The New York Review Abroad (19 page)

To the Psychiatry Department’s Mental Health Centre it is a three-mile drive into the dry countryside. The Centre is a collection of low buildings spread out around a compound. (Even the “snakepit” mental hospitals of India’s big cities tend to be less oppressive than their Western counterparts because they are built outward rather than up: space is something India is not short of.) Inside, doctors’ offices open off shady corridors; half-doors allow what air there is to circulate.

Dr. Abraham Verghese—his name shows him to be a Christian and probably from Portuguese Goa—is holding a teaching session for his juniors with the day’s new patients. Mr. Krishnan Reddy is called first: quiet and docile, fifty years old and head of a joint family that includes four married sons and their wives. He has been lucky, until recently, in having a secure job: he is a government forester earning Rs. 300 a month (in 1978, about $38). Reddy is an alcoholic. He gazes with submissive intensity at Dr. Verghese and ignores the circle of other people in the room; he needs no interpreter because he speaks English (of a sort), the
lingua franca
of southern India.

He has been drinking arak heavily for the past ten years, he says. In the past two years his drinking has got worse, and for six months now he hasn’t worked. This morning he had a fight with his wife and
she brought him to the main hospital, which referred him to the Centre. His father was an alcoholic. He can’t work or concentrate; when he is drunk he cries. He drinks to forget financial and family worries, he says. He has no sexual intercourse now; he is “too weak.” He has tried a cure for his drinking before, was given medicines but didn’t take them; but “from today I won’t drink.” He leaves as gently as he arrived, and it is decided he will be admitted to the Centre, if he really wants to be cured.

Govind Ramathayan, twenty-two years old, a teacher, is equally self-effacing in manner. Since he speaks neither Tamil nor English, one of the junior doctors interprets to the group. He has come alone to the Centre (which is unusual), sent by his doctor. He can’t sleep or eat properly; he has fits of dizziness and he aches all over; he too suffers from “weakness.” Before his marriage he was chaste; his illness began soon after his marriage, and is getting worse. The interpreter conveys the message that he must come back with his wife before any therapy can be started. After he has gone one of the junior doctors reads his notes on a similar case: a twenty-year-old man, married six months ago, suffering from pains, sleeplessness; he had a sexual relationship before marriage, but has been impotent with his wife. (These marriages, of course, would almost certainly have been arranged ones.)

The third patient, a pretty woman in her twenties in a peasant sari, enters with an air of drama. In the few steps from the door to the chair her walk succeeds in suggesting that she is suffering greatly and that it is somebody’s fault—perhaps the fault of all of us in the room. This time a Tamil doctor interprets. She wants to die, she says. She has a pain in the shoulder—she jerks her left shoulder continually—and terrible headaches every day. She can’t sleep; she doesn’t care about anything. She went to her local hospital (she has come 200 miles) and they gave her electric shocks and antidepressant medicine; she was better for four days and then worse than ever, so she was sent
to CMC. She can hear sounds coming from all over her body. She suspects her husband of being interested in their neighbor’s wife, but when she accuses him he shouts at her that she is a jealous woman, and she can’t bear that.

Dr. Verghese has a hunch and asks if her husband has had a vasectomy; yes, returns the interpreter. “We quite often hear this story,” says Verghese. And she has only two children—both girls. There is a rustle of surprise in the room. The financial award for vasectomy might be tempting, but scarcely enough to take the place of a son. Perhaps her husband is a farmer who was refused fertilizer supplies until he had the operation; perhaps he wanted a driving license, or rehousing from a slum. Or perhaps his village was offered a new well in return for thirty vasectomies.

Going to India from the West is like stepping onto another planet; but is having a mental illness in India any different from having it in Manhattan? Is treatment similar—if it is available? Do you get ill as often there, or less, or more? Do poverty and overwork leave any time for mental illness, is it a side effect of affluence—or do the hardships of a poor country provide all the more cause for disintegration? Are there differences in the Indian character structure itself that make mental illness and its treatment take different forms from those in the West? And does a third world country, obviously so much less well equipped with psychiatric and psychotherapeutic services than affluent societies, need more mental health care—or does greater provision for illness conjure up the illness to meet it, as new roads bring out more traffic?

Dr. Verghese does not believe that poverty provides a miraculous immunity to mental afflictions. Suicides, for instance, happen fairly often, even though attempted suicide is a punishable offense. He quotes a survey of his district that found psychological disturbance
in 66 per 1,000 people, of which about a third were psychotic. Psychotic illness, schizophrenia in particular, occurs in a relatively constant pattern from culture to culture; the interesting question regards the other two-thirds, the nature of the less severe mental illnesses of a third world country. Their incidence may vary between the less and the more sophisticated sections of society, for one thing: a study carried out in Bengal found Brahmins to have about four times as many symptoms as non-Hindu tribesmen.
¹

It is at any rate safe to say that rural India does not run to the shrink with a problem as Manhattan does; nor indeed could it in view of the scarcity of psychiatric resources. When India gained independence, there were about fifty psychiatrists in the country, many of them army doctors; now the number is estimated at only about 500 for India’s 640 million people; others—perhaps too many—leave India to practice abroad. Medical and psychiatric facilities range from the basic care given free in clinics and large hospitals, through part-payment, to expensive private treatment.

