Tag Archives: India


Dr Shyam K Bhat MD is a
Psychiatrist and Integrative
Medicine specialist.

He is board certified in
Psychiatry, Internal
Medicine, and
Psychosomatic Medicine,
with additional certification
in clinical hypnosis

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Flat World Psychiatry


Earlier this year, I was in Bangalore on a brief vacation, eager to see India’s recent economic progress first hand. I was not disappointed—new flyovers, crowded shopping malls, gleaming glass buildings—the city was almost unrecognizable. One pleasant evening, I was sipping a particularly tart Mojito at one of Bangalore’s many new nightspots.

The place was packed—confident and hip young things milled around the place, laughing, flirting, dancing, drinking, as a DJ in the far corner mixed house music. It was about 9 o’clock on a Friday. I had paid 1000

rupees—about $25—as cover charge; a cocktail was $8, and food started at $20 an entrée. People sat on low-lying beds arranged around a pool in the center, reminiscent of lounges in South Beach.

“Bangalore’s changed a lot, man,” I remarked. “This is more like Miami than Miami itself.”

Anand, an old school friend of mine, now a successful architect, nodded, waved his hand around, “Yeah, but don’t let it fool you. These guys aren’t really happy. Everyone’s stressed out of their minds. I mean, did you ever hear of divorces in India before? Now almost everyone I know is divorced!” With a start I realized that 3 out of the 5 at our table had been through a divorce.

“How’re things at work?” I asked Mahesh, a high school classmate who was now the marketing head of an American company with opera-tions in India.

“Busy, man. Very busy. Next week I’m off to Singapore, then to London, and DC in August. It’s crazy.” He grinned. “But the real stress is not work but my love life.”

I had attended his wedding almost 10 years previously, when he married his high school girlfriend against his parents’ wishes. They had divorced recently, and he was now dating again.

“I thought you were seeing that journalist?”

He shook his head. “I almost miss my ex, it’s that bad. They’re too independent these days. This girl, she doesn’t want to have kids, she doesn’t want to get married. She doesn’t want any kind of commitment, man. Get this. She tells me, ‘We both have busy lives. When we are free, we’ll hook up. Just don’t get sentimental on me.’ ”

He shook his head and smiled, managing to look regretful and proud at the same time.

A few days later, I was driving my father-in-law’s new sedan through peak Bangalore traffic. My wife was sitting next to me, trying to stifle her gasps as I edged past the cars and bikes, buses, and autorickshaws.

My son sat in the car seat at the back, blissfully unaware of the drama outside. The distance from my in-laws’ to my parents’ was only 10 miles, but it had already taken us more than an hour.

“Almost there,” I said to Ashwini.

One more traffic light, a last stretch, and we would be home. A space about 4 feet wide opened up, but as I tried to squeeze past a small Suzuki on the left, we heard a scraping sound over the din of traffic. The other driver, a big swarthy man with a large moustache, began to scream obscenities, threatening dismemberment because I had scratched his car.

I reacted in the time-honored way, shouting back a few obscenities of my own. He gesticulated wildly, indicating that I should pull over, but I couldn’t do that with the traffic coursing all around us, and besides, his demeanor wasn’t exactly reassuring. I motioned for him to follow us and continued through the traffic. It was a sign of progress, I thought, that no one had taken the slightest notice of our skirmish. This was vastly different from the India of the past, where the slightest altercation on the road would draw, within minutes, a large enough crowd to fill a small concert arena.

The Suzuki followed us through the traffic, and I could see the man in the car, still shouting and shaking his fist, agitated and sweating, while his wife and children sat in silence. Maybe I’d been away too long, or maybe I’d spent too much time practicing psychiatry, but I found myself thinking: Why is the man so angry? What was it exactly that this man was so angry about?

I stopped the car at the side of the road, and he screeched to a halt, a good 50 feet ahead. “You bloody fellow!” he shouted. “You buy big-big car and you don’t even know how to drive. Come here and look what you did.”

“Before I do that, please calm down. What’s the problem? Why are you so angry?” I said, as if in some surreal clinical encounter, where I was ineffectually trying to calm an agitated patient.

He blinked for a moment, his rhythm thrown, then recovered enough to shout, “Problem? You are the problem. Rich fellows driving without looking.”

I felt a sudden anger in the pit of my stomach. Therapeutic approach be damned—he wasn’t my patient. “You better learn some decency—”

“Decency?!” He charged toward me. “I will show you decency.” He pushed me hard, and I staggered a step back.

His son, who was sitting in the car, shouted, “Appa!”

I reacted instinctively. Furious, I made a motion to push him back, when the absurdity of the encounter struck me, and I stopped myself.

We stared at each other for a few seconds, and then I broke the silence. “Look,” I said in my less-than-fluent Kannada. “This is not worth fighting over. I will take care of the damages.”

“It’s your fault. You should have looked where you were going,” he said belligerently.

“That’s right; it’s my fault.”

