Vanee Surendranathan has over two decades of experience working in the NGO sector. Her specialties focus on community mental health and disability. In this interview, she talks about the significance of community approaches for mental health, issues relating to mental health and the ageing population of Sri Lanka, and the need of paying attention to mental health issues within reconciliation and transitional justice processes.
You have over 24 years of experience in the NGO sector in the fields of development and community mental health. How did this journey begin for you?
I started at Practical Action, earlier known as the Intermediate Technology Development Group, which worked with appropriate technology in communities. I started in 1993. I still remember my very first field visit. It was to a cashew processing community. My boss, Vishaka Hidellage, took me to see the women who were processing cashew. We were helping them with appropriate technology. That’s how my interest in the development field started. But a lot of the work that I did in the early years was with programming, finance, and administration. Something that intrigued me to become where I am today was that earlier I was confined to doing a lot of filing work because I was the program secretary. I would sit in the conference room and separate my filing. Then my curiosity got me wanting to see what the others were doing going to the field. So, I started reading. That actually made me think that there is something interesting happening out there. I decided that I also wanted to go to the field and get involved in the program work.
You have vast experience in the field of community mental health. What are some of the work you have done in this area?
My work in community mental health started in 2001. The same way, I was initially doing more of managing the organisation. But from 2009 onwards where I took over the program as the country program manager of BasicNeeds, I started leading. My mental health work has been in different contexts – war, tsunami, post war, and institutionalized people at the National Institute of Mental Health in Angoda. I have also worked with different groups of people, such as children and elders. For the past six years, before I took over my current position with CBM, I worked with children. The focus on children occurred because we realised that there are some programs that did not pay enough attention to children and their mental health problems. That’s why we designed this children and mental health program for which we worked in 5 districts in Sri Lanka. The latter part of the program focused on the Eastern Province because it had experiences of tsunami and the post war situation. I am also very much motivated to work on elders and their mental health issues. This interest was also triggered because my grandmother who was in her eighties was suffering from Alzheimer’s. Explaining to my family that she was going through some illness and that this is not part of ageing became very much a challenge. Sometimes she was laughed at. She could not identify her children. Her behaviour changed. It was very sad to see the last stages of her life. She really suffered because of that. That personally motivated me to really work on elders and mental health problems in Sri Lanka. This is very much ignored in Sri Lanka. Because specialized geriatric care is very much less in this country even though alarmingly our population is ageing very fast. Our elderly care is not planned for that situation at the moment.
What can be done to strengthen those mechanisms, to raise awareness and educate on issues such as these?
We did a research with the elders. They have a fear. In Sri Lanka, the transport system is not very friendly even for a normal person. When you are old and you want to travel it is not very friendly. So, they fear of travelling. Then they start isolating themselves because otherwise they have to travel with someone accompanying them all the time, which is not going to happen. The isolation may lead to severe depression. Also, if you look at our suicide rates the elderly suicide rate is increasing alarmingly. There are different reasons like chronic diseases and poverty. Whatever the reason, it is increasing.
We have one of the best primary health care systems in Asia. It goes up to the village level – to the mid-wife who makes even home visits. We had the systems put in place a long time ago. What we have to do is use the systems that are already in place. At the moment, it is focused on reproductive health and childcare. Something that we can do is give additional responsibilities or use the same mode to educate about the elderly. That is the same system that we used to educate communities on mental health, with our earlier projects at BasicNeeds. We tapped into the system that is already existing and we educated these people to carry the message of mental health. It gave a lot of access to our program because there is a large workforce of primary health care workers in this country. If primary health care workers are trained properly, I think we can do a lot. I also do understand that they have a workload at the moment but we have to think about this.
People living with mental illness in low and middle income countries tend to be some of the world’s most marginalised people. What is the context in Sri Lanka regarding perceptions on mental health?
Stigma is very much at large for us. Our society is built in such a way that we don’t want to talk about it. Even to a family member, we are reluctant to tell them to seek help because our culture is built in such a way. In the communities where we work there are a lot of issues because you can’t keep a secret in a village. Everybody finds out what is happening in the next house. Even when they wanted to keep it a secret, it comes out. Stigma comes in different forms. Nobody wants to associate with you, nobody wants to have a marriage proposal in your family, and you will be isolated from family functions. If you are in a very closely knit village community, occasions such as going to a wedding house become problematic for them. No matter how much we have educated, stigma exists at large. In some communities, such as in the East or in the North, it is much higher than in the Southern province. We have worked for a long time in these areas. People also did overcome to a certain extent.
