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Psychiatric problems in emerging countries—India
Psychiatric P r o b l e m s in E m e r g i n g Countries--lndJa ByM.
R. GAITONDE
I " N D I A is both a new and: a n o l d country, and therefore, i n o r d e r tO better
l : u n d e r s t a n d the psychiatric problems in emerging
India;"one-would~.have
to consider history, tradition, a n d t h e continuous e v o l v i n g present i n m o d e r n India. r~¥ith this context i n mind: I:will briefly a d d r e s s .mysel f tot_he following areas: ( a ) :SoeioeulturaI Aspects,- (b ) Clinical Syndromes, ( c ) Psychiatric Facilities, ( d ) Education, ( e ) Research. A . . T h e s o c i a l c u l t u r a l -matrix- in. -India still, has t h e persuasion -of- orthodox joint f a m i l y s y s t e m ; though superficially,: t h e t r a n s f o r m a t i o n i s enormous; almost, b e y o n d recognition to- a c a s u a l observer. ~Child r e a r i n g .is :gok;erned b y social sanctions emphasizing t h e u n i t y Of- the child with his parents, ' and therefore, breast, f e e d i n ,g weanin, g a. n d. .t o i. l e.t training p r .o b. l e. m. s . a.r e. i n a n a g e d without compulsive adherence to c u t o f f t)°ints .as. . . . .d. .e.t.e r m i n e d by: t h e a g e -of the.child. T h e early developmental influences ' t o :which "an Indian. child is. exposed emphasize a s e n s e o f belongingness t o the it:amily a n d a iSense o f responsibility toward the family, members; leading, i n turn, tO t h e formation.. of a superego which has m o r e a social than p e r s o n a l c h a r a c t e r ~. Tlae religious outlook which emphasizes that a p e r s o n ' s e x i s t e n c e is o n l y a m o m e n t o n the infinite scale of life's cycle enables him t o tolerate.frustration with tranquility and minimizes the urgency of personal initiative to change ' things. ~and m a k e life more bearable. Respect for the elderly: makes it possible to grow o l d in Indian society with grace and equanimity.. T h e social, religious,--and family organization promotes the development of a basic p e r s o n a l i t y p a t t e r n in which personal initiative is replaced by a sense 10f conformity, i n w h i d a :responsibility is exercised w i t h o u t personal a u t h o r i t y ; i n wlaich- security: is associated w i t h a sense o f d e p e n d e n c e ~a n d self-respect ' with a . s e n s e o f helplessness, b u t in w h i c h opportunities for. isolation ' and a c u t e anxiety are minimized. B. C l i n i c a l S y n d r o m e s : W i t h . t h i s b a c k g r 0 u n d , l e t us proceed to e x a m i n e llow the sociocultural factors are; reflected:in thepsyeliiatric, syndromes t h a t one encounters in India. In t h e first p l a c e , b e c a u s e o f , economic deprivation, the problems of reality assume great Significance, and ,,the energiesof the Indian are invested in h o w to Satisfy his need for. food, clothing, and shelter. The definable code o f c o n d u c t enables, h i m to.solve the problems o f social identity with considerable ease since his modes of social interaction are clearly prescribed. It is, therefore, n o t u n c o m m o n to see the presence o f actual neurosis in India, as described b y Freud, rather t h a n psychoneurosis. I do not mean to i m p l y that there is no psychoneurosis; however, the k i n d of psychoneurosis that you see in I n d i a i s of a different character and seems to Paper delivered at the one=hundred-and-nineteenth annual ineetlng o f The American Psychiatric A.vsoctatttm in St. Lout.% Mall, 1963.
75 CO~iPliEIII'iN$IVE PSYf,'H|ATIIY, VOL. 5 , Nn. 2 (AI'RIL), 1964
76
M, Xa. GAITONDE
arise etiologically: from the demands of external r e a l i t y rather than from t h e manag~ernent Of instinctual drives. A s mentioned earlier, t h e structure and f u n c t i o n of the isuperego ~h a s a m o r e social character; therefore: t h e problems o f s e t t i n g the limits, rebellio nl toward authority, are n o t overwhelming. An instance i n point i s the ~satisfactory functioning Of a n open prison System in a small town in sout"nern India. Prisoners who have shown their abLlity to conform t o l t h e social sanctions are transferred f r o m a l o c k e d p r i s o n to a l l open p r i s o n with lno walls, and the: guards ~have n o •weapons w i t h them. The 0nly p e n a l t y f o r a d e l i n q u e n f l a c t i o n is: t h e return Of the prisoner to the closed prison. ~Inlthe o p e n prison, the prisoner is provided an opportunity to d e v e l o p some skills in :farming or i n cottage i n d u s t r y ; and :this program has p r o g r e s s e d so satisfactorily t h a t the local ~state .ministry envisages it's expansion on a larger scale. Coming to the area of psychosis, one s e e s a fair a m o u n t of: o r g a n i c psychotic disorders h a v i n g bacterial; viral or nutritional etiology. ::I n t h e category Of functional psychosis, it m a y b o pointed out that there is an