Mental health [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • OCTOBER 1974 • UK 30 p • USA $ 0.70 mental health 2 WORLD HEALTH mental health Front cover—Coloured scraps of material form a cheerful picture. Poig- nantly, this collage was created by a teenaged patient at a mental health cen- tre in Tunis. ( Photo WHO/T. Farkas) Contents Caring for the mind 3 The pace of progress by Leon Eisenberg . . 4 Mental health=public health by Karl Evang 8 A nurse in Tanzania by T. Nchimbi Sekamaganga 12 Social stresses by Peter Sainsbury . . . 20 S.-E. Asia's problems by J.S. Neki 24 Brighter prospects by Carlos A. LeOn . . . 28 Mental health explained to children . . . 34 World Health appears in Arabic, English, French, German, Italian, Portuguese, Russian, and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO Avenue Appia, 121 1 Geneva 27, Switzerland the challenge of mental health caring for the mind Mental health, once the Cinderella of the medical sciences, is gradually achieving the status which is rightfully due to this area of prime concern for physicians and sociolo- gists as much as for experts in the psychia- tric field. We make no apology for returning to this theme for the present issue of World Health after an interval of only 16 months. Nor do we claim that with this issue, together with that of May 1973, we have exhausted all the possible aspects of the subject. The implica- tions for society of the new research which is being undertaken into the diagnosis, the prevention and the treatment of ailments of the mind ensure that this growing science will always provide new avenues for explo- ration. Last year, World Health looked at defini- tions of mental health, the role of tradi- tional methods of mental treatment, the spe- cial problems of youth, the phenomenon of suicide, community services for the retard- ed, and the need for a common "language" in psychotherapy. This month, the accent is on the evolution of modern ways of treating and preventing mental diseases, and the challenge posed by ever-increasing stresses and strains in every- day life. Besides the worldwide application of new research and new therapeutic methods, we look at the problems specific to one region—South-East Asia, at community therapy in action in Tanzania, and at an ex- periment in "open doors" treatment at a hospital in Italy. Mental ill-health remains even today a topic which arouses irrational fears in many people. Where once the mental patient was mocked and possibly stoned, today he is still The gap between genius and madness may be a narrow one. Our cover picture of a Tunisian mental patient's collage is not too far removed from the disturbing art of Goya. In 1799, the brilliant Spanish artist included this engraving of a disturbed man reverting to childhood—with more than a hint of what was later to be called schizophrenia—in his series Los Caprichos. ( Photo WHO) ostracized and isolated; he may no longer be kept shackled or in a straitjacket in a barren cell, but his world is often narrowly circumscribed and he may not be allowed normal human contacts. Slowly things are changing. As the Trieste experiment described in this issue shows, some hospitals try new and more liberal methods, not merely to alleviate the lot of the unfortunate mental sufferer but to give him the best possible chance of recovery and rehabilitation. The problem of mental health is being in- creasingly recognized around the world as forming an integral part of public health. Medical services are taking more and more for granted that care of the body's ills must be matched by care of the ailing mind. Out- patient treatment of the mentally sick is becoming more commonplace : they need no longer be totally isolated from the society in which they live but may continue to play a normal role there while undergoing treat- ment. At the same time, new drugs are constant- ly being evolved from those already known to have special properties for controlling or modifying extreme abnormalities of the mind. Psychiatrists are not satisfied even with the advances so far made, and are eagerly prospecting for new treatments and new preventives. The search also continues for methods which will help to prevent mental illnesses before they even arise. This is a battle of crucial importance which must be won, as the stresses of man's living and working conditions continue to grow ever more in- tolerable. For the developing world, there are the new problems of facing technologies and cultural ideas which are alien to everything that a well-tried tradition has taught. For the industrialized world, there are insidious pressures from often artificial notions of competition as well as from such environ- mental factors as noise, soulless housing areas and unsatisfying mechanical drudgery. It is with some facets of these vital themes that World Health concerns itself this month. ■ 3 research the pace of progress by Professor Leon Eisenberg T dramatic achievements of modern medicine are the fruit of what has been called "the scientific era" of medicine which began in the last half of the 19th century. In autopsy rooms, pathologists were able to demonstrate the relationship between the symptoms of diseases and the underlying changes in body organs. In bacteriology laboratories, the germs that caused the great infectious scourges of mankind were grown in culture media, identified under the microscope and shown to produce disease in experimental animals. When a widespread and serious mental affliction known as general paralysis of the insane was proved to be due to the spiro- chete of syphilis, in the same way that the tuberculose bacillus had been shown to be the cause of tuberculosis, great expectations were aroused that the other major psychia- tric disorders would soon be explained by tissue damage in the brain and ascribed to bacterial causes. But decades of frustration were to follow; careful post-mortem studies of the brain failed to find structural abnor- malities and exhaustive search in the labora- tory for causative agents proved fruitless. Thus, while the rest of medicine witnessed an explosion of biochemical and phar- maceutical findings, biological research in psychiatry was largely barren; major em- phasis during the first half of this century shifted to an examination of psychological factors, both as causative agents and as therapeutic methods; major innovations in psychiatric care resulted but the practising psychiatrist was left with limited means of coping with severe forms of insanity. In the last 20 years, stimulated by the un- expected discovery of new drugs able to cor- rect severely disturbed behaviour, biological research in psychiatry has been rejuvenated. Important new information has been added to our knowledge of brain function and its derangement in mental illness; new drugs are being "made to order" in the laboratory according to new principles of drug action. No complete review is possible in a short ar- ticle; a sense of the pace of progress may be conveyed by focusing on development in two areas of research—genetics and bioche- mistry. The belief that mental illness is inherited is an old one, based on the observation that it frequently runs in families. However, since there are also good reasons for arguing that the way a child is raised has a decisive effect on his behaviour as an adult, the ag- gregation of cases in families can as readily be explained by the psychological effects of disturbed parents on their children as by the concept of inheritance. Systematic observa- tion of twins provided the first solid clues to hereditary influences. There are two kinds of twins, one egg (identical) and two egg (fraternal). In the first type, a single ferti- lized egg splits into two at an early stage of development and forms two exact replicas containing precisely the same genetic material; in the second, two separate eggs are fertilized at the same time and grow simultaneously in the uterus (womb); since they are the products of different eggs and different sperm they share no more genetic material than any two brothers or sisters in the same family. Thus, if it can be demon- strated that a given disease in one twin is more likely to be found in his or her co-twin when the two are identical than when they are fraternal, there is a strong case for inher- itance. And, indeed, this proved to be true for schizophrenia, a psychosis characterized by disordered thinking, social withdrawal, hallucinations and delusions. However, the reported rates of concor- dance (the percentage of cases when both twins have the same disorder) varied from study to study; some were criticized for bias because the examining psychiatrist knew the status of the first twin when he saw the second; further, some critics argued that parents were likely to treat identical twins differently from fraternal twins because of visible differences between the latter. The in- troduction of a new approach, the adoption study method, provided a more decisive an- swer to the question. A large number of adults who had been adopted as infants were selected from a national register of adoptees. A search of all mental hospital records in the country concerned enabled the investigators to find those adoptees who had been hospitalized for schizophrenia. The hospitalized group was compared against a matched group of adoptees who had not been hospitalized. Then, the biolog- ical relatives and the adoptive relatives of each individual in the study were thoroughly investigated. If the disease is inherited, cases of schizophrenia should be found more of- ten in the biological families of the patients; if the disease is induced by parental beha- viour, a surplus of cases should be found among the adoptive families (who were re- sponsible for the rearing but not for the bearing of the children). The results were unequivocal: schizophrenia was found to be concentrated in the biological families and to occur at no more than the average rate of the population among the adoptive families. Particularly striking is one detail of the results : within the biological families, schi- zophrenia occurs much more frequently than expected among the paternal half-sibl- ings of adopted-away schizophrenic patients (paternal half-siblings are brothers or sisters who share the same father but have different mothers). This rules out any in utero effect from factors that conceivably could circu- late in the blood stream of a schizophrenic mother, problems during delivery or effects of early mothering. Bizarre patterns of chromosomes which may indicate the transmission of mental illness from one generation to the next. Scientists at work in a genetics research laboratory in Bel- grade. (Photo WHO/P. Almasy) 4 4a* &AM.