In England Now
1
1446 The mental health problems are acute psychosis, epilepsy, drug dependence, depression, and mental subnormality; the place is Pakistan. An enormous expansion has occurred since the services were first described on these pages: medical officers have now been trained from every province in the country, and the school programme has spread across the nation and is carried forward by the teachers themselves-who have formed the All-Pakistan Teachers Movement for Mental Health.2 The genie is out of the lamp, and will never go back inside. Although the school programme has had a deep impact on the basic health units (BHUs) that serve each village, the reason that it will continue lies in the effects it has had on the schools themselves. While the former is of great interest to doctors in public health, the latter are surely of great interest to psychiatrists. As might be expected, the BHUs experience a great increase in referrals of patients with mental health troubles after the campaign opens in each school, but this increase should be seen in a context of a twofold increase in referrals for general medical care. The paradox is complete: psychiatry has made general medicine respectable. If psychosis and depression can be treated medically, then maybe haemorrhoids and jaundice can be as well. And as more village women come to the BHUs for childbirth, the programme may be expected to achieve the primary prevention of many cases of subnormality and epilepsy. None of this accounts for the enthusiasm for the programme which seems to affect teachers and pupils equally. The teachers say that they feel closer to the children and now know more about them as people; some even claim that the children are dressing with more care and achieving better grades. The children are perhaps excited 1. Pakistan revolution in mental health care. Lancet 1987, i: 736. 2. Wig N, Murthy S, Harding T. A model for rural psychiatric services Indian J Psychiatry 1981, 23: 275-80. by their role as active participants in the programme, instead of their usual passive role. The certainly vote with their feet, since absenteeism is down by as much as 50% in some schools. They devote enormous energy to the preparation of wall-charts and posters, and see to it that every letter posted in the village is stamped with a mental health slogan. Collaboration between religious healers and psychiatrists is not a new idea in developing countries. What is original to Pakistan is that these healers are issued with the same coloured case-identification cards as are used by the multipurpose health workers. One healer said that, although he thought that his results with hysteria were better than those obtained by the BHU, he had never done well with epilepsy or drug dependence, and was pleased to have his religious help for these patients supplemented by medication from the BHUs. Orthodox psychiatrists often object that working with faith-healers gives the healers a legitimacy that they do not deserve; but if enough patients receive treatment who would not otherwise have done so, the price is surely worth paying. Developments in Pakistan should be seen in the wider context of provision of mental health services based in primary care in a part of the world not usually noted for medical innovation. The leadership provided by the East Mediterranean Regional Office of WHO has allowed the countries of the region to coordinate their efforts. Pakistan may have taken the lead, but Democratic Yemen, Yemen, Afghanistan, and Iran are not far behind. Moslem may not speak to Hindu, but a movement that began in India2 has entered the Islamic world, and has even been improved by it. When rehabilitation schemes for those with chronic psychoses also derive their power from the people, community psychiatry will have crossed its last frontier. The crossing may yet be made in Pakistan. University of Manchester DAVID GOLDBERG In England Now AUTuMN; the season of mists and mellow fruitfulness; of evenings drawing in and clocks going back; of Heathrow closed owing to fog; and of that peculiarly British phenomenon, the evening class, for which a quarter of a million Londoners register every year. But what to choose? London must surely be the evening-class capital of the world; and this year the soon-to-be-abolished Inner London Education Authority has provided a cornucopia rich in choice. Languages are the staple of all evening classes. But not here just the French, Spanish, Greek, and Italian for next year’s package holiday; and not here only the languages of the European Community (the provision for which would put the future national curriculum to shame). For those searching for their roots there are Cornish and Gaelic, and for the more exotically minded there are Amharic, Catalan, Euskera, Farsi, Ibo, Kweyol, Patwa, Putonghua, Romany, Somali, Sylheti, Tigrinya, Twi, Yiddish, Yoruba, and Zulu. And if academic linguistics doesn’t appeal, then try French through Cooking or Cultural German. Music also gets a broad range-everything from Introductory Bagpipes (mercifuly conducted on the top floor of a disused school), through Bamboo Pipes (Including