considerable social tolerance with regard to m e n t a l illness, w i t h the result ~that deviation f r o m t h e n o r m a l is not that quickly defined as would be t h e easeTin some other culturesl B e c a u s e : o f the I n d i a n ' s cosmic view of l i f e and suggestible frame of m i n d , the patients are t r e a t e d in t h e family setting, initially b y s o o t h s a y e r s , s a d h u s , and religious men before t h e y are brought t o the office o f t h e psychiatrist. Incidentally, in t h i s r e g a r d , I would like t o mention t h a t l t h e role of :the family:doctor stillpursues a l o n g orthodox lines where h e t r e a t s the patient and the relatives with understanding," reassurance and support, and does not emphasize the investigating procedures, as most of the time: such facilities are n o t available except in largecities. One cannot hel p b u t be impressed: by the personaI :quality of relationship that exists between the patient and the physician~ ~Vhilelwe are o n the subject of clinical syndromes, I would like t o state t h a t t h e current diagnostic c a t e g o r i z a t i o n does not emphasize sufficiently, the socioeultural influences t o w h i c h the p a t i e n t is s u b j e c t , and which materiallyinfluences both the origin and outcome of his illness. In addition; I have frequently s e e n psychiatrists who, having b e e n : t r a i n e d a b r o a d , return to their native l a n d a n d diagnos e a condition •in t h e context of their l e a r n i n g experiences abroad. Consequently,: when a n a t t e m p t i s m a d e t o understand the incidence and c h a r a c t e r of m e n t a l illness in various c u l t u r e s , one get9 a distorted picture. More lemphasis s h o u l d be given to the following thought expressed b y Dr. Galdston: ,'There is an international surgery b u t only a national[ psychiatry, ~.- - ! n psychiatry, [the physician intercedes between, not only m a n and nature, but most often and mainly b e t w e e n man and s o c i e t y ; a n d society, that is, the social organism, its" structures, operations, exactions, etc., quite unlike nature's, is not the same the world over. "1 C. Psychiatric Facilities: T h e major responsibility for the psychiatric facilities is shouldered b y ' t h e state governments; for example, in the State of Bombay, which i s somewhat typical, there are" 35 million people, about 10 per cent of the population of India, and two large mental hospitals located near the principal cities of Bombay and Poona, each housing approximately 1200 to 1500 patients. These hopsitals have about 6 to 8 doctors who belong to the government medical service and are not permitted private practice.
I~SYCHIATI~IC
I°ItOBLE~XIS IN
INDIA
77
A f e w Of t h e m a r e trained p s y c h i a t r i s t s , b u t t h e m a j o r i t y of them a r e p h y s i eiaias. T h e r e IS no p o s i t i o n of clinical director in t h e hospital, For. a: m e d i c a l man, w o r k i n g in a m e n t a l h o s p i t a l d o e s n o t h a v e p r e s t i g e Value unless h e i s s u p e r i n t e n d e n t , a n d t h e salaries of t h e medical p e r s o n n e l are d e t e r m i n e d b y t h e Civil S e r v i c e classification w h i c h is r a t h e r unattractive. Most o f t h e s e laospital s a r e a w a y f r o m t h e c o m m u n i t y , a n d t r a n s p o r t a t i o n to t h e hospital is a problom. T h o u g h t h e p h y s i c a l s e t u p is u n i m p r e s s i v e b y W e s t e r n standards, it c o m p a r e s f a v o r a b l y w i t h t h e local facilities. T r e a t m e n t m e t h o d s used are ataractic drugs, electroconvtilsive a n d insulin t h e r a p y , a n d in some~ places, h y d r o t l l e r a p y . T h e p a r t i c i p a t i o n of the un!versity in t h e s e hospitals is p e r i p h eral w i t h t h e i-esult that the i n t e l l e c t u a l s t i m u l a t i o n is minimal.: In addition to t l~e m e n t a l hospitals, t h e r e are several s o c i a l institutions d e v o t e d to : specific p r o b l e m s i n social p a t h o l o g y ; f o r example, i A n a t h : Balikashram, d e v o t e d t o t]!e p r o b l e m of u n w e d m o t h e r s , facilities for rehabilitation o f the b l i n d , e t c l A l t h o u g h t h e facilities for i n p a t i e n t hospita|iziation of t h e m e n t a l l y ill a r e ina d e q u a t e , it i s m y fexa, e~at h o p e t h a t I n d i a will incoal~orate i n its p l a n n i n g t h e lessons l e a r n e d b y t h e West. S h e Should n o t build m a m m o t l i hospitals, w h i c h c r e a t e a t r e m e n d o u s p r o b l e m ; both in t e r m s o f organization a n d t r e a t , m e n t o f patients: I n addition, i n I n d i a the c u l t u r e differs: c o n s i d e r a b l y f r o m place to p l a c e with p e o p l e s p e a k i n g different:languages, h a v i n g different habits in food, dress, a n d worship, a n d therefore, small!::l~ospitalS staffed with p e r s o n n e l i