PLOS Mental Health ‘Community Case Studies’: When the System Fails – Student Suicides, State Violence, and the Public Health Costs of Democratic Erosion in India

The latest blog in PLOS Mental Health‘s ‘Community Case Studies’ series has been guest written by Dr Abishek Bala – a Child & Adolescent Psychiatrist and Assistant Professor of Psychiatry. Dr Bala shares with us his reflection of the recent student protests in India and the broader trends in youth mental health.

***Content Warning: The below contains some topics of conversation such as suicide and violence that some may find uncomfortable. Please engage at your own discretion. The views expressed in the below article reflect those of the guest author alone and do not necessarily represent the views of PLOS, PLOS Mental Health, or any of its affiliated editors.***

Navigate this article:

1. System Failure: Youth Suicide, Academic Pressure, and the NEET Crisis
2. Protest as a Healthy Democratic Response
3. When the State Responds with Violence: Health Sequelae of the Jantar Mantar Crackdown
4. Suppression of Dissent: Eroding Trust and Help-Seeking
5. The Worsening Cycle: Democratic Erosion as a Public Health Emergency
6. A Global Pattern: Health Professions Trainees and Protest

1. System Failure: Youth Suicide, Academic Pressure, and the NEET Crisis

India reports the highest absolute number of suicide deaths in the world, with an estimated 230,314 suicide deaths in 2016 alone.[1] Suicide is the leading cause of death among Indians aged 15–39 years, with 71% of female and 58% of male suicide deaths occurring in this age group.[1][2] India’s contribution to global suicide deaths has been rising: from 25% in 1990 to 37% among women and from 19% to 24% among men by 2016.[1] The suicide rate among Indian women remains twice the global average.[2]

It is against this backdrop that the NEET-UG 2026 paper leak scandal unfolded. The National Eligibility Entrance Test (NEET), India’s centralised medical school entrance examination, was designed to replace multiple state-level exams and curb payment-driven entry into medical education.[5] For millions of aspirants, particularly those from economically disadvantaged and rural backgrounds, NEET represents the singular pathway to social mobility through a medical career. A cancelled exam or a lost year is a manageable setback for aspirants with financial reserves, private tutoring, or the option of studying abroad; for aspirants without those resources, it can foreclose the only route they had. When the National Testing Agency failed to safeguard examination integrity, the consequences were immediate and lethal: in the 46 days between the cancellation of NEET-UG 2026 and the scheduled re-test, at least 11 NEET aspirants died by suicide.

This cluster of deaths is the predictable consequence of concentrating life-determining stakes into a single high-stakes examination within a population already experiencing epidemic levels of academic stress and suicidal ideation, then allowing institutional corruption to shatter the system’s legitimacy. The Lancet Commission on a Citizen-Centred Health System for India has itself called for NEET to reform its selection criteria to be more equitable for students from disadvantaged backgrounds, and for the National Testing Agency to develop inbuilt systems of transparency and accountability.[5]

2. Protest as a Healthy Democratic Response

When institutions fail, civic engagement, including protest, is a healthy and necessary corrective. Civic engagement is positively associated with important health and developmental benefits for participating adolescents and young adults.[6] The American Academy of Pediatrics recognises that youth civic engagement is often inspired by problems salient to a young person’s lived experiences, and that providers should empower youth and encourage civic participation.[6]

The Second Lancet Commission on Adolescent Health and Wellbeing (2025) frames this developmental capacity explicitly: during adolescence, people become increasingly able to perceive unfairness, inequity, and the uses and abuses of power. Adolescence is also when optimism about the future is at its highest. For the past two decades, adolescent political activism has focused on ecology, war and conflicts, social justice, gender equality, and economic inequality, with digital technologies enabling unprecedented engagement.[7] This engagement stands in contrast with formal political power. Currently, only 2.9% of members of parliament globally are younger than 30 years.[7]

Protest, in this framework, functions as a form of public health advocacy. As Lane (2021) argues in the Annals of Global Health, the capacity to translate demonstration into dialogue and coalition should be a core public health competency.[8] The students who gathered at Jantar Mantar on July 20, 2026, demanding accountability and institutional reform, were exercising precisely this competency: translating grief and systemic failure into collective action for structural change. That capacity is not equally available to every young person, though: showing up at Jantar Mantar carries physical, legal, and academic risk, and students without financial or family cushioning have the least room to absorb any of it, which means the same inequities that made NEET’s failure catastrophic for some aspirants also make protesting that failure riskier for them.

