Recovery From Schizophrenia: Psychiatry And Political Economy

HEALTH, ILLNESS AND THE ECONOMY 33increased genetic predisposition towards schizophrenia in the lower classes. Whenwe come to look at the prevalence of schizophrenia in the Third World (inChapter 9), we will find that the relationship between class (and caste) andschizophrenia is reversed. In the developing world it is the upper-class, bettereducatedindividuals who are more at risk for schizophrenia. As industrializationadvances, moreover, this inverted social-class gradient switches around to conformto the pattern found in the West. These phenomena clearly defy explanation byeither the social-drift or genetic hypotheses and they invite speculation aboutpossible socio-economic and socially determined obstetric causes.The shifts in the occurrence of schizophrenia that accompany the advance ofindustrialization may be a result of class-related changes in nutrition, obstetriccomplications and survival of the newborn (as we shall see in Chapter 9). Toacknowledge that class-related factors provoke the development of schizophreniais not to deny that social drift is also important. Indeed, it is not unusual to findpeople with schizophrenia who have had marginal levels of social functioning forsome years before their first, clear psychotic break. In such cases, downwardmobility is unavoidable, and this, in itself, becomes an additional source of stress.An interesting observation emerges from the research on the social mobility ofpeople with schizophrenia. While many patients may not show a decline inoccupational status to a level lower than that of their fathers, the occupationallevel of the general population is sometimes found to have risen around them. 36Relative to the rest of the population the people with schizophrenia have lostground. What is happening, then, is not exactly social drift but social stagnation.This is what one might expect to see in a group of people who are not high indrive and ambition. For individuals living in some settings this would not be agreat weakness. In modern industrial society, however, where to stay at the samelevel is to lose status, the pre-schizophrenic person may be at a disadvantage incomparison to more driven individuals and under greater pressure than he or shewould experience in a non-industrial setting.SCHIZOPHRENIA AND URBANIZATIONThe link between social class and mental disorders such as schizophrenia,interestingly, has only been conclusively demonstrated for city dwellers. Strongestin large cities, it becomes weaker in smaller cities and most rural areas. In smalltowns like Hagerstown, Maryland, 37 and Pueblo, Colorado, 38 or suburban areaslike Rockland County, in New York state, 39 the prevalence of schizophrenia wasnot related to social class. Dorothea Leighton and her co-workers did detect asocial-class gradient for mental disorder in rural Nova Scotia, but not in ruralSweden. 40 In two British studies, one comparing London women with women inthe crofting and fishing community of North Uist in the Outer Hebrides andanother comparing women in London with women living in the rural Isle ofWight, 41 the prevalence of mental disorder was found to be highly influenced byclass in the urban setting but not at all in the rural communities. On the rural