n t u n e w i t h t h e s u r r o u n d i n g c u l t u r e w o u l d b e t t e r m e e t t h e d e m a n d s of t h e situation. D. Education: T u r n i n g to the area of tradition a n d history in m e d i c a l e d u cation, records i n d i c a t e t h a t a n c i e n t I n d i a h a d ~vo Iarge u n i v e r s i t i e s ; o n e a t Taxila ( w h i d a is n e a r t h e p r e s e n t c i t y o f R a w a l p i n d i ) , a n d anotlaer a t Kasi ( now k n o w n as B a n a r e s ) : Specialization ]~ad o c c u r r e d in India e v e n in i600 to 400 B.C., as i n d i c a t e d b y t h e fact t h a t C h a r a k a , the t e a c h e r a t Taxila U n l versity, m a d e i m p o r t a n t c o n t r i b u t i o n s to: m e d i c i n e , w h e r e a s S u s r u t a , o f t h e U n i v e r s i t y o f Kasi, was a s u r g e o n , h~ledical l i t e r a t u r e i n ! n d i a C o n t a i n e d treatises o n osteology; a n a t o m y , physioloE¢, e m b r y o l o g y , i a n d ~t h e r a p e u t i c s . T h e m e t h o d o f t e a c h i n g m e d i c i n e w a s " ' p u p i l s t t i d y i n g a t th e f e e t o f t h e m a s t e r . " T h e pupils l e f t their h o m e a n d l i v e d w i t h the ~m a s t e r t o : l e a r n i h e principles a n d p r a c t i c e of medicine. An oath similar to:thel Hipp0eratie:i,Oat]i b o u n d tJlo s t u d e n t to high s t a n d a r d s of practice of m e d i c i n e . :Medicine con~ finued to ~Iourish in the e r a of King Ashoka; b u t w i t h t h e d e c l i n e of~:the I n d u s Valley,, ci~dlization, scientific d e v e l o p m e n t o~ m e d i c i n e in ' I n d i a h a d :ia c h e q u e r e d history. T h e system o f m e d i c i n e in I n d i a is: called ~A);urx,eda, with t h e M o h g u l Conquest,~ the U n a n i system of m e d i c i n e w,~--introduced in I n d i a . T w o a n d one-half centuries ago, with t h e a d v e n t o f E a s t I n d i a C o m p a n y , scientific m e d i c i n e w a s b r o u g h t b y the Britis h i n t o India. B e c a u s e their medicir;e a n d m e t h o d s w e r e different, it w a s considered a n entirely different system of medicine. T h u s , Ayxtr~,edie form of i n d i g e n o u s system of medicine, U n a n i s y s t e m of m e d i c i n e a n d m o d e r n scientific m e d i c i n e co-exist i n t h e country at the p r e s e n t time. In the field of the s t u d y of m i n d ' a n c i e n t I n d i a n s h a d p o s t u l a t e d the h u m o r a l constitution of the b o d y , a n d w e r e cognizant of the i m p o r t a n t influence t h a t m i n d exercises over t h e well-being of t h e body, T h e u n d e r s t a n d i n g a n d control of the m i n d , however,, did not c o m e
78
~[. I~. G A I T O N D E
under the d o m a i n o f medicine b u t u n d e r philosophy, and it is:a v e r y enlightening experience to d i s c o v e r on going tlarough t h e ancient I n d i a n books o n philosophylthat a great majority of the:concepts discussed tlaerein have a parallel i n t h e psychoanalytic t h e o r y of t h e huinan mind. I have elaborated at considerable length on tlais para|lelism in a n earlier paper.'-' The first in0dern m e d i c a l School in India iwas started in 1822, and in 1835 m e d i c a l c o l l e g e s w e r e established in the principal cities of Calcutta, Bombay, and M a d r a s . In 1933 the I n d i a n M e d i c a l Council : w a s established. ~Medical education i n : I n d i a / w a s directly under the supervision of the General Medical ~2ouncil o f G r e a t Britain, a n d the university degrees o b t a i n e d i n India c o u l d be registered w i t h t h e G e n e r a l Medical Council. B y : the time India attained its independence i n 1 9 4 7 , t h e r e w e r e a p p r o x i m a t e l y 20 medical colleges. I n ' t h e last fifteen:years, there has been a phenomenal increase in the n u m b e r o f m e d i c a l colleges, w h i c h are now 63, and it is e x p e c t e d that b y t h e e n d of the t h i r d fiveiyear plan,)t]iat is in 1966, t h e r e will be 75 m e d i c a l colleges; T h e N a t i o n a l Government-is t a k i n g financial responsibility in assisti n g State Governments in developing these new medical colleges. Currently, in p s y d a i a t r y , t h e I n d i a n medical student receives didactic l e c t u r e s in p s y c l l o l o g y and: psychiatry.: He h a s opportunities to become fa' miliar with the psyclaiatric d e p a r t m e n t o f the universityhospital, and most o f the university hospitals now have a p s y c h i a t r i c outpatient clinic and a f e w inpatient)beds/ Since psychiatry is considered a s a clinical specialty, :a s in most other clinical Specialties, the staff is not on a f u l l time basis, and g'ives h o n o r a r y service t o the medical college both in t e r m s of t e a c h i n g and f_reatmerit o f p a t i e n t s t h a t c o m e t o the university hospital s. Obviously, this leaves a 10t t o be: desired: A l t h o u g h there is a g r o w i n g recognition