the meaning of illness (perceived causes) andbehaviours related to risk and help-seeking The EMIC was adapted for


studying patients suffering from common mental disorders (depression orsomatoform disorders) and schizophrenia and patients who presented fortreatment after an episode of deliberate self-harm The EMIC also needed to beadapted to study comparable mental health problems as they are understood bynon-affected persons and health care providers treating mental health problemsin the community Unlike interviews with patients in the clinic which focusedon personal history questions for interviews in the community referred tovignettes depicting mental health problems of particular interest

Methods

Planning ethnographic research

The rst phase of ethnographic research involved intensive eld research inthree villages of both Sagar Island and Gosaba development blocks It alsorequired consulting records and secondary source documents from the localgovernment and governing councils (panchayats) At the outset in planning thisphase of the research the investigators approached leaders in each developmentblock with the assistance of medical of cers in the government health systemMeetings were arranged with the Chief Medical Of cer of Health (CMOH) theAssistant Chief Medical Of cer of Health (ACMOH) and the Block MedicalOf cers of Health (BMOH) at three Sundarban Primary Health Centres topresent the objectives and plans for the research A discussion was held toconsider the feasibility of the plan accessibility of different blocks and villageswithin those blocks and the opinions of the medical of cers

Visits to four sites were planned including Sagar Island Kakdweep Nimpithand Gosaba blocks with the idea of determining which among them would beselected as research sites Based on this visit from 2 to 9 January 1996 whichalso involved meetings and introductions to local leaders (but without commit-ments at that point) two blocks were selected namely Gosaba and SagarIslands The two sites complemented one another inasmuch as Sagar wasrelatively more accessible linked to the mainland by a regular ferry service andGosaba was more remotely situated in the Sundarban interior burdened by apoor infrastructure and in close proximity to dangerous wildlife in the tigerreserve which from time to time threatened the local population Some of thevillages of Gosaba also suffered from lack of basic resources such as anadequate supply of fresh water The three villages at each site were also chosento represent a range of conditions with these blocks (Table II)

Developing the research agenda

To develop the research agenda and to integrate the mental health planningperspective with other social and environmental priorities a eld researchadvisory group (FRAG) was organized It included an anthropologist environ-mentalist block medical of cers block primary health nurse medical of cer of


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an NGO active in Gosaba block (Rangabelia Tagore Society) and the assistantCMOH from Diamond Harbour responsible for the Sundarban region Twoteams of research assistants (RAs) with masters-level social science training and eld experience in remote sites were selected for the study one team to work inSagar and another in Gosaba

A detailed plan for the ethnographic eld research was developed at athree-day workshop attended by the RAs and the FRAG specifying the methodsand the kind of information that was needed from a minimum one-monthperiod of residence in each village A data collection format and plan was agreedupon to facilitate collection and management of data ensuring that these datawould be in a suitable format for use of a computer-assisted qualitative dataanalytic software program that would facilitate analysis and reporting Researchmethods and their speci c use in the study were reviewed these methodsincluded interviews focus group discussions participatory observation transectwalks with key informants and participatory mapping Other aspects of trainingin preparation for the eld research included sessions reviewing relevant back-ground in social science theory and research methodologies mental healthconcepts interviewing skill which RAs practised in mock interviews in thecourse of training at the Institute of Psychiatry a review of the demographic andenvironmental features of the Sundarban region and planning of eld researchlogistics

The RAs then visited the Sundarban eld sites for two weeks at villages otherthan those designated for the research so that they could gain pilot experiencewith the village survey schedule as a guide for their eldwork When theyreturned and in consultation with the FRAG feedback from the RAs wasconsidered to prepare the nal version of the Ethnographic Village SurveySchedule that was used to guide the eld research that followed in the villages(see Appendix) Field research proceeded over a period of ve months fromMarch through July 1998 in three villages of the two development blocks wherethe RAs lived during that period Twice monthly supervisory visits by theprincipal investigator AN Chowdhury often accompanied by one or moremembers of the FRAG provided an opportunity to review experience in the eld and assist the RAs

These supervisory visits made it possible to clarify questions in the eldreview ndings over the course of the work and ensure a consistent focus ofattention on issues relevant to the study Questions of course arose for examplewhat constitutes suf cient data for sensitive issues that people were reluctant todiscussmdash like wife-battering gender discrimination sexual promiscuity drugand alcohol use and teenage pregnancy Training of the research assistants ingeneral anthropologymdash but not medicine or specialty training in medical anthro-pology apart from the training provided in the studymdash sometimes made itdif cult for them to manage and interpret health-related data This made thesupervisory visits and the opportunity to clarify eld experience especiallywelcome and useful

Community reactions to the researchers were generally positive and the


interest of outsiders from Calcutta in improving local health services wasappreciated Because the ethnographic component of the research had noimmediately visible service component however some people were annoyed bythe presence of researchers and asked about the material bene ts that mightresult from cooperation A few remarked that they had spoken about com-munity problems to other researchers in the past but the persisting lack ofdrinking water poor transportation and inadequate health facilities showedlittle or nothing had come from that Consequently interviewing and datacollectionmdash which for the most part transpired smoothlymdash became dif cult atsome points

The highly complex political structure of these villages also required consider-able sensitivity discretion and skill on the part of the researchers to managerelations with different segments of these complex communities When thecomposition of focus groups brought together antagonistic participants the aimof the activity was sometimes derailed Timing of individual interviews naturallyhad to be arranged for the convenience of respondents More dif cult inter-views with people who had survived deliberate self-harm required particularsensitivity to maintain privacy and con dentiality of the information disclosed inthe course of those interviews

