Recovery From Schizophrenia: Psychiatry And Political Economy

156 SCHIZOPHRENIA IN THE THIRD WORLDcombined, and few were in the worst categories; these results place Moscow in anintermediate position between centers in the developed and developing worlds.Could patient selection have influenced these results? It is possible that thepeople presenting for treatment of schizophrenia at Third World centers, whileappearing comparable with those in the Western samples, were in fact notrepresentative of all those with schizophrenia in the community. It seems unlikely,however, that those who were admitted to treatment would be predominantlypeople with less severe forms of the illness, and a more recent WHO study allowsus to be certain about this point.WHO TEN-COUNTRY STUDYBeginning in 1978, the WHO conducted another international follow-up study ofpeople suffering from psychosis, 34 using the same standardized diagnosticprocedure as the earlier research. The study, conducted at twelve locations in tencountries around the world, aimed to include every person at each location whomade contact with any helping agency because of psychotic symptoms for the firsttime in his or her life during the study period. The sites for the study wereAarhus, Denmark; Agra and Chandigarh, India; Cali, Colombia; Dublin, Ireland;Honolulu and Rochester, USA; Ibadan, Nigeria; Moscow, USSR; Nagasaki,Japan; Nottingham, UK; and Prague, Czechoslovakia. At the Third World sites, avariety of traditional and religious healers was contacted to identify subjects—herbalists, Ayurvedic practitioners and yoga teachers in India, for example, andbabalawo and aladura healers in Nigeria. This wide-ranging effort to identify everynew case of psychotic illness at each location virtually eliminated the chance thatthe cases in any area were biased by the selection procedure.Again, the outcome for Third World cases was substantially better, indicatingthat the results in the earlier WHO study were probably not a result of a selectionbias. Nearly two-thirds (63 per cent) of the subjects in the developing-world sitesexperienced a more benign course leading to full remission compared to littlemore than a third (37 per cent) in the Developed World. Similarly, a smallerproportion of Third World cases suffered the worst type of outcome; only 16 percent of developing-world cases were impaired in their social functioningthroughout the follow-up period compared to 42 per cent in the DevelopedWorld. The superior outcome for Third World subjects was certainly not a resultof more intensive treatment; more than half (55 per cent) of the developingworldcases were never hospitalized, in contrast to a mere eight per cent in theDeveloped World; and only 16 per cent of developing-world subjects versus 61per cent of cases in the Developed World were taking antipsychotic medicationthroughout the follow-up period.Did the Third World cases experience a milder course because more of themwere, in reality, suffering from some good-prognosis condition that mimicsschizophrenia—an acute atypical psychosis or an organic disorder caused by aninfectious agent? If this were the case, we would expect there to have been more