about, the ineed and usefulnessl o f the~ discipline 0f psychiatry, still its acceptance on t h e part of other . . .clinical . . . d.e p.a r.t m.e n t s leaves scope for iinir o v e m e n t p . Post.graduate courses:inll psyehiatryi:have been i n t r o d u c e d i n the past t e n years, and the degree o f D . , P . M. :is a w a r d e d to the:candidates w h o successfully p a s s - P a r t I e x a m i n a t i 0 n , : : ( i n c l u d i n g neuroanatomy , neurophysiology; : neuropathology, anc! psychology); and Part I i examination, ( d e a l i n g with clinical psychiatry, var ious: schools o f psychotherapy,: e t c : ) , AlthOugh the: : d i d a c t i c informa~-i0n is Of good quality, individual supern,ision by t r a i n e d psychiatrists is lacking beCause of non-availability of p r o p e r l y t r a i n e d personnel. E . : Research- I n 1 9 1 1 , the government o f India f o u n d e d the I n d i a n Res e a r c h F u n d Association. The n e x t important s t e p was taken in 1949 with t h e formation •of: the I n d i a n : C o u n c i l of Medical: Research t o r e p l a c e the functions of t h e Indian R e s e a r c h F u n d Association. T h i s body in recent years has been able t o g e t l a u d a b l e collaboration with international organizations like the R0ekefeller Foundation, qTae World H e a l t h Organization, The Technical Cooperation Mission of the United States, and The U N I C E F . To mention a f e w e r ° tjae research units established in recent years: The Neuropathological Unit at B o m b a y , The Neurophysiologie Unit in Delhi, T h e Industrial Health Research Unit and The All I n d i a Institute of Hygiene and Public Health in Calcutta, and The Mental H e a l t h Institute at Bangalore. The Goven~ment of I n d i a , in 1952, started the community development project
PSYCIIDk'I'RIC
PROBLE~[S
IN
79
INDIA
ill order to improve t i l e general lmalth o f its citizens. I t is mainly a n attempt to improve the livin standards on all fronts All tlie nation buildin de)artments of the.. governnlent .. sucll. as. education, . . . . health, coo..I~eration;:,..garieulture. a n d roodproduction, ~mimal husbandry,: communication a n d Iindustries :-are involved in this: project a n d are: workmg uncter the..comnaon-administrator, file~block develo ment officer T h i s endeavor: is a inammoth experiment: in social aglvancement along democratic lilies. Tliere is a:great potential :in-the country for the r e s e a r c h a n d understanding[of a large n u m b e r o f d r u g s which h a v e b e e n u s e d empirically f o r centuries b y Indian physicians; for: example, Rauwolfia could well be the forerunner Of a host of indigenous d r u g s which could profitably b e investigated under m o d e r n scientific, techniqueS. : In l i k e m a n n e r , available: teclini(.lues, in neurol3liysiology, i eleetroenoeplaalography, e t cetera, could be h a n m s s e d t o investigate t h e ancienl} Science o f Yoga-which: postulates t h a t ; th!-oug!a systematized series: o f exercises 0f postures (asana)i breathing (pranayam), and lax,ages, one can control the :autonomic:functions of the b o d y voluntarily. T h e Kayvalyadlaama H e a l t h Center near Boiribay has been e n g a g e d in this very. worthwhile endeavor: over a p e r i 6 d o f years under quite difficult financialsituati0ns: Another Pr o b l e m which, t h o ug h. political . . . . in nature, m i g h t . .have . . . . . . . important ..... re3ercussions on the growth a n d develo 9ment o f psychiatry in India, is the resolution of t h e issue of n a t i o n a l language. Bigoted : interests :are: urging for t h e displacement of: the ;medium of E n g l i s h from thel l~resent:-position it enjoys which inevitably would decelerate t h e e x c h a n g e 0 f ideas:and isicentifiCi-nforrnation between Indian workers iand their"eOlleagueS;"in:(otlaer: iandsi T o conclude this discuSsion; it may be Stated lthat t h e psychiatric. )roblemS of emerging India. a r e closely-linked, t o the. Social,:;political,." economic,:.;, and llealth issues l a t i n i theieountry~ and t h e picture.~:iS :by i ~ o imeans i:bleak :0r clisa ointin . O n the contrar., y, in :India, in t h e past -ten or :fifteen yem-s; great ~ advances have 7been. m a d e . l i n the. development ..of-. t h e nation;: and..:.:there.:-is Cause ~or restrained optimism~ f o i : I:feel tha{:tlie :situati6nii!:iS:::.:botia':::ofi6::!~of cllallenge and promise.. Emerging; India ]aas-itheproblem: of lmaldng::-a(;aiiable to. its: people the blessings: of.m0aern science,! Wfiiel~ h a s ilso'iabl~':made".i~'~ai;~a stride, in disclosing: t l i e nature 7of. t i e universe" and:i~Sliarin£, it: exchafigg::iWitli: t h e afftuent societies,.: tlie Storehouse tradition about:.the nature of: man: .Ill seems: to"mb :that :the:~rob]em.:of i:emerg~ i n India a n d t h e e m e r - n -man :of: the. 20th denM6/:;:~e ;:corn :l{m~ntaa-~'~. inasmuch as science brings k'nowledge_and.phflosophy brings wisd6m. •