RAs were required to live in the village communities they were studying andtheir introduction and planning for their stay required careful considerationIntroductions were made through village leaders A careful introduction with aclear discussion of the research objectives was important to gain cooperationand trust within each village A house was rented for the RAs rather than theirstaying somewhere as a paying guest which would likely complicate relations byinadvertently motivating expectations of the host family who might expectfurther nancial help beyond payment for accommodations or expect jobopportunities to be forthcoming There was also the danger of being identi edin the community as someonersquos relative or unwittingly becoming identi ed withlocal social and political alignments and controversies

The villages of the Sundarban where this research was conducted are politi-cally sensitive and occasionally volatile People wanted to know the politicalaf liations of the researchers and in some instances attempted to make use ofthe researchersrsquo presence for personal gains It quickly became clear to theresearchers that they required a keen sense of observation and a healthyscepticism before reaching conclusions about many of the issues they werestudying To proceed effectively it was necessary to balance a sense ofidenti cation and membership within the community while also maintaining adegree of scepticism independence and distance required to proceed with thework Working in pairs helped to achieve that

Analysis of ethnographic data

A preliminary review of ndings from the rst phase of research was presentedin a workshop to consider their implications plan further analysis and plan for


the next phase of eld research in phase 2 with the EMIC Two consultantsfrom the National Institute of Mental Health and Neuro Sciences(NIMHANS)mdash including an anthropologist Prof Jayashree Ramakrishna and apsychiatrist engaged in other cultural epidemiological studies in India Prof RRagurammdash participated as consultants in that workshop in July 1998 Findingswere compiled in detailed village reports following the structure of the ethno-graphic village survey schedule Reports were based on debrie ng the RAs andtheir eld notes which were translated and transcribed in a format for analysiswith TextBase Beta a software program for qualitative data analysis Participa-tory maps were grouped according to themes and location and other secondarysource materials were summarized referenced and cited in the village reportswhich were presented and discussed in the workshop

The outcome of these discussions were initial reports plans for furtherdetailed analysis and a draft of 4 EMIC interview instruments for the secondphase of the study For interviews with laypersons and health care providers sixvignettes depicting mental health problems of particular interest in planningservices for the community were developed as the basis for these interviewsThese conditions included depression hysteria schizophrenia somatoformdisorder possession and deliberate self-harm The selection of the conditionsand drafts of the vignettes were thoroughly discussed incorporating inputs fromthe FRAG the consultants from NIMHANS the eld research assistants andthe investigators These discussions informed the development of lists of cate-gories for various sections of the EMIC including names of the variousconditions identi ed locally particular symptoms and patterns of distressperceived causes the varieties of assistance available to those seeking help forsuch mental health problems and life events

Phase 2 research with the EMIC

Work on drafts of the EMIC continued and eight research assistants and onepsychiatrist research coordinator were trained to use the four different versionsincluding one for patients coming for outpatient treatment of designated mentalhealth problems (depression somatoform disorders and schizophrenia)(EMIC-PAT) patients admitted after a suicidal episode of deliberate self-harm(EMIC-DSH) laypersons without overt mental disorders in the community(EMIC-NAP) and health care providers in the community (EMIC-HCP) Eachof these instruments was translated into Bengali and back-translated intoEnglish Initial translations were completed by the PI and checked by a collegeteacher of Bengali language by an anthropologist and by a sociologist With thebene t of their comments the translation was reviewed word by word amongthe investigators and research assistants who were to conduct the interviews andthese deliberations produced a semi- nal version for pilot interviews

Further training of the RAs and pilot testing of the four versions of the EMICproceeded at the Rudranagar Rural Hospital clinic at Sagar Island whichsuggested some further revisions The training phase was completed with 37


interviews with psychiatry outpatients in the clinic at the Institute of PsychiatryCalcutta and in Kulpi a eld setting approximating conditions of the researchsites with the EMIC-NAP (nine interviews) and EMIC-HCP ( ve interviews)Kulpi is located 60 km south of Calcutta at the entrance to the Sundarbanregion Following the conclusion of these interviews the full research team metonce again to nalize the translation of the interview forms which were sent forprinting

Examination of interrater reliability was completed with these nal formsincluding 25 interviews with the EMIC-PAT 21 interviews with the EMIC-NAP and 17 interviews with the EMIC-HCP Techniques for analysing theinterrater agreement of structurally similar items of the EMIC were developedand agreement overall was good Findings from the pilot study of interraterreliability have been presented in greater detail in another publication (Chowd-hury et al 2001)

Results from ethnographic study

Nature of stress and support in the community

Several issues emerged repeatedly as important stress-related concerns in par-ticular villages Some of these were more social and political and others weremore a matter of changing environmental conditions and disrupted ecology Inthe villages of Sagar Island particular concerns arising from threats to the socialorder came from alcohol use adultery and the in uence on young people of thevideo parlours which have become a more pervasive in uence as a result of theavailability of cash from tiger prawn seed collections and betel leaf cultivationOther perceived threats to the social order reported by some people includedintercaste and interreligious marriage community violence and unemploymentAs in many poor communities for some people debts and obligations to themoney lender are important concerns Gender-based cultural stressors includedbarrenness among women birth of female children and the stress imposed byobligations of a persisting dowry system Political tensions arose from con ictsbetween the panchayat and alternative traditional systems of local village admin-istration corruption and nepotism Like all agricultural communities the threatof environmental conditions leading to crop destruction was a major concernOn Sagar and Gosaba Islands land erosion is also a serious threat in an estuarysubject to ooding and where embankments are being weakened by increasedhuman traf c to collect tiger prawn seeds which brings both cash and neglectof other livelihood activities In those villages where men go on shing expedi-tions for weeks at a time the threat of storms and questions of whether theywould return were also matters of serious concern

