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The Hidden 40 Million

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THE DISABLING WORLD [image, unknown]

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The hidden 40 million
Although it is well-known that a quarter of all illness in the industrialised world can be classified as psychiatric disorder, the problem of mental illness in the developing world is almost a taboo subject. In recent weeks, former New Internationalist staff writer Sue Tuckwell has been talking to doctors, psychiatrists and social workers in Bangladesh and in Africa and finds that they have a different story to tell. Her report:-

Among the many myths which shroud the subject of world poverty is the idea that the poor somehow do not suffer as the rich do. And the commonly-held belief that mental illness is rare in the developing world - that life is simple but sane, lacking the mental and emotional stresses of complex modern societies - is an extreme example of that myth.

For myth it is. There is no fundamental difference between rich and poor countries in either the kind, severity or incidence of mental illness. According to the World Health Organization, for example, there are an estimated 40 million men, women and children suffering from severe and untreated mental illness in the developing world today.

In Bangladesh alone, at any one time, there are almost one million people who are mentally ill. A study in a Dacca hospital has shown that 21 per cent of medical outpatients have solely mental illnesses and that a further seven per cent have a combin-ation of emotional and physical disorders. A local G.P. gave me a similar estimate - 25 per cent of his patients came with mental disorders.

Nor is Bangladesh exceptional. A Nigerian doctor also told me that, in the last three months, he has had as many new cases of mental illness as of malaria. And in Addis Ababa's general hospital, twice as many visitors to the out-patients ward came with mental illness as with infectious disease.

Overall; mental patients make up between one-quarter and one-third of the people who use medical services -roughly the same as in the industrialised nations.

Mental pain
Yet not one-quarter, not even one-hundredth of medical facilities in the developing world - of beds, buildings, equipment, personnel, training, research - are devoted to the prevention and cure of mental illness.

Bangladesh, for example, has nine psychiatrists - all men - for a population of 85 million. As one of the nine told me ruefully - `though things are changing, psychiatry is still a disreputable specialisation,'

Amid all the other pressing problems, the needs of the mentally ill lie buried. Says A. K. M. Nazimuddowlay Chowdhury, Professor of Psychiatry in Dacca, `when I first came, I was told to go straight to work at the mental hospital because there was no general need for psychiatric services among the people.'

In that one mental hospital, Pabna, there are 400 beds. In all other regional hospitals combined, there are a further 100 beds. That's 0.2 per cent of the country's hospital space. In the nation as a whole, there is one hospital bed for every 3,000 people. But beds allocated to the mentally ill work out at one for every 180,000 people. Neighbouring India fares slightly better - one place in a mental hospital for every 40,000 people.

It is very well known and too well accepted that people in the Third World have to endure pain and suffering which could easily be relieved if they lived in the rich world. Yet much less well known, is the even more acute contrast when it comes to mental pain.

Part of the problem is that mentalillness is more nebulous. Unlike the great plagues of smallpox, cholera, malaria and hunger, mental illness offers no graspable treatment, no identifiable germ, no available vaccine, and people rarely die from it. But as Dr. Abdus Sobha, consultant psychiatrist at Bangladesh's Pabna mental hospital says, `the brain is as important as the stomach and the lungs. We should not segregate this aspect of health from all others.'

The problem is also partly one of fear, misunderstanding and stigma - breeding an attitude of `I don't want to know'. Many studies have been published on the effects of malnutrition on the growth of the body. But near-silence reigns on the effect of malnutrition on the growth of the mind.

Obviously, there is also a perennial economic problem. Most people can simply not afford treatment for mental illness. A study by Professor Chowdhury at the post-graduate hospital in Dacca shows just how elite are the psychiatric out-patients - 93 per cent of the men and 79 per cent of the women could read and write, as opposed to a national norm of 22.2 per cent - most of them male.

The average mental patient is sorted through a series of economic sieves, beginning with the local healers, graduating to local doctors and hospitals, and eventually passing to either the large teaching hospitals or the Pabna mental hospital itself. Many, many drop out along the way - for the family must make realistic decisions about how to spend limited amounts of money. Poverty and stress

Though poverty alone does not cause mental illness, it undoubtedly makes it worse. Stress is known to precipitate emotional illness, and the rural masses in the Third World, subject to frequent bereavement, floods, fires, famines, wars, enforced migration, and rising expectations unmatched by rising incomes, would seem to be under great emotional pressure. Yet little is known about their feelings and reactions.

Particularly vulnerable are the women. A pioneering study of a Bangladeshi village has put facts round that conclusion. Sixty-nine out of every 1,000 people were found to have significant psychiatric illness - but women outnumbered men two to one. Most of them were suffering from anxiety neurosis and depressive illness.

According to Professor Chowdhury, `the main cause is family stress. Purdah is an important cause of neuroticism in women; it also tends to lead to tension or even breakdown because of a lack of alternative, of choice. Problems for women arise through living physically together and through economic helplessness. Among village women, there is an extreme fear of divorce or second marriage and that is the chief cause of anxiety. And it is a fear often reinforced by the mother-in-law.' Dacca family planning workers unanimously agree. Most families they visited, they said, were unhappy, and the brunt of the burden fell on the women because of their total economic dependence on men, especially in the time of economic crisis. A recent incident illustrates how real those fears are. A newspaper reporting a recent food shortage, described how women were being divorced by theirfarmer husbands because there was not enough food for the whole family. This, said the leader writer, was very sad for the men.

Overall, it emerges clearly that more women than men are sufferers, but that far more men are getting treatment.

The family
In addition to the self-selection of mental patients, the problem finds another root in the selection of the doctors themselves. Too many doctors cannot cope with or understand the problems of the poor, or of women, because they are almost inevitably from rich backgrounds and almost invariably male.

Shahabuddin Ahmad, a Bangladeshi social worker, recounts a conversation between a local doctor and a poor farmer, the father of an 11 year old boy: `The doctor told him the boy was dying, but if the family put him into hospital he might live. The father refused and the doctor became furious. "You people. Life means nothing to you. You're inhuman!" But the father replied, "I have four other children. For one to go to hospital, they must all go without food. Perhaps we still could not pay, and probably the boy will still die." What could he do? Yet the doctor did not understand the poverty of the family.'

In most Third World countries, the main source of care and health for the millions who are mentally disabled is - and will continue to be - the family and the community. Fortunately, most rural societies are much more tolerant than industrialised communities, of odd or eccentric behaviour, especially among the very young or the very old. And they will normally try to care for the sufferer in the family as long as is possible. And the true measure of the success of mental health programmes is how effectively they supplement the family's care - by identification of disability, by drugs, by counselling, and by the teaching of simple, low-cost treatment. Another yardstick is the degree to which they reach women, children and disadvantaged groups. And a third essential criterion is cost - how cheaply can it be done, how can the maximum number of people take advantage of any service which can be provided.

Unlike smallpox, mental illness can never be eradicated. But recognition of the incidence and severity of the problem - and its effects on the quality of human life and on every other aspect of the development effort - is long overdue.

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