Merchant R. Social Prescribing: An antidote to India’s suicide crisis? Harvard Public Health Review. 2021; 28.
June 14, 2020. On this day, Sushant Singh Rajput, a well-known Bollywood actor, died by suicide. Sushant’s celebrity status meant that his tragic death made national news in India.1 Unfortunately, Sushant’s story is not atypical.
In 2016, India recorded 36% of the world’s female suicides and 24% of the world’s male suicides.2 These summary statistics are outlined in a study by Rakhi Dandona and her colleagues, published in the Lancet in 2017. The study also reveals a chilling fact. Suicide was the primary cause of death among the 15-39 age group, implying that this malaise disproportionately affects young adults, the promise of any country’s future.2 The coronavirus pandemic has compounded these concerns. A recent systematic search of online news media reports compared suicidal behavior during India’s COVID-19 lockdown to corresponding dates in 2019. The analysis found a 67.7% increase in online news media reports of suicidal behavior during the lockdown, suggesting that there may have been an increase in suicidal behavior.3 Furthermore, in 2020, suicide rates went up in Japan for the first time in 10 years with a particular increase in the rate of female suicides.4 These findings are congruent with the evidence from recent pandemics. During the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, the suicide rate in Hong Kong reached a historical high, with the most significant increase recorded among older adults aged 65 or above.5 A rise in suicide rates was also recorded in the United States during the Great Influenza Epidemic of 1918.6
Suicidal ideation is often rooted in broader issues of social justice. One year before Sushant Singh Rajput’s death, Dr. Payal Tadvi, a 26-year-old resident physician, died by suicide. Her death also made national headlines in India as Dr. Tadvi’s colleagues precipitated her suicide by subjecting her to persistent, caste-based discrimination.7 Similarly, sustained unemployment, stultifying social norms, and a rigid educational system also cause suicidal ideation. What role can a health care worker play in addressing these factors?
To answer this question, we can draw on the ideas of Rudolf Virchow, a 19th century German polymath. He suggested that doctors are the ‘natural attorneys of the poor,’ implying that their role extends into the realm of social justice.8 This approach outlines that doctors have a moral imperative to combat the socio-political basis of a condition. We need to reclaim this idea and empower physicians and administrators to expand the ambit of care delivery to include the individual, relational, institutional and societal dimensions of a patient’s complaint.
To apply Virchow’s philosophy to the issue of suicide, a health system level innovation is required to integrate clinical care delivery with the social determinants that influence suicidal ideation. Social prescribing is one such innovation that has been pioneered in the British National Health System (NHS). This approach targets primary care settings and involves the physician referring a patient to support services within the community.9 These support services include necessary non-clinical services that enhance mental health and well-being such as legal advice, employment support, group learning and artistic activities.
Most models of social prescribing also involve assigning a ‘link worker’ to the patient.9 The ‘link worker’ acts a bridge between the clinical and non-clinical arenas, working with the patient to link them to the most appropriate community and social sector resources. In the Indian context, the link worker will likely partner with the patient to explore options to access credit, enroll in government schemes in case of financial distress, or connect with civic organizations in the face of social oppression. A recent systematic review of social prescribing schemes in the United Kingdom suggested that patient outcomes included an increase in self-esteem and confidence, improvement in mental well-being and positive mood, and reduction in anxiety, depression and negative mood.10 These outcomes can play a critical role in suicide prevention.
To adapt social prescribing to the Indian context, the Indian state must develop the necessary welfare and community-based infrastructure. This includes a cadre of link workers, access to credit, employment guarantee schemes, an expanded public distribution system (PDS), partnerships with grassroots civic organizations and a lot more. The state has already built a nationwide cadre of health workers, the Accredited Social Health Activists (ASHAs), who focus on maternal health and childcare. This experience could be leveraged to drive the initiative. Further, the social sector has undergone a recent boom, suggesting that civil society is particularly active.11 The government should leverage the expertise of civic organizations to build technical capacity and deliver a basket of coordinated services.
Fortunately, the broader policy environment is favorable. The recent Mental Health Act decriminalized suicide, allowing individuals who have attempted suicide or have suicidal ideation, to access a range of support services.12 Equally, the central government’s commitment to create 1,50,000 Health and Wellness Centers (HWCs) across rural and urban parts of the country is also encouraging.13 The HWC initiative aims to provide comprehensive primary healthcare to individuals in their respective communities, and incorporates a focus on wellness, making these centres the ideal site to introduce innovations in care delivery. Furthermore, in the 2021 Budget, the government has proposed an additional scheme, the Pradhan Mantri Atmanirbhar Swasth Bharat Yojana (PMASBY). This program allocates ₹64,180 crore over six years to the health sector, with a portion of these funds designed to provide additional financial support to the health and wellness centres.14 As such, the favorable policy environment could be leveraged to embed social prescribing into every HWC, transforming the centre into a gateway for a broad range of clinical and non-clinical support services.
Death by suicide is heart wrenching. The statistics suggest that there are many like Dr. Tadvi and Sushant Singh Rajput, aspirational young people whose lives were snuffed out by the system. These people were the future of India, indeed the future of our world.
For all of us, the light of continued hope animates our existence. A society teeters on the cusp of decline when this flame starts to flicker. A commitment to social prescribing can act as a concrete policy intervention that preserves hope, providing supports for young adults to navigate their circumstances at a time when these are most needed.
Rutvij Merchant is a MPH student at the Harvard T.H Chan School of Public Health. His work seeks to address the global treatment gap for mental disorders. He is also interested in health systems reform, with a focus on primary care.