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REFERENCES
1. Galdston, I.: International psychiatry: Am. J. Psychiat. 114:103-108, Aug. 1957.
2. C.aitonde, .M.R.:. Hindu philosophy•and psycliotherapy.: Comprehensive "-Psychiat.:-2:5:299-'303, Oct, 1961.
~!. R. Gaitonde, I~I.D., D.P.M.,:Assi~ant Professor o[ Psychiatry. Department o f Psychiatry, Kansas U n i v e r s i t y Madical Center, Kansas City, Kansa&
R. GAITONDE
I " N D I A is both a new and: a n o l d country, and therefore, i n o r d e r tO better
l : u n d e r s t a n d the psychiatric problems in emerging
India;"one-would~.have
to consider history, tradition, a n d t h e continuous e v o l v i n g present i n m o d e r n India. r~¥ith this context i n mind: I:will briefly a d d r e s s .mysel f tot_he following areas: ( a ) :SoeioeulturaI Aspects,- (b ) Clinical Syndromes, ( c ) Psychiatric Facilities, ( d ) Education, ( e ) Research. A . . T h e s o c i a l c u l t u r a l -matrix- in. -India still, has t h e persuasion -of- orthodox joint f a m i l y s y s t e m ; though superficially,: t h e t r a n s f o r m a t i o n i s enormous; almost, b e y o n d recognition to- a c a s u a l observer. ~Child r e a r i n g .is :gok;erned b y social sanctions emphasizing t h e u n i t y Of- the child with his parents, ' and therefore, breast, f e e d i n ,g weanin, g a. n d. .t o i. l e.t training p r .o b. l e. m. s . a.r e. i n a n a g e d without compulsive adherence to c u t o f f t)°ints .as. . . . .d. .e.t.e r m i n e d by: t h e a g e -of the.child. T h e early developmental influences ' t o :which "an Indian. child is. exposed emphasize a s e n s e o f belongingness t o the it:amily a n d a iSense o f responsibility toward the family, members; leading, i n turn, tO t h e formation.. of a superego which has m o r e a social than p e r s o n a l c h a r a c t e r ~. Tlae religious outlook which emphasizes that a p e r s o n ' s e x i s t e n c e is o n l y a m o m e n t o n the infinite scale of life's cycle enables him t o tolerate.frustration with tranquility and minimizes the urgency of personal initiative to change ' things. ~and m a k e life more bearable. Respect for the elderly: makes it possible to grow o l d in Indian society with grace and equanimity.. T h e social, religious,--and family organization promotes the development of a basic p e r s o n a l i t y p a t t e r n in which personal initiative is replaced by a sense 10f conformity, i n w h i d a :responsibility is exercised w i t h o u t personal a u t h o r i t y ; i n wlaich- security: is associated w i t h a sense o f d e p e n d e n c e ~a n d self-respect ' with a . s e n s e o f helplessness, b u t in w h i c h opportunities for. isolation ' and a c u t e anxiety are minimized. B. C l i n i c a l S y n d r o m e s : W i t h . t h i s b a c k g r 0 u n d , l e t us proceed to e x a m i n e llow the sociocultural factors are; reflected:in thepsyeliiatric, syndromes t h a t one encounters in India. In t h e first p l a c e , b e c a u s e o f , economic deprivation, the problems of reality assume great Significance, and ,,the energiesof the Indian are invested in h o w to Satisfy his need for. food, clothing, and shelter. The definable code o f c o n d u c t enables, h i m to.solve the problems o f social identity with considerable ease since his modes of social interaction are clearly prescribed. It is, therefore, n o t u n c o m m o n to see the presence o f actual neurosis in India, as described b y Freud, rather t h a n psychoneurosis. I do not mean to i m p l y that there is no psychoneurosis; however, the k i n d of psychoneurosis that you see in I n d i a i s of a different character and seems to Paper delivered at the one=hundred-and-nineteenth annual ineetlng o f The American Psychiatric A.vsoctatttm in St. Lout.% Mall, 1963.
75 CO~iPliEIII'iN$IVE PSYf,'H|ATIIY, VOL. 5 , Nn. 2 (AI'RIL), 1964
76
M, Xa. GAITONDE
arise etiologically: from the demands of external r e a l i t y rather than from t h e manag~ernent Of instinctual drives. A s mentioned earlier, t h e structure and f u n c t i o n of the isuperego ~h a s a m o r e social character; therefore: t h e problems o f s e t t i n g the limits, rebellio nl toward authority, are n o t overwhelming. An instance i n point i s the ~satisfactory functioning Of a n open prison System in a small town in sout"nern India. Prisoners who have shown their abLlity to conform t o l t h e social sanctions are transferred f r o m a l o c k e d p r i s o n to a l l open p r i s o n with lno walls, and the: guards ~have n o •weapons w i t h them. The 0nly p e n a l t y f o r a d e l i n q u e n f l a c t i o n is: t h e return Of the prisoner to the closed prison. ~Inlthe o p e n prison, the prisoner is provided an opportunity to d e v e l o p some skills in :farming or i n cottage i n d u s t r y ; and :this program has p r o g r e s s e d so satisfactorily t h a t the local ~state .ministry envisages it's expansion on a larger scale. Coming to the area of psychosis, one s e e s a fair a m o u n t of: o r g a n i c psychotic disorders h a v i n g bacterial; viral or nutritional etiology. ::I n t