Although many common problems affect both the Sagar and Gosaba com-munities there are also some distinctive features Extended deep sea shingvoyages are frequent from Sagar but not Gosaba Political rivalries have almosttotally disrupted the panchayat system in Gosaba depriving residents of what-


ever stability the panchayat provides on Sagar mediating familial and localdisputes and providing support from funds at their disposal The threat of wildanimalsmdash such as tigers crocodiles sharks and snakesmdash is a serious threat insome villages of Gosaba especially where villagers close to the tiger reserve arefrequently tempted to venture in for honey gathering and wood-cutting exceptfor snakes humanndashanimal con icts are not a concern in Sagar The impover-ished widows who survive fatal animal attacks on their husbands are a measureof the persisting human and social cost of such humanndashanimal con ict The lackof drinking water is similarly a serious problem for some villages of Gosaba likeDayapur where women wait for hours on end so that they are ready to collectwater when the erratic pumps nally bring it from a distant pumping station

A number of local organizations provide various kinds of support to people ofthese Sundarban communities These organizations include the FishermenrsquosSamiti (Cooperative) which makes loans available to shermen to purchaseboats and nets The Tagore Society in Gosaba also provides loans supports treeplanting makes seeds available for agriculture and supports womenrsquos vocationaltraining Poor students may receive free coaching from teachers Governmentloans are easily available for political supporters and money lenders offer creditat low interest about 4ndash5 on for gold ornaments they hold as collateral

Notwithstanding the politics and con icts a number of examples show thatvillagers may also help one another especially when nancial needs arise forpressing matters such as dowry and health care Social workers have organizedlocal womenrsquos groups (mahila samiti) Some doctors provide free treatment orextended credit and a Sagar youth welfare club organizes blood donation campsand camps to promote awareness of the dangers of addictive drugs Sometraditional health care providers (including magico-religious healers known asgunin and ojha) offer free treatment for snakebites The Rotary Club of Calcuttahas also established a child education centre The Eco-Committee of ProjectTiger provides clean canals for irrigation and solar lights in the market place ofsome Gosaba villagers A sub-branch of the Ramakrishna mission offers low-cost housing and builds latrines and sheries and like some panchayats they alsooffer loans to farmers

General medical concerns

Childrenrsquos health was identi ed as a priority in all of the six villages that werestudied Womenrsquos health and reproductive health were also included amongpriorities of women in Gosaba Snakebites were a particular concern inJhaukhali and the adverse health impact of scarce drinking water troubled thepeople of Dayapur Among respiratory diseases apart from the usual commonailments people of Jhaukhali and Dayapur emphasized concerns about tubercu-losis and in the latter village they explained that many people will avoid anyoneknown to currently have or even to have had TB as well as their families InArampur people noted that because of a relatively good water supply they are


less troubled by diarrhoeal diseases (It is in fact from a pumping station nearArampur that water is pumped to Dayapur) On Sagar Island in Beguakhali avillage where shing is especially important people identi ed diarrhoeal illnessas a seasonal problem occurring mainly in winter when the dry sh is notcooked properly More inland in Rudranagar diarrhoea is considered more aproblem in the summer

In the two smaller villages of Sagar fevers were associated with possession butin the Gosaba sites fevers appear to be more typically attributed to infectionsand seasonal changes Skin diseases in Sagar were often neglected and theywere considered a common problem among those who spend a lot of time in thewater collecting the tiger prawn seeds Similar accounts came from Arampurand in Jhaukhali and Dayapur eczema and vitiligo were identi ed as stigmatizingconditions Snakebites in both blocks were considered more a matter thatrequired the attention of a magico-religious healer rather than a doctorAlthough people of Sagar were more likely to refer to possession as the cause ofvarious health problems possession was also a recognized cause of illness inGosaba reports in Dayapur attributed dizziness (called lsquoreelingrsquo) and nausea tothe effects of sorcery and possession

Local health system

The allopathic health system in both blocks is mainly a mix of governmentservices and NGO clinics In Sagar the block hospital is a more substantialpresence for government services and in Gosaba the Rangabelia clinic of theTagore Society represents a more substantial presence of an NGO At both sitesthere are many uncredentialled medical practitioners frequently known locallyas quack doctors Some of them even refer to themselves by that term whichappears to have a more derisive meaning for outsiders than it does locally Onesuch practitioner who spoke a little English explained ldquoI am doing quackpracticerdquo Nevertheless many of these uncredentialled practitioners and thenature of the regard some people have for them indicate a sense of inferioritycompared with those who have recognized training and standing as allopathshomeopaths or Ayurvedic practitioners

In addition to the few allopaths more homeopaths and even more uncreden-tialled lsquoquackrsquo practitioners there are also many magico-religious healers (guninor ojha) who serve these communities As we found out when we initiated thestudy of health care providers with the EMIC-HCP interviews in phase 2 wehad initially underestimated their number As we observed their practice it alsobecame clear that we had also failed to appreciate how many of them routinelydeal with emotional problems and common mental disorders such asdepression and anxiety but without necessarily designating these as particulardisorders or discrete medical conditions Appreciation of the dynamics ofsomatization that is the way patients transform emotional suffering into somaticexperience may also affect the way some practitioners interpret the clinicalproblems they encounter in their professional practice


