Bedlam And Beyond
DURING the 1950s I was a resident in psychiatry in India. Under my care was a middle-aged woman who had been in the hospital for God-alone-knew how many years. Sitting alone, facing a dingy corner of the ward, day in and day out, she just muttered to herself. No-one could remember her ever making any conversation with anyone. For years she had only her fantasies and the dreary solitariness of that corner.
After I took over I went to her, patted her shoulder and tried to initiate conversation. But only neglectful silence greeted me. Every morning, as long as I continued to work in that ward, I tried to talk to her. And every day my efforts were coldly thwarted. Then my spell of duty came to an end and I moved to another ward. The next moming, however, not finding me around, this patient left her corner, went to the nurses’ counter and asked in a subdued whisper, ‘Where is that bearded doctor?’
The news was soon all over the hospital. The authorities transferred me back to the ward to see if we could make any further progress with her. And we did. Gradually she inched out of her solitariness, her fantasies receded, her delusions loosened their grip. Finally it was possible to discharge her.
But during the 15 years she had been in hospital both her parents had died. So she had no home to go to. Luckily an aunt still survived in a far off town and was willing to accept her. And there she has lived ever since, caring devotedly for her aunt during a terminal illness, and, since her death, managing the house on her own.
Few cases could have demonstrated better what a large mental hospital could do to some patients. And in this particular case we were lucky. Not many homes were willing to accept psychiatric patients back from hospital. Often their families had closed their ranks and adopted a pattern of living that did not include the patient. And often the patients themselves were reluctant to leave the sheltered environment of the hospital.
The result was that admissions outnumbered discharges and mental hospitals became more and more overcrowded and disabling.
Such, then was the scene over almost the entire developing world 30 years ago. Mental hospitals - the major source of mental health care - were like prisons providing practically no therapeutic help for their inmates.
The next move was to provide psychiatric care at ordinary hospitals. Patients could be saved the stigma of having been in a mental hospital and could be treated nearer their homes. India for example proposed to open psychiatric units in over 400 hospitals. But 15 years later less than a quarter of those units had been started because of a shortage of psychiatrists. In Tanzania, too, the Dares-Salaam psychiatric unit opened in 1956 was without a psychiatrist for nearly ten years. And the story was the same throughout the developing world at that time. Burma, for instance, had 0.3 psychiatrists per million population, Indonesia, 0.9, Malaysia, 1.3 and India, 0.8. Many African countries did not have even one psychiatrist and the situation in Latin America was much the same.
It began to dawn on most developing countries that they would never have sufficient numbers of psychiatrists in the foreseeable future. Psychiatrist-manned psychiatric units as the mainstay of mental health care was therefore a wild dream.
It became clear that provision for mental health care would have to be made at health centre, dispensary or village health post level if one really cared to reach the unreached. And the key figure in such a venture would have to be the primary health worker.
So small-scale community mental health experiments began to sprout all over the developing world: in India, Indonesia, Sudan, Egypt, Zambia, Tanzania, Mexico, Colombia and Brazil.
What was now needed was a country with the faith and political will to try such a scheme out on a broader basis. Tanzania volunteered. Because it already possessed quite a comprehensive health care infrastructure with a coherent referral system - from rural dispensary, to clinic, to health centre, to hospital - it was relatively easy to add the capacity for mental health care. Nurses, nursing assistants and medical assistants were trained to diagnose five serious mental health problems: depression, schizophrenia, epilepsy, alcoholism and subnormality. And even medical assistants, who man the rural dispensaries at village level, were taught to dispense basic drugs - for the first three of these.
Cases too senous or complex for the medical assistants could be referred, ifnecessary, via clinic and regional hospital to the main psychiatric hospital in Dar es Salaam. The scheme appears to be a success. And there are now plans to extend it to the remaining regions in the country and to build a rehabilitation village, 20 kilometers from Dar, for patients discharged from the psychiatric hospital.
What Tanzania’s experience showed was that it is unwise to institute a community mental health care’ programme without taking account of the traditional healer. Other countries have leamed the same lesson. Indonesia, for example, is ahead of many other developing countries in enlisting the cooperation of traditional healers for their mental health care programmes. And a couple of years ago I had the opportunity of visiting a number of traditional healers and watching them at work.
I was most impressed with the therapeutic skill of a middle-aged lady healer in Surabaya. She always had the right penetrating question ready. One woman complained she suffered from headaches and the healer asked her ‘Who gives you this headache?’ Another woman with backache was asked ‘What is your burden?’ She seemed to be able to go straight to the core of the problem, as if instinctively, and then proceed deftly toward the solution or resolution of conflict. Nowhere else have I seen briefer and more effective psychotherapy than I witnessed being done by this lay therapist.
Yet there are healers and healers. Some are effective, ethical and wise. Others are otherwise. I volunteered myself as a patient to see for myself the clinical procedures of a healer who diagnosed by applying pressure over certain body areas. Because I did not wince when he applied pressure over my socalled ‘tender spots’, he squeezed my tendoachelles so hard that it continued to hurt for weeks after that. And then made a diagnoses of ‘high blood pressure’ which I have never had.
The most suitable patterns of collaboration between health workers and traditional healers have yet to be evolved. Bilateral prejudices, guilt attitudes and mutual distrust are major obstacles. But evidence from Indonia and Tanzania suggests that even these are not insurmountable.
Professor J. S. Neki, formerly Director of the Postgraduate Institute
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