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In searching for predictors of good outcome in schizophrenia, the WHO Pilot Study examined a number of patient characteristics. We may look at these data for evidence of an association between occupation and outcome in schizophrenia but, in so doing, we encounter difficulties presented by the variety and complexity of work and subsistence patterns in the developing world. Poverty can be extreme in the urban slums of the Third World, where many eke out an

existence by self-employment in street-vending and similar activities or with low and irregular earnings from work in the formal and informal segments of the urban labor market. Outright unemployment, however, is often most severe in the upwardly striving, urban middle classes. In rural areas, this reversal of the usual Western pattern is even more marked, with unemployment among the aspiring educated at times being severe, while those working the land are largely outside the labor market.50

In rural districts, therefore, we should look for a reversal of the usual Western pattern of outcome from schizophrenia and for superior outcome in the less educated—the subsistence farmers with limited exposure to Western acculturative forces. A mixed recovery picture might be expected to occur in those urban areas where economic development is incomplete and is creating stresses for the new managerial and professional classes. In the most highly developed cities of the Third World we should expect a pattern of recovery similar to the West with the best outcome in the high-status occupations. In general, we might anticipate outcome to be better in villages, where more of the population is outside the wage-labor market, than in the cities.

In fact the WHO data show neither rural nor urban living to be strong predictors of good outcome.51 _{The information on residence, however, was}

gathered at intake rather than at follow-up. The lack of association between residence and outcome, therefore, may merely reflect what several authors have noted—that migrant laborers who fall ill while working in the industrial areas return to the village to recuperate.52 _{City-dwellers with psychosis may benefit}

from this return to traditional village roles.

Other WHO Pilot Study data more clearly document an association between occupation and outcome. Farmers were more likely than patients of any other occupation to experience the most benign pattern of illness—full remission with no relapses—and the unemployed were least likely to experience such a mild course to the psychosis. In urbanized Cali and Taipei patients from high-status professional and managerial occupations were found to achieve good overall outcome, while this was not the case in the largely rural catchment area around Agra, India.53 _{This pattern confirms the impression that schizophrenia may be}

more benign in the successful upper classes in the industrialized setting, but more malignant among the better educated in India who are known to suffer rates of unemployment several times greater than the poorly educated and illiterate.54 _The

data from Nigeria do not fit as neatly. Even though many patients in the sample appear to have come from rural districts, Nigerians with schizophrenia in managerial jobs experienced good overall outcome.55 _{This could be explained by}

a strong local demand for educated labor at that time or, again, the high mobility of the migrant labor force may confuse the picture; patients who were unable to continue in managerial positions could return to a less demanding role in their farming community.

Migrant-labor practices allow people with schizophrenia in the Third World to change occupation and residence after developing psychotic symptoms. Level of

education, however, is less easily changed. It is therefore interesting to note that a high level of education is one of the few strong and consistent indicators of poor outcome in the Third World,56 _{thus standing in contrast to Western patterns of}

recovery. This point, then, may be one of the most useful pieces of evidence in the WHO study, pointing to a link between good outcome for schizophrenia in the Third World and the maintenance of traditional occupational roles.

STRESS

Unemployment on the one hand and intensified work demands on the other are special stresses of modern industrial society. Are there other increased stresses of life in the fast-paced industrial world that might account for the poor prognosis for schizophrenia in the West? It depends what we mean by stress. Urban overcrowding, job insecurity, productivity pressure and alienation from the creative process are all chronically stressful facets of industrial life. Those who live in peasant communities, however, must face equal levels of domestic discord and often suffer problems of poor health, high infant mortality and inadequate housing, clothing, food and water. With the development of state-level societies and colonialism come increasing difficulties with authority, status disparity, poverty and starvation. To passing tourists, the palm-studded fishing village near Mazatlan on the west coast of Mexico might seem a subtropical paradise; but when Russell McGoodwin, an anthropologist, asked the inhabitants what caused them most suffering they listed many complaints including poverty, family problems, the burden of work, inadequate water supplies and poor clothing. In response to the question, “What do you enjoy?” nearly half answered, “Nothing.”57 _{Life in non-industrial societies is not low in stress. Rousseau’s}

“noble savage” leading a life of peace and perfect order in “the state of nature” cannot be found. But some features of tribal and peasant life might well improve the social integration and the outlook for those who suffer from a psychotic episode.