Until a mental health clinic was recently established in Rudranagar on SagarIsland planned in connection with this research government services werepoorly equipped and poorly regarded in their capacity to deal with mentaldisorders Patients were typically referred to Calcutta for serious mental disor-ders or not treated for what might seem to be less serious or unrecognizedmental disorders Among non-allopathic local healers a homeopath on SagarIsland near Phulbari has established a reputation and become very popular fortreating mental illness Various uncredentialled practitioners have mixed reputa-tions for treating disorders known as lsquohystriarsquo (a linguistic variant of hysteria)and also for epilepsy and childhood convulsions Priests (Hindu pujari andMuslim maulvi) and the various gunins and ojhas are also consulted for a varietyof mental health problems The phase 2 research with the EMIC will clarifydetails and the opportunities for cooperation among these various practitionerswithin the health system at large

Identi cation of mental health problems

In response to questions about the priority of mental health most people thinkof seriously disruptive behaviours and what mental health professionals identifyas serious psychotic disorders Consequently these conditions seem remotefrom the health concerns of most people and are typically regarded as a matterof low priority In Dayapur for example we heard that mad persons are oftenteased by young people and in Jhaukhali that families often abandon suchpeople and they have little faith in the possibility of a cure In Rudranagarhowever the largest population centre of the six villages and the site of the blockhospital and the new mental health clinic there was more consideration of thesocial nature of mental illness and speculation that mental illness may resultfrom unemployment

The concept of mental tension is much more pervasive and when askedabout its relationship to mental illness some respondents distinguished mentalillness from mental tension by unnatural behaviour Others distinguished mentalillness from tension by its severity suggesting that mental tension may arisefrom a medical illness either onersquos own a childrsquos or someone in the familyPeople discussed the whole range of stressors in the communitymdash crop failuresbreached embankments womenrsquos fears about their husbands going to the forestand so forthmdash as potential sources of mental tension

People also seemed to recognize a distinction between intense sadness as anillness and everyday sadness as a part of life that passes Some accountsidenti ed the more severe problematic sadness as associated with weakness andloss of appetite and other people suggested that people who are severelyaffected by it may not realize as well as neighbours how serious the problem maybe In most of the villages people recalled instances of suicide and people whohad tried but failed to kill themselves or to hurt themselves People identi edthe most suicides in Rudranagar recalling 10 in the past ve years but theseaccounts included two homicides that had been called suicides There were


many more attempted suicides In Beguakhali people discussed four suicidesover the past ve years by pesticides and hanging as well as the culturallyrecognized suicide threat known as jhuki mara On Sagar in Rudranagar andBeguakhali jhuki mara was described as the threat to commit suicide often bydaughters-in-law under stress from in-laws and now also among childrenthreatening their parents People feel that it is now more frequent and examplesshowed that the threat may actually lead to suicide either as an unintendedconsequence of a miscalculated gesture or from underestimation by others ofthe lethality of the suicidal intent

Among completed suicides a mix of death by hanging and pesticide ingestionwas also discussed in Arampur where 12 cases since 1985 were identi ed InDayapur all eight of the suicides noted in the past ve years had been withpesticides Only in Jhaukhali were there no cases of suicide that anyone theresearchers spoke with could recall Residents did recollect seven or eight casesin the nearby village of Pathankali however which they associated with the badeffects of romantic entanglements of girls attending college In Beguakhali a15-year-old girl had recently slashed her arm after a love affair

Concerns about problems of drugs and alcohol varied considerably among thevillages On Sagar itself these were less of a concern in Beguakhali the mostremote of the Sagar villages and more of an issue in Phulbari close to the ferrylink to the mainland Ayurvedic tonics with a high alcohol content wereidenti ed as sources of alcohol intoxication in disguise in Rudranagar Ricebeer country liquor (chulu) ganja and various social problems arising fromthem (including violence and wife-beating) were discussed more commonly inthe Gosaba villages Drugs and alcohol are considered especially serious prob-lems in Arampur

Local concepts of mental illness

The study aimed to identify the various local concepts of mental illness in thesecommunities The names of various well-known conditions their main featuresperceived causes reactions of family and society approach to treatment andanticipated outcome were all considered This inquiry was dealing mainly withthe concepts and also in some instances with reference to known cases in thecommunity Accounts of local idealized categories of mental illness provide anethnographic point of reference for analysing responses of patients and the ideasof people discussing such disorders as they affect people with these conditionsdepicted in vignettes which are being used in the phase 2 studies with theEMIC

Pagla or pagal is a common term for madness characterized by such anaffected person talking nonsense or behaving in a hostile aggressive mannerVarious ideas about its cause included diet possession a traumatic shock andsmoking cannabis (ganja) People attempted to treat it in the early stagesseeking help from all available sources gunin ojha homeopaths or allopaths Ifthe disturbance did not quickly improve or respond to treatment however it


was likely to be hopeless and families were known to abandon such people Theterm pagal is widely used to identify someone considered mad and it isrecognized in much of north India Other terms were more local or referred tomore speci c conditions a speci c feature of their condition or a particularattribution of cause Brain short for example was a condition attributed tomental shock but also characterized by someone talking to himself or herselfand by irritability and bad temper Kam pagal was the result of unhappiness witha spouse Hystria was identi ed as a condition that usually affects women andwhich may be linked with possession It might be recognized by clamped jawsloss of speech prickling sensations ts and loss of consciousness A range ofpossession states were also well-known conditions in all six study sites