Making), Gamelan, Gregorian Chant and Lute, to Sitar and Steel Band. Some of the courses are immensely practical, although Woodworking for Beekeepers hardly fits any stereotype of modem inner-city life. Some courses are clearly to be taken in pairs: thus Christmas Cookery Preparation would be nicely complemented by the Workshop on Christmas Stress. Perhaps the only course in which a high drop-out rate may be regarded as a mark of success rather than failure is the one entitled Preparing for your own Death. So what did I enrol for? Well, Introduction to Painting and Drawing was full, and so I was sent along to Life Drawing for Beginners. Explaining the receipt marked "model" was a bit difficult, and the first evening was reminiscent of that dreadful first day in the dissecting room, twenty years ago-flesh everywhere but armed now only with a piece of charcoal instead of a scalpel. But at last the anatomy is coming in useful, as they always said it would. * * * WHEN I was a medical administrator I felt the need to keep my clinical hand in, so I did holiday locums in general practice. These locums were of an unusual type. My approach was to write to a single-handed doctor in the Scottish Highlands and offer him a free holiday for a week or two. Free? Yes, I accepted expenses but took no pay. That way, both sides avoided the attentions of the taxman. The Highland doctors mostly jumped at the chance. There was one practice that covered two of the Shetland Isles, which had an extraordinarily foreign atmosphere. The isolation made the work demanding, but it also made it satisfying. The worst feature was the journey to the second island-fortunately it was a small island and required few visits-because it meant eight hair-raising miles in an open boat through rough seas. The main reason for the infrequency of the calls was that the resident nurse had previously been stationed in Labrador and so could cope with practically everything. She thus matched the doctor, who was not only highly competent but also greatly loved by all his patients. There was no reason to vary any of his treatments. During a locum in the Western Isles I found that the health of many of the patients was sometimes better than that of the doctor I was replacing, who had been too fond of the whisky for too long. He was another who was popular, but for a different reason; he had a good number of his patients on whisky as therapy. So here there was perhaps need to vary my host’s treatment, but I did not. What I did was to polish the wording of my First Law of Locum-tenancy, which states that you must in no way contradict a doctor who cannot answer back. To do so can only mar his status with his patients, and it can do you no good. You will soon be gone; you have no status at all.
-
Upload
nguyenkiet -
Category
Documents
-
view
212 -
download
0
Transcript of In England Now
1446
The mental health problems are acute psychosis, epilepsy, drugdependence, depression, and mental subnormality; the place isPakistan. An enormous expansion has occurred since the serviceswere first described on these pages: medical officers have now beentrained from every province in the country, and the school
programme has spread across the nation and is carried forward bythe teachers themselves-who have formed the All-PakistanTeachers Movement for Mental Health.2 The genie is out of thelamp, and will never go back inside.
Although the school programme has had a deep impact on thebasic health units (BHUs) that serve each village, the reason that itwill continue lies in the effects it has had on the schools themselves.While the former is of great interest to doctors in public health, thelatter are surely of great interest to psychiatrists. As might beexpected, the BHUs experience a great increase in referrals ofpatients with mental health troubles after the campaign opens ineach school, but this increase should be seen in a context of a twofoldincrease in referrals for general medical care. The paradox is
complete: psychiatry has made general medicine respectable. Ifpsychosis and depression can be treated medically, then maybehaemorrhoids and jaundice can be as well. And as more villagewomen come to the BHUs for childbirth, the programme may beexpected to achieve the primary prevention of many cases ofsubnormality and epilepsy.None of this accounts for the enthusiasm for the programme
which seems to affect teachers and pupils equally. The teachers saythat they feel closer to the children and now know more about themas people; some even claim that the children are dressing with morecare and achieving better grades. The children are perhaps excited
1. Pakistan revolution in mental health care. Lancet 1987, i: 736.
2. Wig N, Murthy S, Harding T. A model for rural psychiatric services Indian JPsychiatry 1981, 23: 275-80.
by their role as active participants in the programme, instead of theirusual passive role. The certainly vote with their feet, sinceabsenteeism is down by as much as 50% in some schools. Theydevote enormous energy to the preparation of wall-charts andposters, and see to it that every letter posted in the village is stampedwith a mental health slogan.
