Beginning in 1978, the WHO conducted another international follow-up study of people suffering from psychosis,34 using the same standardized diagnostic
procedure as the earlier research. The study, conducted at twelve locations in ten countries around the world, aimed to include every person at each location who made contact with any helping agency because of psychotic symptoms for the first time in his or her life during the study period. The sites for the study were Aarhus, 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, a variety of traditional and religious healers was contacted to identify subjects— herbalists, Ayurvedic practitioners and yoga teachers in India, for example, and babalawo and aladura healers in Nigeria. This wide-ranging effort to identify every new case of psychotic illness at each location virtually eliminated the chance that the cases in any area were biased by the selection procedure.
Again, the outcome for Third World cases was substantially better, indicating that the results in the earlier WHO study were probably not a result of a selection bias. Nearly two-thirds (63 per cent) of the subjects in the developing-world sites experienced a more benign course leading to full remission compared to little more than a third (37 per cent) in the Developed World. Similarly, a smaller proportion of Third World cases suffered the worst type of outcome; only 16 per cent of developing-world cases were impaired in their social functioning throughout the follow-up period compared to 42 per cent in the Developed World. The superior outcome for Third World subjects was certainly not a result of more intensive treatment; more than half (55 per cent) of the developing- world cases were never hospitalized, in contrast to a mere eight per cent in the Developed World; and only 16 per cent of developing-world subjects versus 61 per cent of cases in the Developed World were taking antipsychotic medication throughout the follow-up period.
Did the Third World cases experience a milder course because more of them were, in reality, suffering from some good-prognosis condition that mimics schizophrenia—an acute atypical psychosis or an organic disorder caused by an infectious agent? If this were the case, we would expect there to have been more
acute atypical psychoses in the Third World sample and for the good-outcome cases to be clustered among these subjects. In fact, this was not the case. The proportion of acute illnesses and of the more atypical, broadly defined cases, it is true, was greater among the Third World subjects; but outcome was better in Third World subjects regardless of whether the illness was acute or insidious in onset, or whether it was of the “core” variety, diagnosed according to the most restrictive criteria, or diagnosed by broad criteria.
In 2000, medical anthropologist Kim Hopper and researcher Joseph Wanderling revisited the data from two WHO outcome studies asking two questions. Followed-up decades after the studies were initiated, are the patients in the developing world still doing better than those from the industrial world? And are the results due to some artifact in research methodology? They examined the outcome for 809 people in both the WHO outcome studies described above, 13 to 26 years later, and in some similar studies, and concluded that the results for people with schizophrenia in the developing world were still consistently better. They looked at six potential sources of research bias: differences in follow-up methodology, arbitrary grouping of centers into developed/developing world categories, diagnostic ambiguities, selective outcome measures, gender and age. They concluded that none of these possible confounding factors explained the observed differences.35
The general conclusion is unavoidable. Schizophrenia in the Third World has a course and prognosis quite unlike the condition as we recognize it in the West. The progressive deterioration that Kraepelin considered central to his definition of the disease is a rare event in non-industrial societies, except perhaps under the dehumanizing restrictions of a traditional asylum. The majority of people with schizophrenia in the Third World achieve a favorable outcome. The more urbanized and industrialized the setting, the more malignant becomes the illness. Why should this be so?
WORK
It was argued in earlier chapters that the dwindling cure rates for insanity during the growth of industrialism in Britain and America, and the low recovery rates in schizophrenia during the Great Depression, were possibly related to labor-force dynamics. The apparently superior outcome for schizophrenia in the USSR in the WHO Pilot Study, if it was not a consequence of diagnostic bias, may have been a result of full employment and an emphasis on work rehabilitation in the country at that time. The picture that has now been drawn of schizophrenia in the Third World gives more support to the notion that the work role may be an important factor shaping the course of schizophrenia.
In non-industrial societies that are not based upon a wage economy, the term “unemployment” is meaningless. Even where colonial wage systems have been developed, they frequently preserve the subsistence base of tribal or peasant communities, drawing workers for temporary labor only.36 In these
circumstances, underemployment and landlessness may become common but unemployment is rare. Unemployment, however, may reach high levels in the urbanized and industrial areas of the Third World.