In some private hospitals, when you look at the board there is a long list of names of psychiatrists. This was not the case ten years ago. That shows that treatment-seeking behaviour has come up to a certain extent. Understandably, our healthcare system focuses on the person and not the reasons around the person causing mental illness. It can be a family problem. It can be poverty. A number of issues can be related. When it comes to mental health you cannot address the person or the illness alone. You have to address the issues that are around it. If you don’t, even though you have cured the person and that person is stabilised, that person cannot go back and lead a normal life. Because the problem still does exist. It could be the family or it could be the community. That is the part that we have to focus on.
What sort of an approach could work in place of solely focusing on the illness or the person?
Sometime back Sri Lanka was really going for community mental health. We were talking a lot about expanding. But sadly, after 15 years, we are slowly working towards institutionalised again. We are only seeking medical care rather than addressing the community aspects of it. One of the interesting things we did is a self-help group concept that helped to battle the stigma a lot. It was a very good initiative. A carer and people with mental health problems form a self-help group. We use that group for multi purposes.
When they get together and talk about their problem they realise that this is not only happening to them. The problem then becomes smaller. When you think that your problem is common or the other person’s problem is larger than yours, that self-reflection comes in. It is also very therapeutic to talk and to discuss about it in a group. When a family member is busy and they are unable to take someone to the hospital a member from the self-help group offers to take them to the hospital. That is very supportive to each other. Then we also use these groups to generate income collectively. When one does income generation individually – say for a person with severe depression, they work for two days and go back to their earlier status. So we use this group together for income generation activities. One of the interesting vocations I saw was twinning of ropes for rope making. They would do the work and also chat in their group. By the end of the month, they sell the products collectively and divide the profit among themselves. It was therapeutic for them to come together and be together. At the same time, it also generates an income. That helped a lot to battle the stigma because mostly these people are breadwinners of the family and when they become inactive the social role that they have played gets diminished slowly. The moment that they start being active and bringing money into the family they get recognised.
Did the civil conflict affect people’s mental health in the North and East in particular ways?
I can very specifically say from the experience that I have had with my children’s project that the conflict affected the mental health of many people in the North and East. We worked in Vakarai, Kiran, and Valachchanai, which were heavily affected by the war. These areas were also affected by the tsunami. During post war, although we built roads and houses, we didn’t pay attention to the broken people in these areas. There are many issues that are connected with mental health. Alcoholism is high in the Batticaloa district. The family structures are broken. Some people who are in their prime were married while they were only teenagers to avoid being recruited for war. Especially, because most of these people were also not legally married at the time of war, there is now a tendency to leave their marriages. Some of these locations are also very remote and job opportunities are scarce. There are also issues relating to disability and war. All these are contributing factors for mental health issues. We didn’t address many consequences of the war at the right time. Many memories were suppressed. Over the years, these issues have been piled up and these need to be addressed. In 2009, if someone was 10 years, they are in their prime now. Just imagine how much they have seen and accumulated. Sometimes they must be making sense now only of what they have seen during the war.
How can we at least try to mitigate some of these issues, perhaps there is no one answer to this question?
Someone who was a young person during the war is now in their middle age. This generation is going through a lot of issues. They have become the breadwinners of the family and they take care of the family now. We need to focus on them, if we are going to save the next generation. It may be a little late but their mental health needs have to be addressed, collectively or individually. Mental health is a very deprioratised subject. People have to accept that there is a problem and we need to address it. Our health care professionals have to think about community approaches rather than bringing the person and treating that person in a hospital. This was actually done some time back but now it has reduced. They are very conveniently going back to the hospital approach. That has to change. Whatever said and done, we are a community who loves to live collectively. This collectivity is still needed for communities in the villages because they are not geared to change that at the moment.
Speaking from your experience working with communities that have faced natural disasters, how do such situations affect the mental health of people?
When there is a death there is usually a grieving process. You have a funeral and the grieving process begins. But during a natural disaster that process doesn’t take place because there are a lot of issues. I think the funeral system helps people by giving them time to process their grief. Many people come and you keep on telling the story. The funerals are not for the dead, it is for the living. You remember the nice things about that person. This helps you to get over it. During natural disasters, it doesn’t happen because you have to think about other things like livelihoods, survival, and relocation. So, you don’t grieve properly and the grief gets accumulated. There is guilt that you haven’t done something for the person who is dead. The other guilt is that someone surviving when another member of the family has died. Again, the children become one of the vulnerable groups here because the adults focus on different things. Children will be just idling and getting along. Nobody pays attention to them. Naturally, we think that they are children and they can. But they also have a lot of issues. They have seen death. They also have the fear.