° 4 r 410, .046, 40Ps alioNbo I for' 441.2 di **4 110.411Catir ••• the pace of progress Although the rates for schizophrenia are much higher in biological families than they are in the general population, not all parents of schizophrenic children show the disease themselves nor are all of the offspring of schizophrenic parents sick. Thus, it is im- portant to realize that what is inherited need not be the disease itself (as is true, for in- stance, in another hereditary disease called Huntington's chorea). The patient inherits a susceptibility to schizophrenia but the ac- tion of some as yet unknown environmental precipitant is required for the disease to become manifest. The other major psychiatric illness, manic depressive disease, is characterized by recur- rent and sometimes alternating moods of ex- citement, elation, rapid speech and flight of ideas, on the one hand, and profound melancholia, slowing of thought, motor ret- ardation and sleep disturbance on the other. Family studies strongly suggest patterns of inheritance, but patterns that are different for unipolar (recurrent depressive) cases and for bipolar (alternating mania and depres- sion). For example, a large family study of bipolar patients revealed a pattern linked to the X chromosome; that is, transmission from mother to children was the same for sons and daughters; transmission from, fa- ther to daughter occurred, but never from father to son. This is what must be the case for an X-linked characteristic since the son gets his one X chromosome from his mother and only a Y from his father. Further sup- port for the possibility of X linkage has been provided by several genealogies in which characteristics known to be X-linked (colour blindness and Xg blood type) were associated in the same individuals with man- ic depressive disease. The growing evidence for an underlying genetic basis for the major types of insanity reinforces the expectation that such patients will exhibit biochemical abnormalities. The genes of heredity are sets of instructions for the synthesis of chemicals. When the genes are abnormal, the chemical products are ab- normal. To the extent that we can identify the abnormal chemicals, we will have a rational basis for designing specific treat- ment for each psychiatric illness. Just as the 20th century reached the half- way point, three unexpected clinical findings set off a veritable explosion of knowledge in brain biochemistry. Physicians using an In- dian drug, reserpine, for the treatment of high blood pressure, observed that some patients became severely depressed. When experiments with laboratory animals demonstrated that reserpine depleted brain stores of the chemicals serotonin and nore- pinephrine, this at once suggested an asso- ciation between mood and the brain levels of these substances. At about the same time, a new class of drugs, the phenothiazines, in- troduced for other purposes, were noted to produce an unusual state of "tranquillity". Tried out on schizophrenic patients, pheno- thiazines demonstrated a remarkable capaci- ty for reversing the specific symptoms of that disease. Subsequent research showed that phenothiazines had an effect on the brain chemical dopamine. The third dis- covery followed upon the introduction of the drug, iproniazid, in the treatment of tuberculosis; alert clinicians were struck by the fact that their patients frequently became high spirited well before their un- derlying chest disease improved. When this class of drugs was given to depressed patients, the great majority showed relief of Euphoria and depression symptoms within three to four weeks. Then it was learned from laboratory studies that these drugs were inhibitors of monoamine oxidase, an enzyme normally present in the brain which metabolized chemical sub- stances known as biogenic amines (that is, serotonin, norepinephrine and dopamine). Thus, by inhibiting the enzyme, these drugs stop the metabolism of biogenic amines and result in an increase in the amounts present in the brain. Other effective antidepressant drugs, the tricyclics, have been shown to af- fect the action of norepinephrine in the brain by interfering with its reabsorption and inactivation. This converging group of findings takes on added interest from the fact that the bio- genic amines are thought to be the sub- stances by which information is transmitted from one nerve fibre to another at the junc- tion known as the synapse. These chemicals are not indiscriminately distributed through- out the brain ; each has a very specific pattern of high concentration in some areas and low concentration in others. Thus, the effects of an increase or a decrease in the normal concentration of a given transmitter will have different effects in different parts of the brain. The evidence at present available sug- gests, but does not prove, that norepine- phrine is related to mood, insufficient amounts leading to depression and excess resulting in mania. But since serotonin activity is also low in the brain of many such patients, even when they are clinically well, a disorder in the metabolism of this chemical may be a background factor which produces clinical symptoms when norepinephrine concentra- tions are abnormal. Schizophrenia seems to be associated with excesses of dopamine. The phenothiazines which improve schi- zophrenia block the effects of dopamine on its receptors; amphetamines, drugs that can produce a toxic state resembling schizophre- nia, enhance dopamine action. At the same time, there is evidence of an accompanying disorder in norepinephrine metabolism in schizophrenics. A clue tying the two obser- vations together is the discovery of the en- zyme dopamine-beta-hydroxylase (DBH) which converts dopamine to norepinephrine at certain endings in the brain. Improper ac- tivity of that enzyme could result in an ex- cess of dopamine and an insufficiency of norepinephrine. A recent post-mortem study of the brains of schizophrenic patients showed DBH activity to be below normal levels. This finding will require confirmation but, if verified, will bring us close to the location of a key biochemical defect in schi- zophrenia. The details of the biochemical story are more complex than this brief account can indicate and the published literature con- tains contradictory findings. What I have outlined is the most plausible, but still not fully proven, explanation of the facts we have. We appear to be nearing answers to basic questions, answers that will have prac- tical outcomes. The cause of mental disorder will not be found exclusively in derangements in body biochemistry. Patients are people; the mind affects the brain and the body just as brain and body affect mind. The stresses of life can unhinge the mind by causing emotional changes and the consequent release of hor- mones. Whatever means of medical treat- ment are employed, the human climate of the hospital can itself speed or retard recovery; indeed, the apathy and regression in behaviour produced by long-term con- finement in inadequate institutions are often more handicapping than the patient's symp- toms on admission. Moreover, even when 6 44. Delightful identical twins—a picture of health. It was the systematic observation of twins which gave scientists the first clues to the hereditary nature of such mental disorders as schizophrenia. (Camera Press London ID) their acute illnesses have abated, patients require time and the right conditions to recuperate and relearn social skills; their recovery will be stable only if they have op- portunities to form loving relationships and to find satisfying work. The strong evidence for the role of genetic factors warrants optimism rather than the pessimism evoked in most people by the idea that a disease is hereditary. For, if we can tell what persons are at risk from a given disease, we are better able to find ways of intervening in order to prevent it. This can be done now for a type of mental retar- dation in children (phenylketonuria) result- ing from an enzyme abnormality; a special diet from birth enables most of the children affected to attain normal levels of intelli- gence. In the case of schizophrenia, we know only that children born of a schizoph- renic parent run 10 times the usual risk of becoming ill; yet only 1 in 10 is affected. If we can pick out that one child before he shows symptoms, we can find some way to reduce the likelihood of his getting sick. Al- ready, we can help manic depressive patients to stay well after they recover from an epi- sode of illness by administering the element lithium as a prophylactic. How much better it will be when we can prevent that first epi- sode as well! If psychiatric research is able to obtain the necessary public support to maintain the present rate of progress, there is good rea- son to hope that, within a decade, investiga- tors will have pinpointed the specific biolog- ical abnormalities in the schizophrenias and the manic depressive disorders. This will provide a basis for tailoring chemical reme- dies (the "magic bullets" of Paul Ehrlich) more closely fitted to the derangements in body metabolism. Up to now, we have had to rely upon chance discoveries like the first phenothiazines and antidepressants; once they had been found, chemists modified the drug molecules in the search for more effec- tive substances. But drug design will be far more efficient when the abnormality that requires correction is known in precise detail. Psychiatric research is not just an in- tellectual stimulus for medical school pro- fessors, nor is it the work of mad scientists trying to dominate the world, although, ob- viously, any scientific technology can be misused. Rather, it is an undertaking in the best tradition of medicine which endeavours to understand fundamental biological processes in order to provide relief for human suffering. As such, psychiatric research merits the support of people the world over. Mental illness is an unsolved problem in every country; the genius of each nation's scientists will be needed for its solution. Science knows no national boun- daries and discoveries made in any country become the common property of all. ■ 7 mental health public health by Dr Karl Evang Dr Brock Chisholm, the first Director-General of WHO (1948-53), was one of the first to emphasize that it would be inconceivable for society ever to produce enough psychiatrists to treat the mental disorders it was creating. A psychiatrist himself, Dr Chisholm pointed out that only preventive measures such as promotion of a healthy environment would enable mankind to preserve emotional equilibrium. Although large numbers of people are able to resist some of the most feared bodily diseases, almost everyone seems susceptible to mental illness if the strains and pressures are strong enough and the social climate is sufficiently unfavourable. This article presents some reasons why public health action should be directed to preserving both bodily and mental health. The term "public health" today creates more confusion than clarity. Although it is still widely used, in fewer and fewer places does it keep its original meaning. As might be expected, the expression arose in coun- tries where health services had long been divided between the public sector, for which the government authorities are responsible, and the private, or commercial, sector left to the individual initiative of the consumer, i.e. the patient, and the producer or distributor, i.e. physician, dentist, hospital and so on. According to the classical formula, the out- put and quality of services in this private sector should be governed by the so-called "law of demand and supply". Nowadays the distinction between the two sectors is becoming increasingly blurred and serves little useful purpose. In many countries it is not accepted, either ideologi- cally or in practice. The USSR, Cuba, the People's Republic of China and other coun- tries based on socialistic principles do not see health as a private affair; the health of the individual as well as of the population at large is, in principle, the full responsibility of the government. In the very poor countries of the world, where health services had to be restarted more or less from scratch when the period of colonialism was over, all types of health services—as a matter of necessity—had to be provided as a public, free service. The purchasing power of the population did not permit even the establishment of a modest prepaid medical care programme, much less individual purchase of health services when needed. In other countries still dominated by capi- talistic ideology, a more or less clear split has gradually arisen between those adopting a "welfare state ideology" (for example Denmark, Finland, Iceland, the Nether- lands, Norway, Sweden and the United Kingdom), and those that stick to the tradi- tional free enterprise and competitive type of society. But even in the leading free enter- prise society, the USA, the Government, as we know, has gradually been pressed to take more responsibility not only for health pro- motion and preventive medicine, but also for diagnostic, curative and rehabilitation services and for care of the long-term patients. It is not only the rapidly rising "In proportion as the strength of the mind is greater than that of the body, so those ills are more severe that are contracted in the mind than those con- tracted by the body." Cicero, Philippic Orations, XI costs of adequate medical care that have contributed so strongly to this development, and created the necessity for society to find a rational way to finance its health services. It also has to do with the general trend in planning the use of the resources in person- nel, institutions and equipment that will be needed in the future health services, and in controlling the quality of those services. However, the expression "public health" is still in current use, and has been retained in the title of this article for at least two rea- sons : First, it calls attention to the current trend for governments to take more respon- sibility in all matters of health, including mental health. Second, it suggests that the methods and approaches first applied by public health authorities in the field of somatic medicine should now be applied, and to an even greater degree, to the field of mental health. Before going further into this last point, we should remember that there does not ex- ist any disease, infirmity or injury, whether inherited, congenital or acquired; that does not include a psychological or, should we rather say, a psychosocial component. Such a factor may have to do with the causation of a disease or may influence the patient's ability to recognize or accept the disease, his willingness to seek advice, or his access to adequate diagnostic facilities, therapeutic procedures and after-treatment care. Quite often the patient survives but has been weakened by the disease or left with physi- cal or emotional after-effects. Psychosocial factors may prevent a harmonious and con- structive return to his former place in his family, his work, or his community. We are slowly gaining a better understanding of the fact, hitherto somewhat ignored by the health services, that the body is a slave of the mind. Cannot, then, the experience gained from the remarkable advances in somatic medi- cine be turned to account in dealing with mental disease and infirmity? This may seem relatively simple, but in practice it becomes complicated. The principles applied in somatic medi- cine may be summarized as follows : Identify and study pathogenic agents. Define vulnerable groups and groups at high risk. Apply epidemiological methods to ana- lyse the many factors in causation and pathogenesis. Select areas where preventive measures may be expected to yield the greatest benefit. In attempting to give a simplified, birds- eye view of the pathogenic agents and pos- sible preventive measures in mental illness, it is useful to go by age groups. 8 9 Mens sana in corpore sano (a healthy mind in a healthy body) has been mankind's goal since the Classic Age. Society, however, may be laying too much stress on physical health while shirking its responsibilities for the mentally sick. ( Photos Adele Macchi (C) ) The body is the slave of the mind mental health is public health The very young child, the baby, is as we now know dependent for its normal mental development on continuous loving care, in- cluding skin contact with the mother or a full mother-substitute. Further, the infant's mental health depends on a sufficient amount of stimulation and activity. If the baby is deprived of any of these components in its psycho-social environ- ment, the well known and clearly defined "deprivation syndrome" may occur. This may present itself in the form of a retarda- tion, an autism or other conditions which later may be very difficult to remedy. It seems that the life pattern in the countries with the greatest economic and technical development increases the risk that these deprivations will occur. The decline in breast feeding, the mechanization of daily life, the fact that a mother is busy most of the day outside the home, are among the ad- verse influences. Whether the mental dam- age produced during the first two years of age can ever be fully overcome is an open question, but it seems that those exposed to such unfavourable conditions will later be at very high risk as far as mental illness is concerned. The pre-school child. In our days, at least in the more developed parts of the world, the pre-school child is now relatively well protected as far as most serious communi- cable diseases are concerned. We may have been lulled into complacency by the low morbidity and mortality figures. Yet the mental health of the pre-school child is highly vulnerable, and perhaps more so the more complex the society in which the child lives. Inescapably, indeed brutally, he or she is faced with the task of adapting to the rules of society and accepting the "yesses" and "nos", the taboos and "holy cows", the suppression of certain natural instincts and inclinations and the encouragement of oth- ers, mostly without any explanation that the child understands. To find a way through these tricky and shark-infested waters, the child has only amateurs as guides—the parents or grandparents, themselves prod- ucts of a highly questionable education and frequently poor examples of mental maturi- ty and harmonious interpersonal relation- ships. That adolescents must be regarded as a group at high risk in most countries is now clearly recognized. In fact, the apparent deterioration in mental health of a consider- able number of young people now causes grave concern not only to their families, but also to society in general and even to the criminal courts in a great number of coun- tries. "Maladaptation", "alienation", "drop- outs", "sub-cultures" are some of the key words we hear in this connexion. Whether the symptoms are general inactivity and non-engagement, abuse of alcohol or other dependence-producing drugs, vagabonding or juvenile delinquency, they obviously pre- sent serious health problems. Traditional health and social services are not organized and staffed to deal with such problems, and readjustments have been slow and difficult indeed. This is due partly to the fact that too often the reactions of society to these problems of adolescence have reflected dis- criminatory and moralizing attitudes instead of taking a preventive and therapeutic ap- proach. Beginning adult life means to enter an arena with new enemies as far as mental equilibrium is concerned. Individuals of both sexes are now supposed to become produc- tive and constructive, to have woven a net- work of interpersonal and social relation- ships, and to get full enjoyment from sex, food, work and leisure time in the family, the community and the place of work. Yet it has become only too obvious that the men- tal health of an increasing number of adults breaks down in one way or another, and we must conclude that psychosocial and—not least—socioeconomic factors often produce problems and create stresses that are too much for the individual to bear, even with the help of family and friends. The Technical Discussions at the Twenty- seventh World Health Assembly in May 1974 brought out very clearly the multitude of social factors that influence mental health and disease. We are indeed faced with the fundamental question whether the model on which most of the world has based its pre- sent and future life—industrial mass-pro- duction, uninterrupted economic growth, in- creased utilization of the earth's resources— is in fact compatible with mental and social health. Old age: Now perhaps finally the individ- ual might expect to find some respite from his worries and stresses, and to enjoy a rest- ful life for the years remaining to him. Yet those dealing with the health problems of the aged tell us that, among them, mental troubles are still dominant. This has been most evident in the countries of the world that are most highly developed economically and technically. The lack of meaningful ac- tivity, the feeling of being forgotten, isola- tion from the rest of society in institutions, the abrupt fall in income—these are some of the burdens added to the unavoidable ex- perience of getting older, with gradually fail- ing capacities of body and mind. The picture I have sketched may seem dark and depressing. Yet it should not be, for we live in an encouraging era when health and social services are discovering and re-discovering the psychosocial and socioeconomic factors influencing both mental and physical health. Investigating and understanding the causes of ill-health must always be first steps towards preven- tion and cure. Since the pathogenic agents of mental troubles are usually man-made, man should also be able to remedy the situ- ation and turn the tide. Mental health is, therefore, "public health" in the sense that society has an over- riding responsibility to include, in its general system of health services, measures to pre- vent and cure mental disease and to rehabil- itate those on the road to recovery. Since social and economic factors play such a great role in mental ill-health, it could even be argued that governments bear a greater and more direct responsibility for protecting the health of their peoples' minds than for protecting that of their bodies. ■ "Youth is full of pleasance, Age is full of care." Despite pension schemes and "senior citizen" clubs, it is no less true today than in Shakespeare's time that ageing limbs must bear increased mental burdens. 1 0 '4„.■ it‘ - 4..r% , • - ". 4 . a nurse in tanzama by Thomas Nchimbi Sekamaganga This article is a first-hand account of how a developing country has been able to adapt to its own needs and put into effective practice some modern methods of care for mental patients. T anzania is a developing country in Eastern Africa that has waged a national war against her most deadly enemies, poverty, ignorance and disease. The mental health service has never lagged behind and psychiatric nursing has witnessed changes. From a service that used to be regarded as forcing the patient away from his family bonds, it has moved to community care of the mentally sick. In this respect community care means treating the patient while in the hands of relatives. Long before the 1960's the writer wit- nessed even worse difficulties in manag- ing the mentally ill in the country. Then there was only one mental hospital ac- tively providing services to mental patients. It was the Mirembe hospital, situated in Dodoma, in the central region of the country, where today the official capital and the headquarters of the Party (TANu) are being moved. Mirembe hospital admitted patients referred from every corner of the main- land of Tanzania. The following are only a few of the numerous problems encountered. The Tanzanian social and cultural background of tolerating the mentally sick restricted opportunities for patients to get to the hospital. This was a delay- ing factor in tackling the disease while in its early phases. The country's vastness and the dis- tances to reach the mental hospital made the journey quite exhausting. The nature of some of the mental disorders resulted in some turbulent experiences en route. Malnutrition and infestation were amongst the factors contributing to physical and mental illhealth and making the patient an easy prey to inter- current infections. As it might be expected, patients took longer to recover their health. Therefore their departure from home was rightly accepted as being one of no return. Another drawback was the economic stand taken by the Government and the relatives. The escort of recovered patients back home by the nursing staff was very carefully scrutinized and had to be carried out cautiously in order to avoid the misuse of funds. Relatives failed or were unable to pay frequent visits, thus straining family ties and planting in most patients an atti- tude of mistrust or ideas of persecution, 4— Bringing water from the well. Unable to cope independently at home, patients at the Mwera psychiatric village undertake communal work as a first step towards rehabilitation and reco- very. (Photos WHO/P. Almasy) hatred and anger. Relapses were not un- common and Mirembe hospital had many chronically ill who remained un- able to readjust well again into the com- munity life following institutionaliza- tion. In the vigorous attempt that was made to re-organize the country's health service and to bring good health to the people, the mental health service was never left out. On the curative aspect of the mental health service two major ideas came up. The first was to open and develop psychiatric units at every regional gener- al hospital and every consulting and teaching hospital, thus avoiding the con- struction of specific mental institutions similar to the Mirembe hospital. The second was that every such psy- chiatric unit had to be accompanied by a Ujamaa (socialistic) psychiatric village. Like any other new ideas brought to mankind, at first these were received with a certain contempt or at least scep- ticism. The idea of having psychiatric units along with the physically ill and organizing villages for, and run by, the mentally disturbed was, in the view