Only the severest cases from the 66 per 1,000 seek official medical help, Verghese considers, the criterion being inability to go out to work or to housekeep. Most—about 80 percent, he estimates—have been to at least one local healer before coming to the hospital. With hysterical and neurotic symptoms he believes the healers can have great success; patients, particularly those from rural areas, are likely to attribute their symptoms to witchcraft or the violation of a taboo, which provides a rationale for the healer.

Erna Hoch, a Swiss psychiatrist who has lived in rural Kashmir, has studied the work of “pirs” and “faquirs” there. She argues that
they use processes that—covertly, anyway—also have a place in Western psychotherapy. The healer may act as a catalyst to the illness; he may “transfer” some of his own health or energy to the patient; he may offer a symbolic rebirth; he may operate a kind of temporary “dialysis” whereby he absorbs the patient’s sickness (“every psychotherapist at some time or other has felt like blotting paper that has to absorb the patient’s anger and other negative emotions,” she adds). She observed frequent instant “cures,” not always lasting ones—though where illness is attributed to wrong actions there is a strong incentive to stay cured. The prescribing of rituals and penances seemed to be among the most effective therapies.
²

In their study of mental illness in a south Indian community, the British psychologists G. M. Carstairs and R. L. Kapur describe the work of a local healer, the Mantarwadi, or expert in horoscopes and mantras:

There were about 20 clients who, it seemed, had been waiting patiently since the early hours of the morning. Without even looking at them the Mantarwadi sat down on the only chair in the room (a bench was soon brought in for us) and started drawing with a chalk the zodiac chart for the day on the desk in front of him.

Having completed this chart he casually summoned the client sitting nearest and from the clock checked the exact time the client came face to face with him. With a wave of the hand he forbade the man from talking—as he evidently wanted to—about his present misery. The next few minutes were spent in some further calculations while the client waited patiently. Having finished the calculations the Mantarwadi spoke out with a clear commanding voice: “You are 60, you come from a place where the fish abound and you want relief from
the pains and aches which have been haunting you for a long time.” “And fever,” said the client. “And fever,” agreed the Mantarwadi.… “Is it true or is it not that your father is dead?” “Yes,” agreed the client. “Then is it true or is it not that during the last three years at least once you did not complete the ritual of Shradda?” The client hung his head down and acquiesced meekly. “Well this is what comes of not attending to your dead ancestors. You will need to arrange a ritual feast to which at least five Brahmins must be invited. You will have to go to Dharmasthala and bathe in the holy water. And here is a thread which you must wear on your aching knees.” Saying this he held out a piece of string, whispered a mantra over it and gave it to the man.

The man folded his hands, touched his forehead to the ground in front of the healer, and left after putting a rupee note on the desk.
³

In the community of 9,000 people studied by Carstairs and Kapur there were twenty-three healers, two doctors, and a government health center. It was common for patients to consult both doctor and healer. “There are many ways to truth,” says Indian tradition and philosophy.

Conventional psychiatric techniques, however, in Vellore and elsewhere, are borrowed from the Western repertoire: electro-convulsive therapy, drugs, occupational therapy, simple psychotherapy, behavior therapy; and psychiatric training follows the Western pattern. ECT is cheaper than drugs and so is freely prescribed. Dr. Verghese’s department gives twenty-five to thirty a day—without anaesthetic because an anaesthetist would be an expensive luxury. His psychotherapeutic sessions are not, of course, modeled on psychoanalysis (though Freudian concepts are familiar here, as everywhere else); Indian patients, he says, expect support and advice from their doctors.

One aspect of his work he is justifiably proud of: his “family participation” scheme, which is either as old as the hills, or very new, or both. The Centre has facilities for forty-two patients to be accommodated with one or two family members. (There is far less institutionalization in India than in the West; patients who are really “put away” are either from the dispossessed of the big cities, or else have no relatives.) Each family has a simple suite in the huts that surround the compound. The scheme has several advantages: cheapness is one, for relatives cook for the patient and look after him. Another is that they can be taught to understand the illness and care for the patient on discharge. And it agrees well with the Indian tradition of expecting relatives to provide much of the food and care for hospital patients; the Centre’s patients, with their strong family ties, find it comforting. “They are frightened of coming here,” says Dr. Verghese, “but when it is time to leave they don’t want to go.”