You also contributed to designing the human rights action plan of Sri Lanka (2017-21) by serving as a member of the subcommittee who designed the chapter of ‘Rights of People with Disabilities’. Is mental health seen as a disability in Sri Lanka?
Very minimal. That’s why this year people with experience in mental health went into that group. This is the first time in the human rights action plan that disability went in as a chapter. For that, some people represented physical disabilities and we spoke about mental health. When people talk about disabilities, they don’t see mental health as a disability. In the disability sector also people with hearing impairment get very little attention because their disability cannot be seen. Mental health faces the same problem. This time we made sure we spoke about it. Some of the problems were addressed, as a result, and it went into the chapter. But it has to be translated into an action plan and funding has to go into that. We have to see how it goes. I would say we get very minimum attention. Some issues are easier to explain but with funding for mental health, it is not easy to show results or visible numbers. When you give livelihood loans or assistive devices it is easy to say I gave for 100 people. With mental health, it is difficult to build the indicators and difficult to show the change. It also takes time because progress happens step by step.
What is your current role with CBM and what are some of the areas of focus?
CBM is an organisation that is about more than 100 years old. It focuses on disability. Their major focus is on eye care. It is one of the largest disability organisations at the moment. In Sri Lanka, we have worked for about 30 years. From funding the government, we have now moved to community approaches. Here some of the organisations are working on mental health. We work with organisations on different aspects of disability, such as hearing impairment, health, and mental health issues. Majorly the focus is on physical disabilities. We are also trying to educate the government about the rights of the people with disabilities. Because the government is always looking at them on a charity base. They are saying that we are doing a favour to you. It’s not a favour. It is about the right of another person. The constitutional right is equal to everybody. That attitudinal change is very difficult. We are trying to educate the Pradeshiya Sabha because social welfare is a provincial subject. We have to educate them on accessible toilets, ramps to get to the offices etc. If I am coming to get a document signed or get my birth certificate registered there has to be access. Attitudinal change and educating the government is also a major part of our work at the time. We have policies. We have the disability policy. We have an accessibility act. We have also signed the UN Convention on the Rights of Persons with Disabilities. But translating those into action is the challenge.
With the advent of social media platforms, we saw very recently in Sri Lanka how suicide victims were revictimised through the sharing of grotesque images and derogated through hate comments, in particular young girls. What are the challenges in working to raise awareness on mental health?
In 1996, we had the highest suicide rates. Measures had been taken over the years. Our measures have worked mainly because our primary health care and emergency medicine advanced so much and we saved lives. That reduced the number of deaths. But the number of attempts still remains at large. If you take the police records, the number of people who attempt are at their prime age. Sometimes there is news, which is very misleading. Why they did it? Is it a love affair? We assume certain things about a person. Even the journalists when they are reporting on suicide they cause more damage sometimes. Sometimes the way they report is very sensationalised. They find a very dramatic story behind it. We need to report in a responsible and ethical manner. For this, along with the journalists BasicNeeds developed guidelines.
You also have a Master’s in Development Practice from the University of Peradeniya (2013-15). How does your education connect with your work?
I did my Master’s much later in my life. I worked a lot in the field. Although I was qualified to enter to university, my family background did not permit me to do so. I started working at the age of 18. The course for my Master’s at the University of Peradeniya gave us different options. The course was designed on what actually happens. One of the things that helped me was, although I had worked a lot in the field, I had little knowledge on putting it into theoretical thinking. That is what the degree helped me with actually. The course also helped me to think about how to statistically analyse. It was very useful to me.
Any future projects to look out for?
I am very passionate about working on elders and mental health. When I was recruited for BasicNeeds, something that the founder director of the organisation told me was that after the Second World War in the European countries they did not pay much attention to the soldiers and their mental health problems. They had a lot of problems. They had seen the war. 20-30 years later, it became a major problem for those countries. We have to realise that we also went through a war. How much ever we want to hide things that have happened or what we have gone through, we went through it. We should talk about it and handle these things. That is how the reconciliation is also going to happen. Unless we heal, the hatred is going to be there.
Date of Interview: 12 September 2017
Interviewer: Shashini Ruwanthi Gamage