of many officials, impracticable if not im- possible. However several psychiatric units have been opened since 1965. One is the Muhimbili psychiatric unit operating under Muhimbili Consulting and Teach- ing Hospital in Dar es Salaam. Along with the unit is the Mwera Ujamaa psy- chiatric village which is fifteen miles away on the Kilwa Road outside the city of Dar es Salaam. This is a psychiatric unit of 50 beds for both male and female patients. Con- TANZANIA Tanzania is a country of approximately 14,000,000 people, bordering the Indian Ocean in East Africa and lying just south of the equator. Before indepen- dence in 1961, it was a trust territory (Tanganyika) administered by the United Kingdom. In 1964, union was achieved with the off-shore islands of Zanzibar and Pemba, which had gained their independence the year before. The result of this union was the United Republic of Tanzania. Since independence, Tanzania has an agrarian socialist form of government. The education of all medical auxiliaries and nurses takes place within Tanza- nia. There are at present 11 psychiatric nurses. The author of this article, Mr Sekamaganga, is among the senior ones. Furthermore, a School of Psychia- tric Nursing was opened in Dodoma in July 1973 at the Mirembe Hospital. It admits male and female nurses who have had several years of experience and 19 students were enrolled for the first 12-month course. The Ministry of Health has set out a detailed curriculum for the course. The introduction includes: definition of psychiatric nursing, mental illness and mental health; history of psychiatry in Tanzania; public beliefs and opinions about mental illness; mental health services. Consideration is given to mental mechan- isms, psychopathology and care and treatment of patients with various mental symptoms and disorders. Special attention is given to community psychiatric nursing: introduction to public health nursing and case-work, pre-care and after- care, and the relationship of the psychiatric nurse with psychiatric social workers and other workers in the health field. Practice is arranged in outpatient and inpatient units, in satellite psychiatric clinics, dispensaries, villages for psychia- tric rehabilitation, and in home visits to follow up patients in the community. A point of importance in the Tanzanian scene is the "ujamaa" (cooperative) village. This village concept serves as an appropriate model for the villages for convalescent psychiatric patients. The idea of the village originated as a means of relieving the over-crowded conditions in the psychiatric hospital and in the subsequently developed psychia- tric units. Lending encouragement to the idea of the village was the international experience that psychiatric patients doing work outside the hospital generally improved in their social and emotional adjustment. These villages are built by the patients, who use local materials, at low cost. The government has made available sufficient acreage surrounding the village. Chickens, goats, pigs, and cattle are also cared for by the villagers to assist in their subsistence. 13 A lesson in bead- work for a girl patient at a Dar es Salaam hospital. nected with it are occupational therapy and EEG extensions and a psychiatric social work department. Patients are admitted, treated and dis- charged to the care of relatives as soon as they are sufficiently stabilized. The maximum length of stay in hospital is four weeks. They come back for follow- up visits either on their own or escorted by relatives. Such outpatient consulta- tions are held three times a week. The psychiatric social work depart- ment has an extremely big role to play in keeping contact by advising and reas- suring relatives, employers and school authorities in conjunction with the psy- chiatric medical and nursing authorities of the unit. Treatment in hospital consists of chemotherapy, physical treatment in- cluding electrical convulsive therapy and occupational therapy, together with recreational activities and intensive nursing care. There is also psychothera- py which includes patients' group dis- cussions. Patients referred in from district hos- pitals around Dar es Salaam are treated and follow-up visits are conducted by a visiting team at the respective district hospitals in consultation with the host District Medical Officers. The District Medical Officers are advised to refer patients to the unit any time between visits should they think fit. The senior psychiatric nursing officer is responsible for organizing, planning and directing all nursing activities in the unit and at the Ujamaa psychiatric vil- lage. He has to supervise nursing perfor- mance and the studies of students at the psychiatric unit. All student nurses from the Muhimbili School of Nursing obtain psychiatric nursing experience even if not taking it as a specific subject. From time to time arrangements are made for students to go and work with mental patients in the village as part of their practical experience in psychiatric nursing. The unit is also a training ground for medical students from the University of Dar es Salaam who have to undergo some elementary training in psychiatry as part of their general medical training. At times, and indeed all too often, some of the patients' stay at home is not quite as satisfactory as expected. This may be due either to the nature of their mental condition, or simply to the patient's social maladjustment. Occa- sionally relatives may reject patients and prefer hospitalization for an unlimited period. In such cases the psychiatric village serves the purpose until the psychiatric social department can find a way through the problems in the home. This is like most of the other ujamaa psychiatric villages in the country. They are, as previously mentioned, run by the hospital authorities and the patients' relatives do not live there. Relatives are encouraged to visit, and transport is available three times a week. The Mwera village can take about 70 patients both male and female. It is ex- actly like any ordinary village in the country. There is no fencing and patients are free to walk to any neigh- bouring villages any time after the regu- lar village activities. The women are carefully screened by the family planning authority. Post- menopausal women are the best suited candidates but that is not a strict rule. Psychiatric ujamaa villages are set up mainly to serve as a permanent home for patients who, for one reason or an- other, have no home of their own and whose state of mind remains such that they would not be capable of living an independent life in the community. They are encouraged in many ways to make the best of the village life. They also serve as a "convalescent home" for patients after intensive hospi- tal treatment and before their final dis- charge and return home, or as a "reha- bilitation centre". They prepare patients for manual work like that of normal village life at home. This is in line with the national policy of "socialism and self reliance". Patients are rehabilitated, learn good habits and are prepared to fit into group work and communal collec- tives. One of the advantages of the village scheme is the small ratio of patients to staff, an average of 4 staff to 50 patients, whereas the staffing in mental hospitals is explosively high. All staff posted to the village must have had some basic inservice training and sufficient psychiatric nursing ex- perience. In addition to that they have to possess or to have acquired some skill in carpentry or masonry or some ele- mentary knowledge in agriculture and animal husbandry. The village has some coconut-trees, cashew-nuts, pineapples, banana plants, orange trees, sugarcanes and garden vegetables. The village also rears some chickens for eggs and for eating and some goats. All this is done by the patients themselves under the supervision of the four village staff. All these projects are steadily being expand- ed. All the staff work together with their patients to discuss and plan their day- to-day activities. Food preparations, laundry and patients' dormitories are run by the patients and supervised by the staff in unison. The unit and the ujamaa village plan have thrown light on many of the prob- lems of the mentally sick in Tanzania. The plan has successfully found its way into the overall National Health Pro- gramme project, but it has a long way to go to realize its full value. This change in the method of taking care of the mentally disordered is doing away with the old method of custodial care which keeps patients away from their relatives, families, properties and jobs, and retains them in mental hospi- tals and institutions to the sad point of institutionalization. Another present advantage of having psychiatric clinics operated at district hospital level is that mental patients detected in general wards are promptly referred to the psychiatric personnel when that course is indicated. Those personnel also see the patients in the general wards and may treat them while still occupying a bed in the same ward; this gives the generally-trained nurse an opportunity to learn how to handle the mentally disturbed. Alternatively the doctor may decide to transfer the patient to the psychiatric ward for prop- er management by the psychiatric nurs- ing staff. Patients tend to benefit more from the short hospital stay, and even the stay at the village does not so very much dis- turb the deeply rooted "African extend- ed relationship bonds"—something much missed once it is tampered with. Families are encouraged to get and to remain interested in their sick relatives, and thus the sense of deprivation and rejection is minimized. The majority manage quite well to live with the patients at home, and escort them back to the hospital from time to time on the dates of appointments. Perhaps the most rewarding of my ex- periences is when I see the general nurse escorting the mentally sick patient from her ward to the psychiatric unit for con- sultations and taking him back with her to carry out the psychiatric treatment. Such a practice would have been regard- ed with ridicule and disgust in the past. It is a great relief to note that the general nurse accepts the mentally dis- turbed as a patient, and that the prob- lems of mental patients become our problems, that is the problems of the general nurse as well as of the trained psychiatric nurse. ■ 15 O ne-third of the patients at the Ari-drea di Servio Galatti Psychiatric Hospital outside the Italian seaport of Trieste go home every evening. Where once 1200 mental patients were confined in huge dormitories, today there are only 578 residents living in single- or double-occupancy rooms. Out-patients number 300—and the figure is still ris- ing. Only potentially violent cases are still kept under strict medical supervi- sion. Restaurants, cafes, games rooms and sports fields, beauty salons for women and barber shops for men all help to reassure the patients that they live in a "normal" society. There is no fixed daily timetable, and residents wander freely in the spacious grounds. But the hospital's director, Professor Franco Basaglia, encourages patients to take part in any activities which may have therapeutic value, and he has start- ed a work cooperative where volunteers are paid at an hourly rate for whatever job they choose to do. ■ Above: A formal setting for a new era of psy- chiatric care. On a hillside above Trieste, the neat buildings of the Andrea di Servio Galatti Hospital stand among tree-lined lawns. Right: The hospital's own church contributes to the impression of an ordinary work-a-day community. Opposite: Where loneliness is a matter of choice. A patient takes a stroll on a woodland path. (Photos WHO/P. Almasy) alo -"9 11111111110 a. 16 experiment in trieste: mei rtal care with a difference experiment in Trieste The friendly argument might be taking place in any Trieste bar. Bar billiards and the fami- liar functional chairs and table recreate an at- mosphere to which psychiatric patients can easily relate. Routine cleaning jobs are done on a voluntary basis and some work is even paid for by the hour. Hospital Director Basaglia believed psy- chiatric institutions should always pay patients for the work they do. Group therapy in action. A psychiatric nurse is present and the accent is on informal and relaxed conversation.