h e category Of functional psychosis, it m a y b o pointed out that there is an considerable social tolerance with regard to m e n t a l illness, w i t h the result ~that deviation f r o m t h e n o r m a l is not that quickly defined as would be t h e easeTin some other culturesl B e c a u s e : o f the I n d i a n ' s cosmic view of l i f e and suggestible frame of m i n d , the patients are t r e a t e d in t h e family setting, initially b y s o o t h s a y e r s , s a d h u s , and religious men before t h e y are brought t o the office o f t h e psychiatrist. Incidentally, in t h i s r e g a r d , I would like t o mention t h a t l t h e role of :the family:doctor stillpursues a l o n g orthodox lines where h e t r e a t s the patient and the relatives with understanding," reassurance and support, and does not emphasize the investigating procedures, as most of the time: such facilities are n o t available except in largecities. One cannot hel p b u t be impressed: by the personaI :quality of relationship that exists between the patient and the physician~ ~Vhilelwe are o n the subject of clinical syndromes, I would like t o state t h a t t h e current diagnostic c a t e g o r i z a t i o n does not emphasize sufficiently, the socioeultural influences t o w h i c h the p a t i e n t is s u b j e c t , and which materiallyinfluences both the origin and outcome of his illness. In addition; I have frequently s e e n psychiatrists who, having b e e n : t r a i n e d a b r o a d , return to their native l a n d a n d diagnos e a condition •in t h e context of their l e a r n i n g experiences abroad. Consequently,: when a n a t t e m p t i s m a d e t o understand the incidence and c h a r a c t e r of m e n t a l illness in various c u l t u r e s , one get9 a distorted picture. More lemphasis s h o u l d be given to the following thought expressed b y Dr. Galdston: ,'There is an international surgery b u t only a national[ psychiatry, ~.- - ! n psychiatry, [the physician intercedes between, not only m a n and nature, but most often and mainly b e t w e e n man and s o c i e t y ; a n d society, that is, the social organism, its" structures, operations, exactions, etc., quite unlike nature's, is not the same the world over. "1 C. Psychiatric Facilities: T h e major responsibility for the psychiatric facilities is shouldered b y ' t h e state governments; for example, in the State of Bombay, which i s somewhat typical, there are" 35 million people, about 10 per cent of the population of India, and two large mental hospitals located near the principal cities of Bombay and Poona, each housing approximately 1200 to 1500 patients. These hopsitals have about 6 to 8 doctors who belong to the government medical service and are not permitted private practice.
I~SYCHIATI~IC
I°ItOBLE~XIS IN
INDIA
77
A f e w Of t h e m a r e trained p s y c h i a t r i s t s , b u t t h e m a j o r i t y of them a r e p h y s i eiaias. T h e r e IS no p o s i t i o n of clinical director in t h e hospital, For. a: m e d i c a l man, w o r k i n g in a m e n t a l h o s p i t a l d o e s n o t h a v e p r e s t i g e Value unless h e i s s u p e r i n t e n d e n t , a n d t h e salaries of t h e medical p e r s o n n e l are d e t e r m i n e d b y t h e Civil S e r v i c e classification w h i c h is r a t h e r unattractive. Most o f t h e s e laospital s a r e a w a y f r o m t h e c o m m u n i t y , a n d t r a n s p o r t a t i o n to t h e hospital is a problom. T h o u g h t h e p h y s i c a l s e t u p is u n i m p r e s s i v e b y W e s t e r n standards, it c o m p a r e s f a v o r a b l y w i t h t h e local facilities. T r e a t m e n t m e t h o d s used are ataractic drugs, electroconvtilsive a n d insulin t h e r a p y , a n d in some~ places, h y d r o t l l e r a p y . T h e p a r t i c i p a t i o n of the un!versity in t h e s e hospitals is p e r i p h eral w i t h t h e i-esult that the i n t e l l e c t u a l s t i m u l a t i o n is minimal.: In addition to t l~e m e n t a l hospitals, t h e r e are several s o c i a l institutions d e v o t e d to : specific p r o b l e m s i n social p a t h o l o g y ; f o r example, i A n a t h : Balikashram, d e v o t e d t o t]!e p r o b l e m of u n w e d m o t h e r s , facilities for rehabilitation o f the b l i n d , e t c l A l t h o u g h t h e facilities for i n p a t i e n t hospita|iziation of t h e m e n t a l l y ill a r e ina d e q u a t e , it i s m y fexa, e~at h o p e t h a t I n d i a will incoal~orate i n its p l a n n i n g t h e lessons l e a r n e d b y t h e West. S h e Should n o t build m a m m o t l i hospitals, w h i c h c r e a t e a t r e m e n d o u s p r o b l e m ; both in t e r m s o f organization a n d t r e a t , m e n t o f patients: I n addition, i n I n d i a the c u l t u r e differs: c o n s i d e r a b l y f r o m place to p l a c e with p e o p l e s p e a k i n g different:languages, h a v i n g different habits in food, dress, a n d worship, a n d therefore, small!::l~ospitalS staffed with p e r s o n n e l i n t u n e w i t h t h e s u r r o u n d i n g c u l t u r e w o u l d b e t t e r m e