Discussion

Experience with various research methods

Among the different types of research methods employed in the study focusgroup discussions worked especially well in sampling the views of people fromdifferent social strata Individual interviews need to be undertaken with fullappreciation of the potential diversity of responses including some extremeopinions on any particular topic We found that interviews with the farmers inthe paddy eld when they were resting were especially productive Joining themin the elds their workplace seemed to indicate to the farmers a genuinenessand the depth of the researchersrsquo interest Participatory mapping was veryuseful It not only provided a product the map to document the deliberationsbut the exercise stimulated discussion and interaction that brought out ideas lesslikely to emerge without the activity (Fig 2) The participatory mappingexercise with a group operates as a kind of enhanced focus group enhanced bythe mapping activity rather than just the remarks of the discussion leader whichis the initial stimulus in typical focus group discussions Although typically usedas a method for working with groups the mapping may also enhance individualinterviews

Over the course of the research the range of considerations relevant towell-being and mental health and to emotional distress and mental healthproblems of the villagers expanded This may be expected as an effect ofparticipatory methods brought to bear on topics of such pervasive interest Anumber of social concerns in the community not anticipated at the outsetemerged as recurring themes such as teenage pregnancy the commercialnetwork of snakebite healers and even concerns about particular crab collectiontechniques and other dangers of life in these villages

Sadness and mental illness

Recognizing the priority of depression as a worldwide contributor to the overallburden of disease this research has been particularly attentive to local concepts


FIG 2 Participatory map of health care facilities and patientsrsquo use of one after another (DayapurVillage Gosaba Block)

of sadness and how its relationship to clinical depression is understood in thecommunity Careful study indicated that sadness was recognized as constitutingan illness in some circumstances when it was very intense and associated withother symptoms Terms for this sadness however were not prominent amongthe local terms for mental illness that researchers endeavoured to elicit Perhapsthis was because of a miscommunication about the kind of problems theresearchers were interested in when they asked about mental illness But theconcept of mental health itself may have a technical professional qualitymdash dis-tinct from feeling goodmdash that is not so well understood in many communities asclinicians and health planners might expect Although people have ideas in mindof what they mean by mental illness the boundaries by which they distinguish


emotional distress mental health problems mental illness and psychiatricdisorders are embedded in expectations arising from the context and setting inwhich the discussion takes place

The fact that such problems were not prominent among the disordersidenti ed in the community does not necessarily mean such a condition is notconsidered serious and even a serious medical condition Our investigation ofsadness as an illness suggested that it was Even professional ideas about whatdistinguishes distress and disorder change over time which to some extentexplains the ongoing process of revision of the DSM and ICD and which is alsothe basis for ongoing controversies in psychiatry about whether posttraumaticstress disorder is really a disorder or a normal expected outcome in response tosevere stress that should not be pathologized (Summer eld 2001)

Summer eld also brings our attention to the fact that many of the conditionsthat concern mental health professionals may not have an objective existenceindependent of the in uence of the clinical gaze of the psychiatrist or otherhealth professional which creates a medical meaning In any event this dis-crepancy between local recognition of intense sadness as a mental illness and itslack of priority among mental disorders speci ed in these communities indicatesthe complexity of community study of mental health problems and concepts ofmental illness These are not just matters of detached academic theorizing butkey issues in the development and implementation of relevant responsivesustainable mental health programmes

Contribution of cultural epidemiology to community health

The approach to cultural epidemiology that guided this research focused on thenature of mental health problems the experience and meaning of concepts ofmental illness and associated behaviour that affects risk and help-seekingThese are questions that were thought to be especially relevant to the infor-mation needs of planning a community mental health programme for theSundarban region and it was this practical objective that motivated the studyFindings from the rst phase of ethnographic research indicate ndings con-cerning the topics outlined in the village ethnographic survey schedule includedin an appendix to this report Findings from the second phase of EMIC researchwill provide additional quantitative and qualitative data constituting a systematicdescriptive account from patient layperson and healthcare provider perspec-tives Such cultural epidemiological data are also expected to be useful forcomparative and analytic study of these conditions

The ethnographic component of this research has already provided usefulinformation that contributes to the relevance of a local programme of specializedmental health services It is also enhancing the sensitivity and responsive-ness to mental health problems in primary care establishing awareness ofmental health concerns in the broader health system that serves the com-munity and focusing required attention on the social and cultural componentsof suicide and deliberate self-harm Although professional expertise is required


the task also requires understanding and appreciation of the concepts andlanguage of the community and continuing dialogue and interactions in thecommunity through community health workers local leaders village panchayatsNGOs and other agents of community-based development activities The aim isto mobilize these resources to minimize the stressors and enhance the supportsthat halt the progression of emotional stress to mental health problems andprevent psychiatric disorders and to promote mental health

This report is an account of work in progress It responds to a need for a clearaccount of the ground reality the communitiesrsquo expectations and needs and thedistinctive and changing social and cultural contexts (Manson 1997) Such anaccount is crucial for the development of a people-orientated community mentalhealth programme (McMichael amp Beaglehole 2000) It is hoped that theapproach described here may also be useful to other researchers and mentalhealth policymakers who may nd the frameworks and methods of culturalepidemiology useful to ensure the development enhance the relevance andsecure the effectiveness of community mental health activities in other areas likethe Sundarban with similar needs

Acknowledgements

Assistance of Salil Kumar Dutta and Sohini Banerjee in preparing this report isgratefully acknowledged Support from the Swiss National Science FoundationGrant 32ndash5106897 Cultural Research for Mental Health is also gratefullyacknowledged

References

CHOWDHURY A N CHOWDHURY S amp CHAKRABORTY A 1999 Eco-stress quality of life andmental health in Sundarban delta of India International Journal of Medicine 6 59ndash63