when social stress proves too strong by Professor Peter Sainsbury Social factors are related to the occurrence of mental illness in a number of ways. It often happens that social events or conditions are largely responsible for precipitating a mental illness, while social conditions may combine with psychological or biological factors to predispose an individual to illness. As the sociologist would put it, the cultural environment and the changes in it certainly affect the prevalence of mental illness in a community and in the social groups composing it. Social factors can also influence the course and outcome of a mental illness, since the effectiveness of treatment will depend largely on the social context in which it is provided. Moreover, retraining and rehabilitation programmes are necessarily designed to meet social objectives. Cultural attitudes and beliefs also play a part in defining who in a society is to be labelled mentally ill, in the process by which a person is recognized as needing treatment, and in the decision whether or not he is to be referred to the psychiatric services; they also influence the scope and the type of psychiatric services that society provides. nforced separations, loss of employ- 1 ment, immigration and moving house are examples of socially deter- mined events in a person's life that have been shown to precipitate both mental illness and suicide. In one study of the employees of a large company that kept detailed medical records, it was found that each individual's illnesses, physical as well as mental, occurred in clusters with intervening periods of normal health. Next, biographies were compiled and the illness clusters were found to coincide with the stressful periods in the life of the employee. In another investi- gation, naval personnel completed a questionnaire listing the social changes they had experienced in the previous year. Their scores successfully indicated their likelihood of becoming ill; the greater the number of changes in their lives the more they suffered from both mental and physical disorders. These studies show us that psychosocial stresses precipitate all kinds of illnesses and not simply mental ones. It has, however, been very clearly demonstrat- ed that people with depression and with schizophrenia have, in the months im- mediately preceding the onset of their illness, experienced more stressful events than have normal people within a simi- lar length of time. Apart from the more acutely disturb- ing psychosocial stresses, there are cer- tain social situations that predispose the people exposed to them to mental illness and engender deviant behaviour. Adverse socioeconomic conditions such as poverty and its concomitants, overcrowding, bad housing and under- nutrition, debilitate the individual and, by fostering frustration, hopelessness and feelings of social rejection, make him more vulnerable to psychological disturbances. But the precise reason for the comparatively high level of mental illness found among the poor is not easy to disentangle. Besides the effects of poverty in producing mental stresses, there is the tendency of the chronically mentally ill and the mentally retarded to fail socially and so drift into poverty; moreover, the standards of health ser- vices available to the poor are usually low. Another aspect is that the effect on mental health is more detrimental when poverty is imposed by misfortune. Sui- cide, for example, is much higher among men who have become poor than among those born to poverty. Rapid social and cultural changes af- fect man's well-being and mental health. In particular, industrialization, popula- tion growth and the other changes that have accompanied technological ad- vances appear to be badly tolerated. Pollution by noise or by industrial ef- fluents, and the unrestricted destruction of the amenities of the natural environ- ment are eroding the quality of life; evi- dence is beginning to accumulate that The child in the concrete jungle. Modern — youth faces as stark an environment as ever confronted the budding caveman. (Photo WHO/K. Kalisher) 20

when social stress proves too strong they actually contribute to psychological illness. Rapid urban growth is another example of change that is affecting health. Alienation is fostered by urban- ization and the resulting lack of recrea- tional facilities, and by the unplanned emergence of areas of social squalor and dormitory estates where people live in anonymity and loneliness. Indeed, wherever people's links with their fami- ly, occupational or community group are diminished, mental illness and other pointers of human despair such as sui- cide and violence are found to increase. The ease with which individuals and populations can move between countries from rural into urban districts, and also between social classes is another rele- vant aspect of social change; social mobility tends to isolate people and to lead to psychological disturbances. Surveys of immigrants to the USA, of people who move within cities and be- tween cities and, most revealing, of peo- ple who are compelled by circumstances to move house have shown that all these have a higher risk of becoming mentally ill than others who have not recently changed homes. Similarly people who alter their posi- tion in the class structure, and thus iso- late themselves from their previous neighbourhood or community of origin, also suffer more mental disorder and are more likely to commit suicide than those who remain static. However, the relation of class mobility to mental ill- ness varies with the type of disorder— neuroses tend to be associated with movement up the social scale and psy- choses with movement downwards. On the other hand, mental illness is not necessarily related to social condi- tions or social change. The individual is as much the product of his biological or inherited make-up as of his personal and social environment. Many people at some time change their positions in soci- ety or live part of their lives in a socially disorganized urban environment, and all suffer bereavements, separations and other social adversities, but only a rela- tively small proportion have a serious mental illness. Hence personality must be considered one of the factors deter- mining how we cope with life's stresses and whether we react to them by becoming ill. But, as has been shown, social and cultural experiences also play an essen- tial part in forming the personality and therefore in predisposing an individual to illness. These experiences are the fruit of membership in a succession of social groups, starting with the family and go- ing on to the school, peer, and occupa- tional groups; each plays a part in determining our beliefs, attitudes and customs. It is as members of these social groups that we learn our roles and ac- quire our values and expectations. But if the child is deprived of a family life, for instance, or if the values instilled in school conflict with those that prevail at work, one teaching Christian humility, say, and the other an aggressive compet- itiveness, personality is impoverished and the seeds predisposing to psycho- logical disorders are sown. The child may simply not acquire the accepted norms of the culture from his family either because of prolonged sep- aration from the parents or through defects in the parents' personalities or because of their social alienation. The child then grows up bereft of the rules and guidelines that shape his behaviour, and this may lead to asocial acts and a proclivity to a psychiatric disorder. The rapid social changes that are now so general profoundly affect the family structure and the roles of its members. Families have become smaller, are sep- arated from the extended family and of- ten live in restrictive urban apartments; family tensions are increased as a result of the widening gap between the values of one generation and the next. Moreover, changing economic needs and modern methods of birth control are both factors modifying the tradi- tional roles within the family. The mar- riage relationship and family life do not easily adjust to these innovations; and it is often the mental health of the children that pays the price of failure. The expectations and standards that children acquire in school are often at variance with the more traditional ones obtaining at home; recent work has shown that changes of school, and even of teachers (the usual pattern in a social- ly mobile community) predispose chil- dren to psychological disorders. The characteristics of the occupa- tional group have also altered as a result of automation and the rationalization of production. Opportunities for finding satisfaction in work and comradeship in working are becoming fewer; imper- sonal relationships, monotony and men- tal fatigue are commonplace; and not surprisingly, the rate of absence due to psychological disturbance is increasing. In England, for instance, absenteeism due to "nervous debility" doubled in seven years from 1.9 million days of in- capacity to 4.2 million. And in Sweden the poorest mental health is found among the workers who feel most alie- nated. In countries where work is a cultural expectation, those who have a different attitude to it are likely to be regarded as social misfits. The unemployed feel guil- ty and anxious simply because they are not working and apart from the fact of not earning, and therefore suffer a high rate of mental disorder and of suicide. The clinical manifestations of mental disorder are also related to social fac- tors. Schizophrenics, for instance, tend to have delusions of persecution if they are immigrants and of grandeur if they belong to the higher social classes; the incidence of psychosomatic disorders is higher among the less educated; certain psychoses such as "amok"—a sudden impulse to violence and murder—are seen in some cultural environments but not in others; and the prevalence of cer- tain disorders appears to change over time according to whether or not they are socially disapproved of. The ap- parent decline of "hysteria" in many in- dustrialized countries during the last few decades is a case in point. Societies therefore differ in the modes of behaviour they condone and those that they restrict. In one, alcoholic in- toxication may be thought evidence of severe mental instability while in anoth- er it may be lightly dismissed. Further- more, the indications of mental disorder also vary with the culture. Behaviour that might be designated as schizoph- renic in one milieu may be seen as laud- able or unexceptional in another. In a rapidly changing society attitudes to mental illness and to the mentally ill will change too, and this can have im- portant effects on the course of mental illness and its treatment. Advances in knowledge of psychiatric illness and especially the development of successful treatments for conditions such as depression, have profoundly in- fluenced attitudes to the mentally disor- dered and to their care. Superstitious beliefs about causation and the resulting fear of the madman are waning; instead a mentally disturbed person is now seen as a patient, one who is suffering from an illness as worthy of study as any oth- er. This more rational approach has led to more tolerant, humane and permis- 22 The scene is a pedestrian underpass in London. But the drama is a fami- liar human tragedy throughout the world: loneliness and the bottle that gives .a brief illusion of freedom from stress. (Photo Camera Press (0) sive attitudes and a decrease in the social alienation of the mentally ill: mental hospitals have unlocked their doors and encouraged the patients' return to the community. These changes in the patient's social milieu have had a remarkable influence on his conduct. It is now apparent that much of the strange behaviour of inmates of the old mental asylums was in fact engendered by the over-protectiveness, the regimen- tation and the impersonal routine of the institution. The passivity and with- drawal punctuated by violent outbursts that characterized the long-term patient are disappearing; they are now recog- nized as symptoms that can be avoided by suitable social action. The social measures to prevent