e t t h e d e m a n d s of t h e situation. D. Education: T u r n i n g to the area of tradition a n d history in m e d i c a l e d u cation, records i n d i c a t e t h a t a n c i e n t I n d i a h a d ~vo Iarge u n i v e r s i t i e s ; o n e a t Taxila ( w h i d a is n e a r t h e p r e s e n t c i t y o f R a w a l p i n d i ) , a n d anotlaer a t Kasi ( now k n o w n as B a n a r e s ) : Specialization ]~ad o c c u r r e d in India e v e n in i600 to 400 B.C., as i n d i c a t e d b y t h e fact t h a t C h a r a k a , the t e a c h e r a t Taxila U n l versity, m a d e i m p o r t a n t c o n t r i b u t i o n s to: m e d i c i n e , w h e r e a s S u s r u t a , o f t h e U n i v e r s i t y o f Kasi, was a s u r g e o n , h~ledical l i t e r a t u r e i n ! n d i a C o n t a i n e d treatises o n osteology; a n a t o m y , physioloE¢, e m b r y o l o g y , i a n d ~t h e r a p e u t i c s . T h e m e t h o d o f t e a c h i n g m e d i c i n e w a s " ' p u p i l s t t i d y i n g a t th e f e e t o f t h e m a s t e r . " T h e pupils l e f t their h o m e a n d l i v e d w i t h the ~m a s t e r t o : l e a r n i h e principles a n d p r a c t i c e of medicine. An oath similar to:thel Hipp0eratie:i,Oat]i b o u n d tJlo s t u d e n t to high s t a n d a r d s of practice of m e d i c i n e . :Medicine con~ finued to ~Iourish in the e r a of King Ashoka; b u t w i t h t h e d e c l i n e of~:the I n d u s Valley,, ci~dlization, scientific d e v e l o p m e n t o~ m e d i c i n e in ' I n d i a h a d :ia c h e q u e r e d history. T h e system o f m e d i c i n e in I n d i a is: called ~A);urx,eda, with t h e M o h g u l Conquest,~ the U n a n i system of m e d i c i n e w,~--introduced in I n d i a . T w o a n d one-half centuries ago, with t h e a d v e n t o f E a s t I n d i a C o m p a n y , scientific m e d i c i n e w a s b r o u g h t b y the Britis h i n t o India. B e c a u s e their medicir;e a n d m e t h o d s w e r e different, it w a s considered a n entirely different system of medicine. T h u s , Ayxtr~,edie form of i n d i g e n o u s system of medicine, U n a n i s y s t e m of m e d i c i n e a n d m o d e r n scientific m e d i c i n e co-exist i n t h e country at the p r e s e n t time. In the field of the s t u d y of m i n d ' a n c i e n t I n d i a n s h a d p o s t u l a t e d the h u m o r a l constitution of the b o d y , a n d w e r e cognizant of the i m p o r t a n t influence t h a t m i n d exercises over t h e well-being of t h e body, T h e u n d e r s t a n d i n g a n d control of the m i n d , however,, did not c o m e
78
~[. I~. G A I T O N D E
under the d o m a i n o f medicine b u t u n d e r philosophy, and it is:a v e r y enlightening experience to d i s c o v e r on going tlarough t h e ancient I n d i a n books o n philosophylthat a great majority of the:concepts discussed tlaerein have a parallel i n t h e psychoanalytic t h e o r y of t h e huinan mind. I have elaborated at considerable length on tlais para|lelism in a n earlier paper.'-' The first in0dern m e d i c a l School in India iwas started in 1822, and in 1835 m e d i c a l c o l l e g e s w e r e established in the principal cities of Calcutta, Bombay, and M a d r a s . In 1933 the I n d i a n M e d i c a l Council : w a s established. ~Medical education i n : I n d i a / w a s directly under the supervision of the General Medical ~2ouncil o f G r e a t Britain, a n d the university degrees o b t a i n e d i n India c o u l d be registered w i t h t h e G e n e r a l Medical Council. B y : the time India attained its independence i n 1 9 4 7 , t h e r e w e r e a p p r o x i m a t e l y 20 medical colleges. I n ' t h e last fifteen:years, there has been a phenomenal increase in the n u m b e r o f m e d i c a l colleges, w h i c h are now 63, and it is e x p e c t e d that b y t h e e n d of the t h i r d fiveiyear plan,)t]iat is in 1966, t h e r e will be 75 m e d i c a l colleges; T h e N a t i o n a l Government-is t a k i n g financial responsibility in assisti n g State Governments in developing these new medical colleges. Currently, in p s y d a i a t r y , t h e I n d i a n medical student receives didactic l e c t u r e s in p s y c l l o l o g y and: psychiatry.: He h a s opportunities to become fa' miliar with the psyclaiatric d e p a r t m e n t o f the universityhospital, and most o f the university hospitals now have a p s y c h i a t r i c outpatient clinic and a f e w inpatient)beds/ Since psychiatry is considered a s a clinical specialty, :a s in most other clinical Specialties, the staff is not on a f u l l time basis, and g'ives h o n o r a r y service t o the medical college both in t e r m s of t e a c h i n g and f_reatmerit o f p a t i e n t s t h a t c o m e t o the university hospital s. Obviously, this leaves a 10t t o be: desired: A l t h o u g h there is a g r o w i n g recognition about, the ineed and usefulnessl o f the~ discipline 0f psychiatry, still its acceptance on t h e part of other . . .clinical . . . d.e p.a r.t m.e n t s leaves scope for iinir o v e m e n t p . Post.graduate courses:inll psyehiatryi:have been i n t