CHOWDHURY A N SANYAL D DUTTA S K DE R BANERJEE S BHATTACHARYA K PALITS BHATTACHARYA P MONDAL R K amp WEISS M G 2001 Interrater reliability of theEMIC in a pilot study in West Bengal International Medical Journal 8 25ndash29

DE B ed 1994 West Bengal District Gazetteers 24 Parganas Government of West BengalCalcutta Swaraswati Press

JENKINS R 2001 Making psychiatric epidemiology useful the contribution of epidemiology togovernment policy Acta Psychiatrica Scandinavica 103 2ndash14

KRAEMER H C et al 1986 Methodology in psychiatric research Archives of General Psychiatry44 1100ndash1106

MANSON S M 1997 Ethnographic methods cultural context and mental illness bridgingdifferent ways of knowing and experience Ethos 25 249ndash258

MCMICHAEL A J amp BEAGLEHOLE R 2000 The changing global context of public health Lancet356 495ndash499

OMMEREN M V SHARMA B MAKAJU R THAPA S amp JONG J D 2000 Limited culturalvalidity of the composite international diagnostic interviewrsquos probe ow chart TransculturalPsychiatry 37 119ndash129

SUMMERFIELD D 2001 The invention of post-traumatic stress disorder and the social usefulnessof a psychiatric category British Medical Journal 322 95ndash98


WEISNER T S 1997 The ecocultural project of human development why ethnography and its ndings matter Ethos 25 177ndash190

WEISS M G 2001 Cultural epidemiology an introduction and overview Anthropology andMedicine 8 5ndash29

WEISS M G ISAAC M PARKAR S R CHOWDHURY A N amp RAGURAM R 2001a Globalnational and local approaches to mental health examples from India Tropical Medicine andInternational Health 6 4ndash23

WEISS M G COHEN A amp EISENBERG L 2001b Mental health In MERSON M BLACK B ampMILLS A eds Introduction to International Health Gaithersberg MD Aspen

WITTCHEN H U 2000 Epidemiological research in mental disorders lessons for the next decadeof researchmdash the NAP Lecture 1999 Nordic Association for Psychiatric Epidemiology ActaPsychiatrica Scandinavica 101 2ndash10


Appendix Ethnographic village survey schedule (summary)

1 Approaches to data collectiona Interviews focus groups and participant observationb Case histories especially of people with mental health problems (considering social

economic environmental [climate and wild life] and political stressors and supports)c Transect walks with key informantsd Participatory mapping focusing on themes such as location of irrigation sites and drinking

water religious places health infrastructure and providers dangerous places recreationaland educational places environmental hazards and features social tensions

e Records and documentation from the village council (panchayat)

2 Identi cation of each village study sitea Location history of settlement environmental featuresb Population ethnic and caste compositionc Economic activities transportation and communicationd Environmental features and problems (soil erosion salinization crop destruction humanndash

animal con ict)

3 Mental health and general health problems and servicesa Mental illness in the community

i What are mental health problems(1) What are they and how are they identi ed(2) Speci c features of experience meaning and behaviour associated with each

ii Are they a matter of concerniii Distinguishing emotional tensions social problems and mental illnessiv Is sadness an illnessv Community reactions to mental illnessvi Experience in the community with suicide and deliberate self-harm

b Drug and alcohol use in the communityc Other health priorities and problems (eg epilepsy leprosy stigmatized and chronic

disease)d Health services in the community especially for mental health problems

i Orientation quali cations and experience of local health care providersii What they treat and how they treat itiii Cost location and perceived quality of care

4 Social contexts and concernsa Communal and political tensionsb Social changes and responses to them order and disorderc Educational opportunities within and outside the villaged Occupational opportunities and local economye Recreational leisure activities (video parlours community festivals)f Sexual promiscuity extramarital sex commercial sexg Gender

i Social role of women in home and communityii Womenrsquos issues that come to panchayatiii Domestic violenceiv Age and patterns of marriage

a Childhoodi Perceived value of education perceived quality and distance of schools school attend-

ance by ageii Child labour


TABLE I Subdistrict administrative blocks of the Sundarban Region South 24 Parganas DistrictWest Bengal Indiaa

Number Population Number NumberAdministrative Area of of ofblocks in km2 islands Total Male Female Mouzasb villages

Basanti 2900 2 226974 116425 110549 65 75Canning I 2057 2 196295 100700 95595 67 62Canning II 2220 151635 77333 74302 62 108Gosaba 3325 11 200514 103286 97228 51 51Jaynagar I 1271 185271 95938 89333 75 75Jaynagar II 1752 177335 91327 86008 45 209Kakdweep 2611 190088 97563 92525 39 113Kultoli 2409 3 156450 80516 75934 43 90Mathurapur I 1484 141888 73264 68624 99 99Mathurapur II 2305 1 172982 90177 82805 28 175Namkhana 2271 1 134354 69018 65336 35 35Pathar-pratima 4695 13 245601 125904 119697 87 94Sagar 4708 4 154202 79242 74960 44 44

a Data from District Statistical Handbook Bureau of Applied Economics amp Statistics Government ofWest Bengal Calcutta T T Traders 1998b Mouza is the term for sub-block divisions which in Sagar and Gosaba blocks approximate villageboundaries

factors including inadequate models and information needed to guide popu-lation-based mental health services contribute to the relative dearth of servicesand needed programmes to prevent mental illness and promote mental health inrural areas