insti- tutionalization and to improve the treat- ment of mental disorders have been of four kinds. First, the development with- in the mental hospital of the "therapeut- ic community" which fosters social con- tact between staff and patients, and their collective responsibility, and the general improvement of the quality of life. Secondly, the introduction of indus- trial therapy and other retraining pro- grammes designed to restore the ability to live normally in the community. Thirdly, the encouragement of relatives, the community at large, and also profes- sional health workers to adopt more tol- erant attitudes towards mentally ill patients and to expect more of them. The growth of psychiatric units in the local general hospital has done much to lessen the stigma of mental disorder. Lastly, the development of community care which allows many patients to be treated in their usual family and neigh- bourhood setting or to return to it quickly after an earlier discharge from hospital than was formerly the custom. When it is not possible for patients to return home, as often happens in the case of the elderly, they may be catered for in day centres and hostels with ac- tive social, occupational and recrea- tional facilities. In developing countries with few mental hospitals it has been the custom for the local community to ac- . cept responsibility for mentally sick members; and now, in some, trained workers assist by organizing village cen- tres where treatment can be provided, as Mr Thomas Sekamaganga describes in this issue. Promoting citizen participa- tion in collaboration with professionals offers new prospects for the care of the mentally ill. These innovations are the first step towards prevention because more effi- cient care prevents relapse and avoids the unfortunate secondary effects of prolonged periods in hospital. By extending services, it becomes pos- sible to cater more effectively for the needs of the mentally ill, and to recog- nize cases at an early stage when treat- ment is more likely to be effective. But whether or not the psychiatric services are improved depends on whether soci- ety recognizes these needs, on its atti- tudes to mental disorder, and hence on where in its social priorities their care is ranked. ■ 23 South-East Asia problems old and new by Professor J.S. Neki The teeming multitudes living in those countries which WHO defines as the South-East Asia Region amount to about one quarter of the total world population crowded into nearly one twentieth of the total habitable land surface. And some idea of the scale of the region's psychiatric problems can be conveyed by estimating, on the strength of the lowest reported prevalence rates of crude mental illness, that there are around 8 million psychiatric patients in this area requiring active treatment. M ost of the developing countries which form South-East Asia have only recently emerged from colonial status into independent states. The new-born national- ism of their peoples is tempered with self- doubt about the chances of success, and thus a whole generation of people can be seen trying to come to terms both with their past history and with their hopes for a new future. Historically, the area has received wave after wave of migrations which brought in new religions—Hinduism, Buddhism, Islam and Christianity. In particular the flow of immigrants has lent these countries some kind of family likeness. But immigration has also left a rich endowment of cultural strains. While a century and a half ago the region must have contained no more than 20 mil- lion people, today the population totals well over 750 million. The fastest growth rates in the area, those for Thailand, stand at 3.3 per cent per year. More than 70 per cent of the population lives in rural areas: by contrast, only 5 per cent of Britain's pop- ulation and only 7 per cent of the United States' is rural. Well-conducted and representative surveys of mental morbidity in South-East Asia are scarce, but they do permit a rough estimate to be made of the magnitude of psychiatric problems in the region. A survey made in Ceylon (Sri Lanka) in 1961 put the prevalence rate of crude mental illness at 10 per thousand. Another in North India recorded a prevalence figure over an 18- month period of 17.9 per thousand, and a third in South India reported a prevalence rate of 9.3 per thousand. Several other surveys have reported much higher rates. However, if even the lowest reported rates are accepted, the region would have some 8 million psychiatric patients in need of treatment. Small wonder, then, that where hospital- ization facilities are generously provided, as in Singapore, about 50 per cent of all hospi- tal beds are occupied by psychiatric patients. Where beds for such patients are scarce, the mental hospitals are very much overcrowded—to the tune of 150 per cent in Thailand, 200 per cent in India, and 250 per cent in the Philippines. The North India survey already referred to found that about one third of all record- ed active psychiatric cases were suffering from hysteria—a rate of six per thousand in the population and about twice as much as for all other psycho-neuroses put together. This figure is all the more astonishing because in Western countries the condition has become so uncommon or so seldom diagnosed that some psychiatrists have begun to doubt its very existence. In the same survey, mental defectives were found to constitute about one fifth of all active cases, while psychotic disorders and epilepsy accounted for between 12 and 15 per cent of the total figures. The bulk of psychotic patients were schizophrenics. Although a significant correspondence has been reported between the data from a number of international centres studying schizophrenia (WHO International Pilot Study of Schizophrenia, 1973), several dif- ferences in the pattern of this illness have been recorded by experienced clinical work- ers in areas of contrasting cultures. For in- stance, the proportion of catatonic schi- zophrenia (characterized by phases of stu- por or excitement) which has been noted among the schizophrenics admitted to men- tal hospitals is larger in India than in most Western countries. On the other hand, the proportion of simple schizophrenics is com- paratively smaller in Indian hospitals. The higher rates of the catatonic variety have been ascribed to delayed treatment in most cases, while the lower incidence of simple schizophrenia seems to be related to better social tolerance in India for this kind of ill- ness. As regards depressive illness, studies made in Java, North India and South India show a greater prevalence of the agitated variety. By contrast the retarded variety ap- pears to be more prevalent in most Western populations. In a cross-cultural study, I have found a relative paucity of delusions of guilt among depressives in India compared with those in Western countries, while fugi- tive impulse was more frequently seen among the former group. Hypochondriac symptoms are very com- monly reported—the most frequent ones be- ing those related to bowel-consciousness or concerned with sexual potency and genital organs. The Indonesian Koro, known in China as Shook yang, is a manifestation of this concern. It is interesting that Koro- morbid fear that the penis will retract into the abdomen—has been found only in those areas of Indonesia where the Chinese cul- ture holds strong influence. Latah, another culture-related syndrome much familiar to the Malayans and Indone- sians, is an acute anxiety reaction which as- sumes psychotic dimensions. It is charac- terized by severe fright and reclusiveness studded with sudden outbursts of violence— provoked or unprovoked. "Running amok," which Professor Sains- bury defines in this issue, is a syndrome first described in Malaya but has also been iden- tified in other parts of the world. Interest- ingly, according to Van Wilfften Palthe, no case of amok has ever been observed or heard of among the many Malayans living in European countries. It may well be that conditions like amok occur because, in some way, they are implicitly accepted by the cul- ture. Among the social psychiatric problems, suicide and drug-abuse present some in- structive cross-cultural contrasts. A study made in Singapore reported significant A patient in the grounds of a psychiatric hos- pital in Agra, India. (Photo WHO/A.S. Kochar) 24

problems old and new ethnic group differences in suicide rates. The Chinese have the highest rate (males 14.9, females 9.0 per thousand) and Malays the lowest (males 1.7, females 1.4 per thousand), while Indians and Pakistanis come in be- tween (males 11.4, females 9.9 per thou- sand). In most studies made in India, female suicides were found to outnumber males ones. This contrasts with the situation in such Western countries as the United States and Norway where male suicides outnumber female ones by four to one (see article on Suicide by Dr Anthony May in the World Health issue of May 1973, which was also devoted to mental health). Self-sought "chemical solutions" to human problems pose a vexing problem in many parts of South-East Asia. In Thailand they assume alarming dimensions. From an estimated 70,000 known to be dependent on drugs in 1952, the numbers rose in three years to 250,000 and by 1970 had reached 400,000. A large proportion of these are dependent on heroin while opium depen- dence too is rampant. In neighbouring Malaysia, on the other hand, where the use of Cannabis indica is more prevalent, the narcotic dependence problem is almost non-existent. In India, chronic use of cannabis has been widespread in select communities of sadhus (holy men). Drug abuse is raising its head in university campuses almost everywhere in the region, partly as a result of the influences of the Western student community and of touring "hippies". Nepal has been considered the drug-users' paradise by such Western tour- ists. Psychiatric services until quite recently were centred entirely in the mental hospi- tals-previously called asylums or even "mental jails". While most of them have now become reasonably active therapeutic centres, a few still retain their old lament- able ways. Psychiatric beds are everywhere in short supply. Mental hospital beds per million population range between 0.4 in In- dia to 2.7 in Sri Lanka. A majority of these beds in every country seem to be choked with "incurable" or long-stay patients. Turn- over rates for mental hospitals in India have been reported as 1.9 admissions and 1.7 discharges per bed-thus the already overcrowded hospitals grow more and more overstretched. Of late, psychiatric services have found an increasing place in general hospitals, espe- cially the teaching hospitals. The following table shows the turnover from the psychia- tric services in these countries . Child psychiatry services are still rud- imentary in the region. In many places, chil- dren suffering from psychiatric disorders are still being kept in the mental hospitals along with adults. Slowly, however, the situation is improving. There is also a lack of special facilities for geriatric patients with psychiatric disorders, and even in mental hospitals the proportion of patients over the age of 60 is extremely small. This stands in vivid contrast to the situation in the developed world, where geriatric patients occupy anything be- tween 40 and 50 per cent of the psychiatric beds. The risk of developing mental disor- ders becomes increasingly high after the age of about 65. With a rising expectation of life in South-East Asia, the rate of mental disor- ders may therefore be expected to increase. Almost all the region's psychiatric care services seem to be located in urban areas, so that vast tracts of each country remain unserved by them. Recently more thought has been given to the needs of the rural communities, and efforts have been made to reach them and provide care. In Thailand, mobile psychiatric units have been set up, and in Indonesia there is a proposal for starting "rural clinics". In India, the ex- periment has been tried of erecting tented camps within the compound wall of the mental hospital where patients from rural areas can stay in company with their rela- tives