3. When the State Responds with Violence: Health Sequelae of the Jantar Mantar Crackdown

On July 20, 2026, over 10,000 protesters gathered at Jantar Mantar. The state’s response was a lathi charge and tear gas deployment. At least 60 protesters were injured, with one hospital alone recording 65 medico-legal cases. Approximately 118 police personnel were also injured and 15–20 government vehicles damaged.

The health consequences of such crowd-control measures are well-documented and severe:

Kinetic impact projectiles (batons, rubber bullets, lathi) cause significant morbidity and mortality. A systematic review of 1,984 people injured by kinetic impact projectiles found that 71% of injuries were severe, 53 people died, and 300 suffered permanent disability. Deaths and permanent disability most often resulted from strikes to the head and neck (49% of deaths, 83% of permanent disabilities).[9] Given the inherent inaccuracy of these weapons and their potential for misuse, the authors concluded that kinetic impact projectiles do not appear to be appropriate weapons for use in crowd-control settings.[9]

Access to care after these injuries is itself unevenly distributed. Protesters with private insurance or family resources can seek treatment outside overburdened public facilities; those without face the same access barriers that made a single, high-stakes examination the only route to a medical career in the first place.

The mental health consequences extend well beyond those physically injured. The landmark Hong Kong prospective cohort study (10 years of longitudinal data) demonstrated that during the 2019–20 social unrest, one in five adults developed probable depression or suspected PTSD. This burden transcended sociodemographics, affecting even those who did not directly participate.[12] Among Yellow Vests protesters in France, 49% displayed severe depression symptoms and 15.5% met criteria for provisional PTSD diagnoses, with prevalence rates comparable to war-refugee populations.[13] These associations were robust to adjustment for physical injuries, demographics, and political extremism, with exposure to police violence independently predicting both depression and PTSD (OR 1.65–3.02).[13]

4. Suppression of Dissent: Eroding Trust and Help-Seeking

The violent suppression of the Jantar Mantar protest does more than produce acute injuries and psychological trauma. It erodes the very institutional trust that is necessary for health-seeking behaviour and democratic accountability.

The Hong Kong cohort study found that fewer than half of affected individuals intended to seek professional care. Those with suspected PTSD, unmarried younger men, and those with low family support were more likely to report privacy concerns that would deter them from seeking professional help.[12] In a context where the state has demonstrated willingness to use force against citizens seeking accountability, the chilling effect on help-seeking is predictable: why would a traumatised student trust a government-run mental health service when the government has just deployed tear gas against their peers?

This dynamic is compounded by the pre-existing mental health infrastructure deficit. India’s National Suicide Prevention Strategy has identified the absence of adequate multisectoral engagement, inappropriate media reporting, and legal conflicts around suicide as major barriers to effective prevention.[2] This deficit falls hardest on students who cannot afford mental health care and depend on the same public system whose credibility the crackdown has just undermined. When the state simultaneously fails to prevent examination corruption, fails to protect students from the mental health consequences of that corruption, and then uses force against those demanding redress, it creates a cascading failure of institutional trust that undermines every level of the public health response.

The suppression of dissent also carries a contagion risk. Media reporting of suicide, particularly when extensive, prominent, and sensational increases the risk of imitative behaviours, a phenomenon known as the Werther effect.[14][15] The NEET aspirant suicides, amplified by media coverage and then compounded by images of state violence against mourning peers, sit inside precisely the conditions suicide prevention guidelines warn against.

The violent suppression of the Jantar Mantar protest does more than produce acute injuries and psychological trauma. It erodes the very institutional trust that is necessary for health-seeking behaviour and democratic accountability.

5. The Worsening Cycle: Democratic Erosion as a Public Health Emergency

Democratic institutions protect population health through a specific mechanism: electoral accountability. Governments that must answer to voters have a standing incentive to invest in health systems, correct policy failures, and respond to public grievances before those failures compound. Autocratic and autocratising governments face weaker versions of that pressure, so a failure like a compromised examination system is more likely to be defended through suppression than corrected through reform. The NEET crisis illustrates this mechanism as a self-reinforcing cycle in which institutional failure, health harm, democratic suppression, and further health harm compound one another:

• Institutional corruption (paper leak) → examination cancellation → academic stress → 11 aspirant suicides

• Democratic failure (lack of accountability) → students protest for redress → state violence → physical injuries, PTSD, depression, further suicidality risk