The Sundarban region of West Bengal south of Calcutta in the South 24Parganas District is an example of a neglected rural area The Sundarban is anactive delta region of the river Hooghly and other branches of the Ganges Riverat their con uence in the Bay of Bengal (Fig 1) It is the largest estuary on theglobe comprising 54 islands and including 4264 km2 of reserve forest for theprotection of wildlife primarily tigers in addition to populated areas (Table I)The total population of the region is approximately 23 million By all measuresof socioeconomic development the Sundarban region is poorly developed andunder-served Its inaccessibility poor agricultural output constantly shiftingland masses and ecological instability lack of industry and hostile climate havemade this area one of the most backward regions of the state of West BengalThe literacy level as well as the per capita income is far lower than the Stateaverage and 425 of the families subsist on earnings below the poverty line(De 1994) The transportation and communication systems are poor includingabout 280 km of paved road and 42 km of rail lines During the annualmonsoon much of the region becomes inaccessible

Inaccessibility travel hazards on land and water and the distances people










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b-p

ost

new

spap

er

of

ce

of

ce

of

ce

dis

han

ten

na

new

spap

er

new

spap

er

new

spap

er

FM

rad

ioamp

FM

rad

ioamp

FM

rad

ioT

VT

V(s

ola

rT

V(s

olar

(ele

ctri

city

pow

er)

pow

er)

4hr

sd

aily

)

Blo

ckd

ata

on

ly

vill

age

dat

an

otav

aila

ble




































Local health system


















Discussion



















Acknowledgements


References























animal con ict)













Aims and approach







Methods







TA

BL

EII

S

un

dar

ban

villa

ge

eld

site

sfo

ret

hnog

rap

hic

stu

dy

Sag

arb

lock

Gos

aba

bloc

k

Fea

ture

sB

egu

akh

ali

Ru

dra

nag

arP

hu

lbar

iJh

aukh

ali

Day

apu

rA

ram

pu

r

Rat

ion

ale

for

Mos

tre

mot

eM

ost

Fer

ryR

emot

eN

ear

tige

rP

op

ulo

us

sele

ctio

np

opu

lou

sco

nn

ecti

onto

rese

rve

mai

nla

nd

Pop

ula

tion

(199

1)

395

056

5310

311

312

47

3552

87

Lit

erac

yra

te24

71

29

3

58

Mal

e30

81

36

4

87

Fem

ale

18

64

21

22

0

M

ain

Ric

ech

illi

Ric

eb

etel

R

ice

bet

el

Ric

ela

bo

ur

Ric

eti

ger

Ric

ese

aec

onom

icb

etel

leaf

go

vern

men

t

shin

gti

ger

pra

wn

shin

gtr

ade

acti

viti

es

shin

gti

ger

ampp

riva

tepr

awn

d

aych

illi

som

eh

oney

pra

wn

va

nse

rvic

es

day

labo

ur

trad

e

shin

gcr

abga

ther

ing

and

pu

llin

gla

bou

rva

nco

llect

ion

w

ood

-cu

ttin

gta

ilori

ng

pu

llin

gh

oney

trad

ega

ther

ing

woo

d-

cutt

ing

Tra

nsp

ort

Bic

ycle

van

Bic

ycle

van

G

over

nm

ent

Sm

all

boa

tS

mal

lb

oat

Sm

all

boat

bu

sfe

rry

serv

ice

serv

ice

serv

ice

serv

ice

tom

ain

lan

d

bic

ycle

van

bic

ycle

van

bic

ycle

van

bus

bic

ycle

van

Com

mu

nic

atio

ns

No

Tel

eph

one

No

Loc

alN

oS

TD

tele

ph

one

tele

ph

on

e(l

ocal

and

tele

ph

one

tele

ph

one

tele

ph

one

bra

nch

and

rad

io

orT

VS

TD

)ra

dio

o

rT

Vsu

b-p

ost

sub

-pos

tsu

b-p

ost

new

spap

er

of

ce

of

ce

of

ce

dis

han

ten

na

new

spap

er

new

spap

er

new

spap

er

FM

rad

ioamp

FM

rad

ioamp

FM

rad

ioT

VT

V(s

ola

rT

V(s

olar

(ele

ctri

city

pow

er)

pow

er)

4hr

sd

aily

)

Blo

ckd

ata

on

ly

vill

age

dat

an

otav

aila

ble




































Local health system


















Discussion



















Acknowledgements


References























animal con ict)













Methods







TA

BL

EII

S

un

dar

ban

villa

ge

eld

site

sfo

ret

hnog

rap

hic

stu

dy

Sag

arb

lock

Gos

aba

bloc

k

Fea

ture

sB

egu

akh

ali

Ru

dra

nag

arP

hu

lbar

iJh

aukh

ali

Day

apu

rA

ram

pu

r

Rat

ion

ale

for

Mos

tre

mot

eM

ost

Fer

ryR

emot

eN

ear

tige

rP

op

ulo

us

sele

ctio

np

opu

lou

sco

nn

ecti

onto

rese

rve

mai

nla

nd

Pop

ula

tion

(199

1)

