Jumla is a district in Karnali Zone of Mid-Western Nepal. Jumla bazaar is the zonal headquarters. Karnali zone has lowest educational, health, and gender equity indicators in Nepal. Jumla district has a population of 109,000. Due poverty, poor health, domestic violence, and a recent decade-long civil war, the prevalence of common mental disorders (depression and anxiety) is 38%. The prevalence of attempted suicide is 8% among the adult population. Mental health problems affect at least 20% of children and adolescents, and 20% of first suicide attempts in Jumla occur before 25 years of age. Between 2015-2020, HeartMind International will initiate mental health and psychosocial services for children and other populations in need. Through the provision of care to this population, we will establish culturally-appropriate evidence-based practices for Jumla and we will provide cost-effectiveness data on provision of care. We are building capacity of local partners including government health posts, subhealth posts, and schools so that they can deliver care sustainably in the region.
When it comes to ageing and mental health in Jumla, we do not look for research, but research finds us. It found us the moment we landed in Jumla. At the airport, a frail grandmother-porter carried a 20kg suitcase behind a young Jumli émigré with dyed blonde hair totting around in her shiny strappy 6-inch heels, most likely returning from her job in India. The old trailed behind the young, carrying the load of the young, trying to keep pace. Metaphorically, I saw a portrayal of the old and the new, the traditional and the modern, the local and the outside, that was to unravel in the days to come.
Whenever the two of us walked into villages, people would inevitably ask us what we were up to. Upon telling them that we were studying older people’s psychosocial health, many an informal focus group would begin. “You should talk to this woman. She lives alone; her sons are working in Nepalgunj and do not look after her”, cases are volunteered to us. The problem is real.
Indeed, what first led to our current research project was an association between the prevalence of depression with ageing found in a longitudinal epidemiological study between 2000 and 2007/8 in Jumla. This trend has not been commonly observed in developed countries. Although physical illnesses and loss of loved ones increase in old age, for reasons such as psychological mastery and socioeconomic stability, the rates of depression have not found to increase in the elderly until they reach their 80s. This led us to investigate the reasons behind the increased prevalence of depression with age in Jumla.
Upon talking to people, a clear theme that has emerged is the inability to do work in old age because of poor physical health. The ability to do work is significant for psychosocial wellbeing for two reasons peculiar to Jumla. Firstly, in a traditional agrarian economy, one’s productivity is intricately linked to physical abilities to work. Secondly, one cannot reap the benefit of the recent wave of development in Jumla without doing work, without carrying heavy loads for various construction sites. “Bikas (development) makes no difference for those who cannot do work’, they told me.
Outside of families, support from the community has also diminished. The elderlies are troubled by a decreased sense of community cohesion. “Now each earns for themselves. No one will help each other to build houses like we did in the old days.” Being able to work is important because one has to do one’s own work. Previously, revered and feared, older people are now dismissed as illiterate and backward. They have internalised much of society’s view into a sense of inferiority and self-loathe, accepting everything outside, young, and new to be superior.
Society’s attitude to the elderly is much akin to the Karnali district’s attitude to itself. The Karnali district, to which Jumla is the headquarter of, is the Karnali that was conquered and politically marginalised, the Karnali with an inferiority complex, and the Karnali that looks down on its own local culture and practices. Arguably, dismissal of local food culture and practices in favour of outside ones has contributed to a chronic food crisis. Continued dependence on government-subsidised rice, some would argue, leads to neglect of local agriculture and further perpetuates the food crisis. Voices of caution warn that Jumla’s economic integration will make the region more dependent on outside food and products, particularly those from India. A Hindu patriarch, pointing to the bazaar of Jumla, rhetorically asked us how food can be produced when the most fertile paddy fields (khet) are turning into shops and hotels instead.
Such is the situation in Jumla. To romanticise either the traditional or the modern is naïve, as power differentials and inequalities exist in any culture. Indeed, the dichotomy between traditional and modern in itself may be simplistic, as the elderlies themselves are adapting and changing through their own agency in creative means. Their situation results from instability and imbalance in the flux of rapid change.
This brings me to the point of why we should care. Ageing and mental health, world apart from popular topics such as infectious disease and child health, has to be one of the least sexy topics in global health. I am not quite sure if my younger self a few yaers ago, with all my modernity, education, and youth, the antithesis of Jumla’s elderly, would have cared. Indeed, why should we care?
But now I do care, because it is a real problem of epidemic proportion. I care, because I can see the value in the traditional as well as the modern. Whenever an older person tells me that they hope I can teach them something, I want to tell them how much I want to learn from them – how much I want to learn about the different food from the forest, about how to make fariya (saree) from scratch, about irrigation channels, and about all the different kinds of local grains. And I care because despite their frustration that they cannot work as well as they used to, they are still working. They are farming, grazing livestock, and looking after grandchildren. They are pulling far beyond their weight in Jumla’s subsistence agriculture that the young has left off, with which much of Jumla’s hopes of food sufficiency and self-sufficiency still rely on.
We should care because we can make a difference. The changes in Jumla are happening because of powerful external forces that can feel outside of the realms of individual control. At this preliminary stage, no clear solutions arise. However, open conversations with stakeholders are needed to bring the problems to the fore and to brainstorm solutions. Moreover, at individual levels, we can make a difference now. At the end of the interview, when the recorder is turned off, the small talks linger; their peaches and apples are exchanged with our biscuits; they tell me that I remind them of their grand-daughters and I am thinking of how I should call my grandmother; silent side glances bespeak of our mutual reluctance to part. I know that connections have been made through the very act of research in itself. From connections come healing.
We should care because we have long-standing connections with the community in Jumla, because we have a long-term, sustained psychosocial counseling program in Jumla. From conversations and counseling, come compassion and the formulations of coping strategies that will give one something extra to carry on to tomorrow. We should care because we have much to offer to the elderly depressed pillars of Jumla’s agrarian economy.Article and photos courtesy of Rennie Qin