r o d u c e d i n the past t e n years, and the degree o f D . , P . M. :is a w a r d e d to the:candidates w h o successfully p a s s - P a r t I e x a m i n a t i 0 n , : : ( i n c l u d i n g neuroanatomy , neurophysiology; : neuropathology, anc! psychology); and Part I i examination, ( d e a l i n g with clinical psychiatry, var ious: schools o f psychotherapy,: e t c : ) , AlthOugh the: : d i d a c t i c informa~-i0n is Of good quality, individual supern,ision by t r a i n e d psychiatrists is lacking beCause of non-availability of p r o p e r l y t r a i n e d personnel. E . : Research- I n 1 9 1 1 , the government o f India f o u n d e d the I n d i a n Res e a r c h F u n d Association. The n e x t important s t e p was taken in 1949 with t h e formation •of: the I n d i a n : C o u n c i l of Medical: Research t o r e p l a c e the functions of t h e Indian R e s e a r c h F u n d Association. T h i s body in recent years has been able t o g e t l a u d a b l e collaboration with international organizations like the R0ekefeller Foundation, qTae World H e a l t h Organization, The Technical Cooperation Mission of the United States, and The U N I C E F . To mention a f e w e r ° tjae research units established in recent years: The Neuropathological Unit at B o m b a y , The Neurophysiologie Unit in Delhi, T h e Industrial Health Research Unit and The All I n d i a Institute of Hygiene and Public Health in Calcutta, and The Mental H e a l t h Institute at Bangalore. The Goven~ment of I n d i a , in 1952, started the community development project
PSYCIIDk'I'RIC
PROBLE~[S
IN
79
INDIA
ill order to improve t i l e general lmalth o f its citizens. I t is mainly a n attempt to improve the livin standards on all fronts All tlie nation buildin de)artments of the.. governnlent .. sucll. as. education, . . . . health, coo..I~eration;:,..garieulture. a n d roodproduction, ~mimal husbandry,: communication a n d Iindustries :-are involved in this: project a n d are: workmg uncter the..comnaon-administrator, file~block develo ment officer T h i s endeavor: is a inammoth experiment: in social aglvancement along democratic lilies. Tliere is a:great potential :in-the country for the r e s e a r c h a n d understanding[of a large n u m b e r o f d r u g s which h a v e b e e n u s e d empirically f o r centuries b y Indian physicians; for: example, Rauwolfia could well be the forerunner Of a host of indigenous d r u g s which could profitably b e investigated under m o d e r n scientific, techniqueS. : In l i k e m a n n e r , available: teclini(.lues, in neurol3liysiology, i eleetroenoeplaalography, e t cetera, could be h a n m s s e d t o investigate t h e ancienl} Science o f Yoga-which: postulates t h a t ; th!-oug!a systematized series: o f exercises 0f postures (asana)i breathing (pranayam), and lax,ages, one can control the :autonomic:functions of the b o d y voluntarily. T h e Kayvalyadlaama H e a l t h Center near Boiribay has been e n g a g e d in this very. worthwhile endeavor: over a p e r i 6 d o f years under quite difficult financialsituati0ns: Another Pr o b l e m which, t h o ug h. political . . . . in nature, m i g h t . .have . . . . . . . important ..... re3ercussions on the growth a n d develo 9ment o f psychiatry in India, is the resolution of t h e issue of n a t i o n a l language. Bigoted : interests :are: urging for t h e displacement of: the ;medium of E n g l i s h from thel l~resent:-position it enjoys which inevitably would decelerate t h e e x c h a n g e 0 f ideas:and isicentifiCi-nforrnation between Indian workers iand their"eOlleagueS;"in:(otlaer: iandsi T o conclude this discuSsion; it may be Stated lthat t h e psychiatric. )roblemS of emerging India. a r e closely-linked, t o the. Social,:;political,." economic,:.;, and llealth issues l a t i n i theieountry~ and t h e picture.~:iS :by i ~ o imeans i:bleak :0r clisa ointin . O n the contrar., y, in :India, in t h e past -ten or :fifteen yem-s; great ~ advances have 7been. m a d e . l i n the. development ..of-. t h e nation;: and..:.:there.:-is Cause ~or restrained optimism~ f o i : I:feel tha{:tlie :situati6nii!:iS:::.:botia':::ofi6::!~of cllallenge and promise.. Emerging; India ]aas-itheproblem: of lmaldng::-a(;aiiable to. its: people the blessings: of.m0aern science,! Wfiiel~ h a s ilso'iabl~':made".i~'~ai;~a stride, in disclosing: t l i e nature 7of. t i e universe" and:i~Sliarin£, it: exchafigg::iWitli: t h e afftuent societies,.: tlie Storehouse tradition about:.the nature of: man: .Ill seems: to"mb :that :the:~rob]em.:of i:emerg~ i n India a n d t h e e m e r - n -man :of: the. 20th denM6/:;:~e ;:corn :l{m~ntaa-~'~. inasmuch as science brings k'nowledge_and.phflosophy brings wisd6m. •
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REFERENCES
1. Galdston, I.: International psychiatry: Am. J. Psychiat. 114:103-108, Aug. 1957.
2. C.aitonde, .M.R.:. Hindu philosophy•and psycliotherapy.: Comprehensive "-Psychiat.:-2:5:299-'303, Oct, 1961.
~!. R. Gaitonde, I~I.D., D.P.M.,:Assi~ant Professor o[ Psychiatry. Department o f Psychiatry, Kansas U n i v e r s i t y Madical Center, Kansas City, Kansa&