395

056

5310

311

312

47

3552

87

Lit

erac

yra

te24

71

29

3

58

Mal

e30

81

36

4

87

Fem

ale

18

64

21

22

0

M

ain

Ric

ech

illi

Ric

eb

etel

R

ice

bet

el

Ric

ela

bo

ur

Ric

eti

ger

Ric

ese

aec

onom

icb

etel

leaf

go

vern

men

t

shin

gti

ger

pra

wn

shin

gtr

ade

acti

viti

es

shin

gti

ger

ampp

riva

tepr

awn

d

aych

illi

som

eh

oney

pra

wn

va

nse

rvic

es

day

labo

ur

trad

e

shin

gcr

abga

ther

ing

and

pu

llin

gla

bou

rva

nco

llect

ion

w

ood

-cu

ttin

gta

ilori

ng

pu

llin

gh

oney

trad

ega

ther

ing

woo

d-

cutt

ing

Tra

nsp

ort

Bic

ycle

van

Bic

ycle

van

G

over

nm

ent

Sm

all

boa

tS

mal

lb

oat

Sm

all

boat

bu

sfe

rry

serv

ice

serv

ice

serv

ice

serv

ice

tom

ain

lan

d

bic

ycle

van

bic

ycle

van

bic

ycle

van

bus

bic

ycle

van

Com

mu

nic

atio

ns

No

Tel

eph

one

No

Loc

alN

oS

TD

tele

ph

one

tele

ph

on

e(l

ocal

and

tele

ph

one

tele

ph

one

tele

ph

one

bra

nch

and

rad

io

orT

VS

TD

)ra

dio

o

rT

Vsu

b-p

ost

sub

-pos

tsu

b-p

ost

new

spap

er

of

ce

of

ce

of

ce

dis

han

ten

na

new

spap

er

new

spap

er

new

spap

er

FM

rad

ioamp

FM

rad

ioamp

FM

rad

ioT

VT

V(s

ola

rT

V(s

olar

(ele

ctri

city

pow

er)

pow

er)

4hr

sd

aily

)

Blo

ckd

ata

on

ly

vill

age

dat

an

otav

aila

ble




































Local health system


















Discussion



















Acknowledgements


References























animal con ict)












TA

BL

EII

S

un

dar

ban

villa

ge

eld

site

sfo

ret

hnog

rap

hic

stu

dy

Sag

arb

lock

Gos

aba

bloc

k

Fea

ture

sB

egu

akh

ali

Ru

dra

nag

arP

hu

lbar

iJh

aukh

ali

Day

apu

rA

ram

pu

r

Rat

ion

ale

for

Mos

tre

mot

eM

ost

Fer

ryR

emot

eN

ear

tige

rP

op

ulo

us

sele

ctio

np

opu

lou

sco

nn

ecti

onto

rese

rve

mai

nla

nd

Pop

ula

tion

(199

1)

395

056

5310

311

312

47

3552

87

Lit

erac

yra

te24

71

29

3

58

Mal

e30

81

36

4

87

Fem

ale

18

64

21

22

0

M

ain

Ric

ech

illi

Ric

eb

etel

R

ice

bet

el

Ric

ela

bo

ur

Ric

eti

ger

Ric

ese

aec

onom

icb

etel

leaf

go

vern

men

t

shin

gti

ger

pra

wn

shin

gtr

ade

acti

viti

es

shin

gti

ger

ampp

riva

tepr

awn

d

aych

illi

som

eh

oney

pra

wn

va

nse

rvic

es

day

labo

ur

trad

e

shin

gcr

abga

ther

ing

and

pu

llin

gla

bou

rva

nco

llect

ion

w

ood

-cu

ttin

gta

ilori

ng

pu

llin

gh

oney

trad

ega

ther

ing

woo

d-

cutt

ing

Tra

nsp

ort

Bic

ycle

van

Bic

ycle

van

G

over

nm

ent

Sm

all

boa

tS

mal

lb

oat

Sm

all

boat

bu

sfe

rry

serv

ice

serv

ice

serv

ice

serv

ice

tom

ain

lan

d

bic

ycle

van

bic

ycle

van

bic

ycle

van

bus

bic

ycle

van

Com

mu

nic

atio

ns

No

Tel

eph

one

No

Loc

alN

oS

TD

tele

ph

one

tele

ph

on

e(l

ocal

and

tele

ph

one

tele

ph

one

tele

ph

one

bra

nch

and

rad

io

orT

VS

TD

)ra

dio

o

rT

Vsu

b-p

ost

sub

-pos

tsu

b-p

ost

new

spap

er

of

ce

of

ce

of

ce

dis

han

ten

na

new

spap

er

new

spap

er

new

spap

er

FM

rad

ioamp

FM

rad

ioamp

FM

rad

ioT

VT

V(s

ola

rT

V(s

olar

(ele

ctri

city

pow

er)

pow

er)

4hr

sd

aily

)

Blo

ckd

ata

on

ly

vill

age

dat

an

otav

aila

ble




































Local health system


















Discussion



















Acknowledgements


References























animal con ict)














































Local health system


















Discussion



















Acknowledgements


References























animal con ict)








































Local health system


















Discussion



















Acknowledgements


References























animal con ict)

































Local health system


















Discussion



















Acknowledgements


References























animal con ict)



























Local health system


















Discussion



















Acknowledgements


References























animal con ict)




















Local health system


















Discussion



















Acknowledgements


References























animal con ict)














Local health system


















Discussion



















Acknowledgements


References























animal con ict)


























Discussion



















Acknowledgements


References























animal con ict)




















Discussion



















Acknowledgements


References























animal con ict)













Discussion



















Acknowledgements


References























animal con ict)
























Acknowledgements


References























animal con ict)





















Acknowledgements


References























animal con ict)














Acknowledgements


References























animal con ict)
























animal con ict)


















animal con ict)











Community Mental Health and Concepts of Mental Illness in the Sundarban Delta of West Bengal, India a. N

Documents

mental health of populations

general health services

selected mental disorders

sundarban delta of west

department of public

rural region

health care providers

government of west bengal