who would otherwise be reluctant to abandon them. The hospital provides pro- fessional care while the relatives look after the physical and emotional needs of the patient. Rural clinics and mobile units on the one hand and hospital encampments on the other symbolize two possible ways of bringing psychiatric services to the commu- nity-a centrifugal and a centripetal appli- cation. But common to all the region's countries is the chronic shortage of trained personnel. The number of psychiatrists per million population, for example, is 0.3 in Burma, 0.8 in India, 0.9 in Indonesia, 1.3 in Malay- sia, 2.1 in Sri Lanka and 3.4 in Thailand. Nepal has one solitary psychiatrist. The few specialists that exist are mostly employed in overcrowded asylums, and are frequently so engrossed with the problems within their citadels that they are almost out of contact with the problems in the commu- nity outside. They are also handicapped by the absence of supporting professionals. General medical practitioners, whose train- ing usually omits any accent on psychiatry and mental health, tend to have a negative attitude towards this field. Psychiatric nurses are few and far between, and psy- chiatric social workers a mere curiosity in most places. Brain-drain further depletes these coun- tries of their trained personnel, to the point where many health administrators advocate that the general physician should carry the main burden of mental health care pro- grammes-a burden for which he is poorly equipped. Besides, the doctor-population ratio is frequently so low that the general practitioner is disinclined to accept the time- consuming responsibilities of tending the mentally sick. One result is that a vast majority of the population, especially in rural areas, has recourse to folk healers or practitioners of indigenous systems of medicine who have always enjoyed the traditional faith and patronage of the people and who in some circumstances may even function better than the psychiatrist. It has been observed in both Singapore and Malaysia that virtually all Chinese patients coming to general hos- pitals had already been to traditional Chinese healers. The same was true of hos- pital patients in Thailand, while in India and Sri Lanka an estimated 80 per cent of the patient population have visited practi- tioners of Ayurveda, the ancient Indian sys- tem of medicine. A cultural and social barrier thus conti- nues to exist between the psychiatrist and the community. Modern psychiatry has so far appeared to make little impact on the cultural beliefs and attitudes of the commu- nity, and a psychiatrist who has been trained in the setting of an alien culture finds himself at a particular disadvantage. Most specialists in the region are trained in Europe and the United States, while only India and Indonesia have established their own postgraduate institutes for psychiatric training. Most of the region's countries still give a low priority to their public health services in terms of allocating public funds, and mental health in turn is given a low priority in pub- lic health. This is understandable while mal- nutrition and infectious diseases continue to require urgent attention. But as these ills are slowly overcome, mental health is going to be one of the region's top priorities for tomorrow, and steps must be taken today to Mental hospitals (in- patients) General hospitals (in- patients) Out- patient units M.H. & G.H. Child gu i dance - cli- I nics - Mental retar- dation homes Day/ night hospi- tals Mobile units Total Burma 2,000 600 2,800 - - - - 5,400 India 39,000 12,000 100,000 8,000 3,000 1,000 500 163,500 Indonesia 9,000 2,000 30,000 - 700 1,000 - 42,700 Malaysia 3,000 3,000 6,000 100 700 500 - 13,500 Philippines 15,000 2,000 4,000 - - 500 -- 21,500 Sri Lanka 7,000 1,000 12,500 250 550 - - 21,300 Thailand 10,000 2,000 8,000 2,000 500 1,000 70,000 93,500 From British Journal of Psychiatry, 123: 257-269 (1973). 26 train the right personnel. More facilities must be organized for training psychiatric specialists at home, rather than abroad. Even then, these countries cannot hope in the near future to have enough psychiatrists to deal with all the community's mental health needs. The brunt of this responsibili- ty will continue to fall on the general physi- cian on the one hand and the indigenous healers on the other—who can share the burden provided that they have been suita- bly instructed in the recognition and treat- ment of common forms of mental illness. As regards the general practitioner, the mini- mum that can be done is to revise the medi- cal curriculum so as to include some basic psychiatric training. The indigenous healers too can be encou- raged to bear their share of the responsibili- ty in an effective way. It may also prove possible to equip the ranks of family plan- ning workers, health visitors and so forth with additional training so that they can function as psychiatric aides. Most countries of South-East Asia have inherited foreign models of psychiatric ser- vices from colonial times, and the tendency continues for such methods to set the pace. Too seldom is it realized that these models may not be as serviceable when exported. Thus child guidance services could hardly operate in a community where parents were not prepared to give up their personal right to guide their own children. In the industrialized world, the concept has evolved of a psychiatric team, consisting at the very least of a psychiatrist, a psychia- tric social worker and a psychiatric nurse, sometimes even including a clinical psychol- ogist. This is quite an expensive set-up, which most developing countries may not be able to afford. They might prefer, as a mea- sure of economy, to train specialists who can combine more than one of these roles. To conclude then, psychiatry appears of all clinical specialities to be the one linked most extraordinarily with sociocultural fac- tors. These factors vary from country to country, from region to region—and so do psychiatric problems. If there is to be a link between training and function, psychiatric education must gear itself to new social roles and new social needs. As these needs become better defined, so the burden of leadership and responsibility becomes clear- er that psychiatrists in the South-East Asia region must shoulder in providing mental health care for their respective communities. It is on their responsiveness to these duties that the future mental health prospects of the region will depend. ■ Thailand's child guidance clinic in Bangkok was set up in 1951. Two little girls arrive at the clinic for tests to determine why they are not getting on well with the people among whom they live. (Photo WHO' Pierre Pittet) prevention and treatment blighter prospects by Professor Carlos A. Leon T he last decades of the 20th century offer a convenient standpoint from which to survey the evolution of various methods of treating and preventing the many different types of mental illness. This attempt to recapitulate what has been learnt already about psychiatric care and to pick out the likely trends of the future does not claim to be exhaus- tive. But its aim is to offer a broad pan- oramic view of mental care during the century in which we live. At the start of the century, while Western psychiatry was still strongly in- fluenced by the notion of "degenera- tion" underlying the majority of mental disorders, the advent of Freudian psy- choanalysis came as a thunderclap and caused an abrupt polarization of opi- nions. Psychoanalysis represented a vigorous alternative to the fatalism and scepticism with which most psychiatrists approached mental cases. In its classic form as well as in its many derivatives, therapeutic psychoanalysis added a new and dynamic dimension to the concept of mental illness, widening and systema- tizing the quest for prevention, treat- ment and cure. About the same time, the Russian physiologist Ivan Pavlov completed his monumental study of conditioned reflexes in animals and turned his atten- tion to those of mankind. In the after- math of his experiments and discoveries, John B. Watson and others formulated the basic principles of behaviour thera- py. The first quarter of the century pro- vided a fertile field not only for theoretic studies but also for the practical treat- ment and prevention of mental illness. Wagner von Jauregg discovered a treat- ment for the general paralysis of syphi- litics by provoking a fever with the inoc- ulation of plasmodium vivax. Joseph Goldberger shed light on the etiology of pellagra and showed how it may be pre- vented and cured by a diet rich in fresh animal proteins and with a high content of nicotine acid. This period also saw the emergence of barbiturates, powerfully effective hyp- notics and sedatives whose versatility, ease of administration and relatively low incidence of side-effects revolutionized the treatment of disturbed mental patients. These drugs definitively replaced bromides and opiates for seda- tion and hypnotic purposes and helped to put an end to the ignominious tradi- tional methods of physically restraining disturbed patients. This period saw the consolidation and spread of Freudian psychoanalysis, most noticeably in the USA and some European countries, but essentially on a universal scale. This was to have reper- cussions not only on the treatment of the mentally sick but also on art, anth- ropology, education, sociology and politics. The work of child psychologists Rene Spitz and John Bowlby stressed the value of a good mother-child rela- tionship for the healthy mental develop- ment of the child. "Somatic therapy" made its appear- ance at this time. Manfred Sakel dis- covered the use of insulin coma for treating schizophrenics. Drug-induced convulsive therapy was superseded by electro-convulsive or electric shock treatment for depressed conditions. Of these innovations, only the latter is still widely used today. Yet all made valu- able contributions to the arsenal of psy- chiatric therapy by helping to control severely disturbed patients and even by eliminating or reducing some symptoms of psychosis. Now too psycho-surgery developed on the basis of experiments carried out by Antonio Egas Moniz using the tech- nique of prefrontal lobotomy. Although originally conceived as a last-ditch way of controlling incurable psychotic cases, such subsequent refinements as topecto- my and transorbital lobotomy simplified the process. The indications for its use are however very limited. All these new methods widened the horizons for mental therapies and led to important changes in the care of hospi- talized patients. Thus the "open-door" policy was introduced into psychiatric hospitals by contrast with the tradi- tional practice of isolating and confining the mentally sick. New concepts of encouraging patients to work, listen to music, play games or take an interest in the arts not only relieved the isolation and inactivity which they had hitherto suffered but also contributed towards their eventual recovery. So too did new techniques of "Stone walls do not a prison make, nor iron bars a cage." Despite the cheerfulness of this mental patient, his recovery and rehabilitation were all too likely to be retarded by such primitive conditions. ( Photos WHO) 28 4 .