Recovery From Schizophrenia: Psychiatry And Political Economy

170 SCHIZOPHRENIA IN THE THIRD WORLDLondon and from other research centers, that was outlined in Chapter 1 and willbe discussed further in Chapter 10. The family environment for people withschizophrenia in the Third World is different from the West. In India, spouses,parents or siblings are willing to provide for a relative, however disabled. 101 Themultiple caregivers in an Indian extended family will handle most of the problemspresented by a family member with schizophrenia without seeking outsideassistance—self-neglect and dirtiness seem to be of the greatest concern. 102 At theend of the twentieth century, however, with urbanization, increased femaleemployment and the break-up of the extended family, the level of tolerance wasdeclining. 103 Increased acceptance, nevertheless, can bring better outcomes. InQatar, on the Persian Gulf, people with schizophrenia in extended families havebeen reported to show better outcome at follow-up than those who return tonuclear family households. 104 The extended family structure, which is morecommon in the Third World, allows a diffusion of emotional over-involvementand interdependence among family members.The emphasis on community involvement in the treatment of mental illness innon-industrial societies similarly tends to reduce family tensions. Responsibility isshared broadly and the patient often escapes blame and criticism, allowing thefamily to be more supportive. According to one study, for example, relatives ofpeople with schizophrenia in Chandigarh, north India, are much less likely to bedemanding or critical of their psychotic family member than are the relatives ofpeople with schizophrenia in the industrial world. In London, nearly a half ofpatients with schizophrenia have such emotionally stressful relatives; inRochester, New York, the proportion is similar; but in north India, fewer than afifth of subjects with schizophrenia were found to have critical and demandingrelatives. 105 As mentioned in Chapter 1, this difference might be a consequenceof the higher achievement expectations placed on Westerners suffering frompsychosis or of the emotional isolation so common for families of people withschizophrenia in the West but so much rarer in the developing world.In the Third World, it appears, the person with a psychotic disorder is morelikely to retain his or her self-esteem, a feeling of value to the community and asense of belonging. These are things that, as we shall see, sixteen billion dollarsdoes not buy the person with schizophrenia in the United States or elsewhere inthe Western world.SUMMARY• Brief psychoses clinically indistinguishable from schizophrenia are a commonoccurrence in the Third World.• Outcome from schizophrenia is better in the non-industrial world than in theWest.• Intermediate levels of outcome from schizophrenia are found in the moreindustrialized parts of the Third World and in the pre-peristroika USSR.