Collaboration between religious healers and psychiatrists is not anew idea in developing countries. What is original to Pakistan is thatthese healers are issued with the same coloured case-identificationcards as are used by the multipurpose health workers. One healersaid that, although he thought that his results with hysteria werebetter than those obtained by the BHU, he had never done well withepilepsy or drug dependence, and was pleased to have his religioushelp for these patients supplemented by medication from theBHUs. Orthodox psychiatrists often object that working withfaith-healers gives the healers a legitimacy that they do not deserve;but if enough patients receive treatment who would not otherwisehave done so, the price is surely worth paying.Developments in Pakistan should be seen in the wider context of
provision of mental health services based in primary care in a part ofthe world not usually noted for medical innovation. The leadershipprovided by the East Mediterranean Regional Office of WHO hasallowed the countries of the region to coordinate their efforts.Pakistan may have taken the lead, but Democratic Yemen, Yemen,Afghanistan, and Iran are not far behind. Moslem may not speak toHindu, but a movement that began in India2 has entered the Islamicworld, and has even been improved by it.When rehabilitation schemes for those with chronic psychoses
also derive their power from the people, community psychiatry willhave crossed its last frontier. The crossing may yet be made inPakistan.
University of Manchester DAVID GOLDBERG
In England Now
AUTuMN; the season of mists and mellow fruitfulness; ofevenings drawing in and clocks going back; of Heathrow closedowing to fog; and of that peculiarly British phenomenon, theevening class, for which a quarter of a million Londoners registerevery year.But what to choose? London must surely be the evening-class
capital of the world; and this year the soon-to-be-abolished InnerLondon Education Authority has provided a cornucopia rich inchoice.
Languages are the staple of all evening classes. But not here justthe French, Spanish, Greek, and Italian for next year’s packageholiday; and not here only the languages of the EuropeanCommunity (the provision for which would put the future nationalcurriculum to shame). For those searching for their roots there areCornish and Gaelic, and for the more exotically minded there areAmharic, Catalan, Euskera, Farsi, Ibo, Kweyol, Patwa, Putonghua,Romany, Somali, Sylheti, Tigrinya, Twi, Yiddish, Yoruba, andZulu. And if academic linguistics doesn’t appeal, then try Frenchthrough Cooking or Cultural German.Music also gets a broad range-everything from Introductory
Bagpipes (mercifuly conducted on the top floor of a disused school),through Bamboo Pipes (Including Making), Gamelan, GregorianChant and Lute, to Sitar and Steel Band.Some of the courses are immensely practical, although
Woodworking for Beekeepers hardly fits any stereotype of modeminner-city life. Some courses are clearly to be taken in pairs: thusChristmas Cookery Preparation would be nicely complemented bythe Workshop on Christmas Stress. Perhaps the only course inwhich a high drop-out rate may be regarded as a mark of successrather than failure is the one entitled Preparing for your own Death.So what did I enrol for? Well, Introduction to Painting and
Drawing was full, and so I was sent along to Life Drawing forBeginners. Explaining the receipt marked "model" was a bit
difficult, and the first evening was reminiscent of that dreadful firstday in the dissecting room, twenty years ago-flesh everywhere butarmed now only with a piece of charcoal instead of a scalpel. But atlast the anatomy is coming in useful, as they always said it would.
* * *
WHEN I was a medical administrator I felt the need to keep myclinical hand in, so I did holiday locums in general practice. Theselocums were of an unusual type. My approach was to write to asingle-handed doctor in the Scottish Highlands and offer him a freeholiday for a week or two. Free? Yes, I accepted expenses but tookno pay. That way, both sides avoided the attentions of the taxman.The Highland doctors mostly jumped at the chance.There was one practice that covered two of the Shetland Isles,
which had an extraordinarily foreign atmosphere. The isolationmade the work demanding, but it also made it satisfying. The worstfeature was the journey to the second island-fortunately it was asmall island and required few visits-because it meant eighthair-raising miles in an open boat through rough seas. The mainreason for the infrequency of the calls was that the resident nursehad previously been stationed in Labrador and so could cope withpractically everything. She thus matched the doctor, who was notonly highly competent but also greatly loved by all his patients.There was no reason to vary any of his treatments.
During a locum in the Western Isles I found that the health ofmany of the patients was sometimes better than that of the doctor Iwas replacing, who had been too fond of the whisky for too long. Hewas another who was popular, but for a different reason; he had agood number of his patients on whisky as therapy. So here there wasperhaps need to vary my host’s treatment, but I did not. What I didwas to polish the wording of my First Law of Locum-tenancy,which states that you must in no way contradict a doctor who cannotanswer back. To do so can only mar his status with his patients, andit can do you no good. You will soon be gone; you have no status atall.