The return of a person suffering from psychosis to a productive role in a non- industrial setting is not contingent upon his or her actively seeking a job, impressing an employer with his or her worth or functioning at a consistently adequate level. In a non-wage, subsistence economy, people with mental illness may perform any of those available tasks that match their level of functioning at a given time. Whatever constructive contributions they can make are likely to be valued by the community and their level of disability will not be considered absolute. Dr Adeoye Lambo, a psychiatrist well known for developing a village- based treatment and rehabilitation program in Nigeria, reports that social attitudes in Nigerian rural communities permit the majority of those with mental disorders to find an appropriate level of functioning and thus to avoid disability and deterioration.37 In India, research workers for the WHO follow-up study of
schizophrenia encountered difficulty in interviewing their cases as the ex-patients were so busy—the men in the fields and the women in domestic work.38 In rural
Sichuan, China, more than three-quarters of people with schizophrenia who had never been treated were working; even people with significant psychotic symptoms were doing housework or farm work.39 The more complete use of
labor in pre-industrial societies may encourage high rates of recovery from psychosis.
But what of the nature of the work itself? John Wing, a British social psychiatrist who undertook a great deal of research on schizophrenia, identified two critical environmental factors that lead to optimal outcome from the illness. The first of these, which we will return to later, is freedom from emotional over- involvement—smothering or criticism—from others in the household. His second criterion, which is relevant here, is that there should be stable expectations precisely geared to the level of performance that the individual can actually achieve.40 Industrial society gives relatively little leeway for adapting a job to the
abilities of the worker. High productivity requirements and competitive performance ratings may be particularly unsuitable for a person recovering from schizophrenia. In a peasant culture he or she is more likely to find an appropriate role among such tasks of subsistence farming as livestock management, food- and fuel-gathering or child-minding. As the authors of the WHO Pilot Study of Schizophrenia comment about life in the countryside of India:
work in the rural setting is mostly collective, agricultural, and often does not require particular skills. Many occupations are passed from father to son. Thus, competitive situations seldom exist. The occupational pursuits do not usually require fine skill and adaptability and often do not demand much effort or strain…. Employment conditions in the country usually do not have any untoward effects on most patients.41
Many clinicians in the West have noticed that the demands of a 40-hour week are often overly taxing for patients suffering from psychosis. In huntergatherer and peasant societies, the distinction between work and non-work may be hard to make (in some cultures it is not linguistically possible to differentiate “work” from “ritual” or from “play”42), but the demands of subsistence are unlikely to be
burdensome. !Kung Bushmen work no more than two to three (six-hour) days a week in hunting and food-gathering for themselves and their dependants, and about two hours further each day is spent on food preparation and “housework.”43 Slash-and-burn agriculture, for example among the Bemba of
north Zimbabwe or the Toupouri of north Cameroon, calls for only three or four (five-hour) working days a week.44 Plough agriculture commonly requires a 30–
35-hour work week.45 Estimates of labor requirements for irrigation agriculture
vary. In Yunnan Province in pre-revolutionary China, the working day was seldom longer than seven to eight hours, including frequent rest periods, even at the busiest time of year; during the slack months, there was virtually no farm work to be done. Elsewhere a demanding 50–70-hour work week has been recorded, but both of these examples of irrigation agriculture involve market production, not just local subsistence needs.46 Where production is for use and not
for exchange, labor needs tend to be low.47
In each setting there is wide individual variation. In pre-revolutionary Russia, for example, peasant farmers in Volokolamsk worked between 79 days a year in the least industrious households and 216 in the most industrious.48 This compares
with an expectation of around 230 to 240 working days a year for employees in modern industrial society. Work demands in many cultures are particularly low for young, unmarried adults49 (who may be at higher risk for developing
schizophrenia), but whatever the usual pattern, workload expectations are more readily adjusted to meet the capacities of the marginally functional individual in a village setting than in the industrial labor market. There can be little doubt that it is simpler for a person with schizophrenia to return to a productive role in a non- industrial community than in the industrial world. The merits of tribal and peasant labor systems are apparent. As in the West during a period of labor shortage, it is easier for family and community members to reintegrate the sick person into the society, and the sufferer is better able to retain his or her self- esteem. The result may well be not only better social functioning of the sick person but also more complete remission of the symptoms of the illness.