• Suppression of dissent → erosion of institutional trust → reduced help-seeking → worsening mental health outcomes

• Media amplification of both suicides and violence → contagion risk → further suicides

This cycle maps directly onto the quantitative evidence linking democratic governance to population health. Bollyky et al.’s analysis of 170 countries (1980–2016) demonstrated that democratic experience independently reduces age-standardised mortality, with HIV-free life expectancy at age 15 improving by 3% within 10 years of democratic transition.[16] Democratic experience explained 22% of the variance in cardiovascular disease mortality and more of the variation in mortality than GDP for cardiovascular diseases, transport injuries, cancers, and cirrhosis.[16] The mechanism is accountability: removal of free and fair elections from the democratic experience variable eliminated the association with non-communicable disease mortality entirely.[16]

Conversely, autocratisation produces measurable health harm. A synthetic control study of 17 countries found that in the decade following the onset of autocratisation, life expectancy increased by only 2.2% compared to an estimated 3.5% without autocratisation; universal health coverage improved by only 11.9% versus an estimated 20.2%; and out-of-pocket health spending rose by 10.0% versus an estimated 4.4%.[17] Democracies are also more likely than autocracies to maintain universal health coverage during economic recessions, when access to affordable health services matters most.[18] The theoretical reasoning is straightforward: democracies, when enforced through regular free and fair elections, have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population; they are more open to feedback from a broader range of interest groups, more protective of media freedom, and more willing to use that feedback to improve public health programmes. 

The NEET crisis is a case study in how democratic erosion, meaning institutional corruption, suppression of accountability mechanisms, and state violence against citizens seeking redress, produces cascading, quantifiable public health harm. In the days that followed the crackdown, Prime Minister Modi issued a late-night video message promising fast-track courts and harsher penalties for future paper leaks, and on July 25, Education Minister Dharmendra Pradhan resigned, prompting protest leaders to declare victory and stand down. Whether this response goes far enough is an open question: the concessions address the exam’s institutional failure, but no comparable accountability, an inquiry, an apology, or consequences for the officers involved, has been extended for the force used against protesters, a gap opposition leaders were quick to note. Jantar Mantar has since emptied, but the injuries, the psychological trauma, and the erosion of institutional trust documented above do not resolve on the same timeline as a resignation. The dead aspirants, the injured protesters, the uncounted thousands experiencing depression, PTSD, and eroded trust in institutions are the health costs of democratic failure, and they are not distributed evenly. Aspirants from wealthier families had more room to absorb NEET’s collapse; protesters with financial and family cushioning had more capacity to demand accountability safely; and the rise in out-of-pocket health spending that accompanies autocratisation falls hardest on families already stretched thin by coaching costs and a lost year of income.[17] Equity is the axis along which every harm in this cycle compounds.

The NEET crisis is a case study in how democratic erosion: institutional corruption, suppression of accountability mechanisms, state violence against citizens seeking redress produces cascading, quantifiable public health harm.

6. A Global Pattern: Health Professions Trainees and Protest

India’s NEET protesters are not alone.

A recent global landscape analysis of protests by health professions trainees, drawing on Armed Conflict Location and Event Data from January 2021 to April 2024, identified protest actions across multiple countries driven by structural challenges in education, compensation, working and living conditions, violence, harassment, and poor governance particularly in Global South contexts.[19] Their protest demands span a spectrum from professional self-interest to the public good, and their discontent reveals major gaps in the prioritisation and resourcing of health professions education globally.[19]

Medical educators are increasingly recognising that the capacity to challenge situations, structures, and acts that are oppressive, harmful, or unjust should be a core aspect of professional practice, not an aberration to be suppressed.[20] The students at Jantar Mantar, demanding accountability for a corrupted examination system that has cost their peers’ lives, embody this principle. Their protest advances public health by demanding accountability; its violent suppression is what undermines it.

PLOS Mental Health would like to thank Dr Bala for sharing this timely and important reflection. Our Community Case Studies series was developed for pieces such as this – to bring community-specific issues into a global space in which all can learn from them and steer progress accordingly. We all have a role to play. As Dr Bala points out, the NEET protestors are not alone.

References

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2. Vijayakumar, L., Chandra, P. S., Kumar, M. S., Pathare, S., Banerjee, D., Goswami, T., & Dandona, R. (2022). The national suicide prevention strategy in India: Context and considerations for urgent action. The Lancet Psychiatry, 9(2), 160–168. https://doi.org/10.1016/S2215-0366(21)00152-8
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