~ ~.: ~f IN COLOMBIA TODAY About 85 per cent of the one million inhabitants of Cali—an inland city on the Pacific seaboard of Colombia—are served by the city's University del Valle Hospital in case of serious illness. It has out-patient psychiatric services but as yet no psychiatric beds. Professor Carlos A. Leon, head of the University's Department of Psychiatry, says: "Our focus is on major mental health problems such as overt psychosis and incapacitating neurosis. Our aim is to reduce disability to the point where people with such disorders can still carry on. We try too to preserve the integrity of the family: it is very difficult for a family to carry on when there is a psychotic relative who is screaming and making a scene. We have found that having an auxiliary nurse to make home visits can bring about a significant improvement in most cases. Apart from this, medication plays a major role." The University Hospital also houses a clinic of the Social Security Programme serving 10 per cent of the population, and also offering out-patient psychiatric care. Cali has two private psychiatric clinics, but non-paying cases are cared for at the San Isidro Psychiatric Hospital. Of the 40 health centres in Cali, only two have psychiatric services. One of these, the El Guabal clinic, is virtually the only source of health care for the residents of that particular barrio or city district. It stands next door to the parish church and the school, and has a full-time medical director, a chief nurse with auxiliary nurses, a half-time dentist with an assistant, a resident member of the University's Department of Preventive Medicine and Public Health, two sixth year medical students, and—one day a week—a psychiatric resident. In recent years, mental health training has been incorporated into the training of the auxiliary nurses, and they spend about two days a week over a period of several months at the San Isidro Hospital. In the barrio, they are well known and respected. When a nurse visits a particular house, it is common practice for a neighbour to call and ask her to stop by at her house; thus another patient may be detected. There is some competition between the clinic and the three "curanderos"—traditional healers or "witch doctors"—who operate in the El Guabal barrio. Their activities are illegal but the law is not enforced, largely because of the healers' popular following. group or milieu therapy as well as com- munity approaches aimed at improving the social environment within the hospi- tal so as to satisfy the patient's emo- tional needs and reduce the risk of per- sonality clashes. The advent of psychotropic drugs was to revolutionize the treatment of the mentally sick. In the early 1950s, chlor- promazine and alkaloids derived from the root of the shrub Rauwolfia were found to have an extraordinary capacity not only to sedate patients but also to restore calm to a confused imagination without harming the workings of the in- tellect. Soon the drug industry was en- gaged in an intensive quest for new products and the new science of psycho- pharmacology was born. Today the alkaloids of Rauwolfia have fallen into disuse because of their adverse side-effects and the risk of depression. The anti-psychotic drugs now in established use fall into three main groups : phenothiazines, butyro- phenones and thioxanthenes. Although the precise mechanics of their action are still not known, they all have the pro- perty of modifying or eliminating psy- chotic symptoms. Optimum dosage and the time it takes for a desired effect to occur may vary from person to person. Generally speaking, patients who re- spond well to these drugs start to lose their psychotic symptoms some six to eight weeks after treatment begins. Further compounds have appeared in rapid succession—various minor tran- quillizers, antidepressants, and drugs to combat acute anxiety such as meproba- mate and diazepam. Lithium salts are widely used for the treatment of hypo- manic and manic conditions, and if ad- ministered regularly under careful medi- cal supervision may prevent manic crises occurring. New refinements in the prep- Communal therapy takes a practical turn at Cali, Colombia. Patients and nursing staff enjoy an informal dance session, complete with paper streamers. 30 .0.07' a VII0;■■••■••■•10... favolpodo..r...,...sradil■ do`

A new spirit has infused Colombia's mental care services. Student nurses enjoy a moment of playfulness during their psychiatric training. brighter prospects aration of psychotropic drugs have pro- duced medications which can be admi- nistered conveniently at extended inter- vals without losing therapeutic effect. One result of the appearance of psy- chotropic drugs and the markedly in- creased use of group and milieu therapy and community psychiatry has been an actual decline in the number of patients detained in psychiatric institutions, while a majority of patients hitherto requiring hospitalization may now be considered for out-patient treatment. A whole new philosophy is involved in the concept of "community psychiatry." The big regional psychiatric hospitals are being replaced by mental health cen- tres situated in the very heart of each community, with the emphasis on out- patient treatment of people who may continue to play their normal role in society. Epidemiological studies enable scientists to pinpoint those sectors of the community at greatest risk of mental ill- health and to concentrate preventive measures on them. As for psychoanalysis, the present trend is for it to be replaced by other therapeutic methods, particularly group therapy and most recently "encounter groups." Hypnotherapy has also received fresh impetus. Psychosurgery, after suffering an eclipse for some 15 to 20 years, has made a comeback with the use of stereotaxic techniques which permit intervention deep into tiny and specific areas of the brain. "Orthomolecular" psychiatry pre- scribes vitamins in huge quantities for the treatment of mental disorders, but there is as yet no conclusive proof of their effectiveness. Some psychosomatic cases have been successfully treated by the so-called "bio-feedback" process, whereby sensitive instruments indicate graphically the degree of frequency or magnitude with which the brain can produce a desired response. This in turn offers a promising field for the study of neuro- and psycho-physiological pro- The man who has most to gain from the increase in trained staff and the improving conditions. Today, a distracted and bewildered individual; tomorrow, perhaps, another useful citizen. cesses. It is noted for example that by stimulating the production of alpha waves in the brain, states of conscious- ness have been induced similar to those of meditation or contemplation. Every day, refinements or innovations are added to the therapeutic methods at the disposal of the psychiatrist. New drugs are produced to solve ever more specific problems, and with ever more reduced side-effects. Memory, thought processes, and the human emotions themselves will continue to be key target areas for the new psychopharmacology. The advance of electronics, neurophysiology, biochemistry and the sciences of communication may carry bio-feedback techniques to unsuspected levels in using certain untapped potentials of the human brain. Extrasensory perception (ESP) and the whole realm of para-psychological phenomena may be subjected to scientific investigation whereas today they are given only marginal attention. As for psychotherapy, the ideal conditions for a therapeutic system to replace those now current would be as follows : (1) the system should be compatible with accepted cultural values or, better still, should generate its own values based on those ideals which the present cultural climate has not yet permitted to flourish to the full; (2) it should be consistent with scientific knowledge or contribute further to that knowledge, while opening new perspectives for investigation and adhering to principles that are easy to grasp ; (3) the system should be within the reach of large numbers of professionals, and not require too long a time for training; (4) it should be rapidly applicable, preferably to groups of patients together; (5) financially it should be within the reach of large numbers of people. Public demand and the high rate of technological and industrial develop- ment ensure that ever more effective means of treating mental illness will be found. But the basic problem continues to be that of putting these therapeutic methods within reach of all the people who need them, since large numbers of world's population still lack access to the resources that could restore their health. Let us hope that in this direction too significant progress can be made during what remains of the 20th century. ■ 33 34 mental health explained to children people are different... the more you get to know them, the more differences you see. Sometimes it is hard to understand what another person wants to say, or what he is doing. some people act... —so "different" that they are called "crazy" or "mad". Don't laugh at them. They are in fact ill, and you know that anybody can get an illness and be cured of it. the brain... — is a very complicated device which makes us able to think, learn, feel, and command all the other parts of our body. To work properly the brain needs food and rest, in other words blood and sleep. The brain may be damaged by a hard blow on the head. The body may suffer from insufficient or poor food or from a high fever which disturbs the normal work of the brain. The brain might also become overloaded with worries. But many mental illnesses can be treated and cured. 49 49 111 awn 4161k ' Before we knew better, mentally sick grown-ups or children were harshly treated, teased or even stoned. This should not happen. Medicine now knows how to help people who could not be helped before. Kindness and understanding may be as important as the treatment. old people... are tired, their brain grows older, and some- times it can no longer work properly. Often, however, they know much and can give you good advice. If you show old people that you love and respect them and want to look afterthem, they will keep their good health longer. slow learners... Some children are very slow at learning to walk or to talk. Their actions may be clumsy and they cannot play difficult games. When they grow up, some of them may still behave like a child, because they have a disease which makes the brain grow up more slowly than -abccte-r3hijklmnop it should. But they 3)(2=6' can be helped and en- couraged in many ways, especially if other children let them join their games and praise them when they get things right. little things... All of us have pet hates or pet fears. Some of us don't like spiders, or thunder, or eating things like mushrooms. Mentally ill people may suffer much more from these kinds of fears and hatreds. It would be very unkind to tease them. The best thing is to help them to avoid whatever upsets them, or to comfort them when they are afraid or anxious. authors of the month Professor Leon Eisenberg (United States of America) is Professor and Chairman of the Executive Committee of the Department of Psychiatry at the Harvard Medical School, a post which he com- bines with that of Chief of Psychiatry at the Children's Hospital Medical Center in Boston. He is a member of the WHO Advisory Commit- tee on Medical Research. Dr Karl Evang (Norway) was Director-General of Health Services in Norway from 1939 until his retire- ment in 1972. One of the "founding fathers" of WHO, he was elected President of the Second World Health Assembly in 1949 and Chair- man of the wno Executive Board in 1965-66. Mr Thomas Nchimbi Seka- maganga (Tanzania) is a senior nurse with the Psychiatric Unit at Muhim- bili Teaching and Consulting Hospital in Dar es Salaam, the Tanzanian capital. Professor Peter Sainsbury (United Kingdom) has been Director of the British Medical Research Council's Clinical Psychiatry Unit since 1957, and is Con- sultant at the Graylingwell Hospital, Chichester. Professor J. S. Neki (India) is Head of the Department of Psychiatry at the All-India Institute of Medical Sciences, New Delhi. He has made a special study of psychiatric problems in the countries of South-East Asia. Professor Carlos A. Leon (Ecuador) has headed the Department of Psychiatry at the Univer- sidad del Valle Medical School in Cali, Colombia, since 1955. He was appointed a member of WHO's Expert Advisory Panel on Mental Health in 1967. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to World Health as follows: US $ * £ * Sw.fr.* One Year 5.60 2.40 16.- Two Years 9.80 4.20 28.- Three Years 14.— 6.— 40.— One year: Two years: Three years: I enclose cheque/postal order in the amount of Name: Street: City: Country: * or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland im er ie s R du n ie s S. A . La us an ne Despite the pretty frock and the well-brushed hai-, this little girl is a disturbed ch;id. She is seen here tackling an intelligence test at a child guidance cynic in Bangkok. (Photo WHO/Pierre Pittet) Pr in te d in S w i