That seemed to deflate him, and by the time we exchanged insurance information, the mask of anger had dropped and I saw him for what he was—a family man, on his way home, burdened by the stress of living in a city where a new wave of young software engineers and entrepreneurs flaunted their money, trivialized his values, and diminished his self-worth.

The following week, I called a friend at a local hospital. She’s a psychiatrist, one of only about 50 in Bangalore, a city of 6 million people. “Lots of depression and anxiety, but people still don’t like to go to psychiatrists,” she told me.

“So who treats them?”

“If they go to a doctor at all, it’s usually to a general practitioner, who will often prescribe some Valium.”

Now that I was looking for it, I could see portentous signs everywhere: hardworking corporate couples who spent very little time together, tales of rampant affairs at the workplace, reports of suicide in the newspaper almost every day, road rage, escalating violent crime.

I looked up the statistics online. They were appalling. India has the highest suicide rate among young people— more than 10 times the average suicide rate in the Western world.1

On our flight back, I looked out of the window at the sparkling lights of Bangalore that extended in every direction, announcing India’s arrival as a major economic force. It is a flat world now, as Tom Friedman writes2 globalization is here to stay. But on this visit, I realized that globalization extends not just to the economy and business, but to social change, and therefore to psychopathology as well. Two-fifths of the world’s population are facing an unprecedented challenge to their sanity, as everything that defines them—social norms, institutions, values, modest aspirations—is dismantled by the flat world. Unfortunately, the flat world analogy does not extend to access to psychiatric services, or to awareness about mental illness, and those suffering have to manage largely without the help of mental health professionals— India has only 3000 psychiatrists for a billion people.3

This is the flat world of psychiatry. Across the globe, people are richer, but unhappier. They carry an iPod in one pocket, and a Valium in another.

 

REFERENCES

1. Aaron R, Joseph A, Abraham S, et al. Suicides in young people in rural southern India. Lancet 2004;363:1117–1118

2. Thomas Friedman. The World Is Flat: A Brief History of the Twenty-First Century. New York, NY: Farrar, Straus and Giroux; 2005

3. Das M, Gupta N, Dutta K. Psychiatric training in India. Psychiatr Bull 2002;26:70–72


My First Day


Dr. Venkatesh, Professor of Psychiatry and Head of the Department, had a thick mustache and a permanently disgruntled attitude.

“What is schizophrenia, I say?” he asked by way of greeting, as we stood in his small office, sweating in the Bangalore summer.

“Sir,” I ventured, “it’s a psychotic disorder in which there are delusions, hallucina-tions, and decreased functioning.” I’d read a few pages from the abridged version of Kaplan and Sadock—bought the book, in fact—and since this was the only subject where my interest exceeded that of my peers, I hoped this was my turn to shine.

Dr. Venkatesh looked at me as if I was unclean. “You fellows don’t study, only come here to enjoy,” he said, which was a bit unfair because, frankly, there was not much to do at Victoria Hospital by way of enjoyment. “Get out, all of you,” he said, with disgust. “Go and learn something, I say.”

We shuffled out of his office, our heads bowed. In those days, in most medical schools in India, humility and subservience were the preferred modes of relating to one’s teachers and seniors. Confidence was often interpreted as arrogance, an unforgiv-able sin, and could result in failing the rotation. The safe approach was to replace any trace of confidence with a profound, almost theatrical meekness—head down, voice high pitched and soft, and minimal eye contact.

The less one knew about the subject, the more humble one had to appear. Ignorance was permissible, as long as one was sufficiently humble. Years later, while working in the U.S., I would be surprised by the unabashed self-assurance of medical students in the West, who would wax eloquent even on occasions they did not know the answer to a question. “Well, I think the data is not clear on that. In my experience. . . .”

I would never have passed medical school with that attitude. As medical students, it was essential for us to understand the dynamics of each department—who to keep happy, who to avoid, and so on. In psychiatry, the word was that Dr. Venkatesh was only the ceremonial head. The man who was really in charge was Dr. Sreenivas, a PG in psychiatry. PG was short for postgraduate, the term used in India for resident physician.

Dr. Sreenivas met us in a dark classroom next door, which was also used as a conference room of sorts, and on occasion, an interview room.

We would have to sit here, he said, until we got some patients.

I was surprised that we would have to wait for patients. This was the government hospital—free health care for the poor—and consequently, clinics and wards were overflowing with patients. In the medicine clinic, for example, a physician would rou-tinely see more than 200 patients a day. Obviously, business was slower in the psychiatry department.

I sat on the edge of the front bench from where I could see the Skin and Venereal Disease Clinic, which was adjacent to the psychiatry clinic. I am not sure why exactly sexually transmitted diseases were clubbed together with dermatology, but there it was.

I passed time by trying to assign patients waiting in line to one or the other. Skin or VD?

There was a man with white patches on his face—leukoderma, probably. Skin. Behind him, in the queue, a woman with the obvious lesions of leprosy. Definitely, Skin.

Then a man without any obvious abnormalities. I noticed his hand straying towards his groin. VD, I decided.

Almost half an hour passed in this manner. Two of my classmates were playing makeshift cricket at the back of the room, using a rubber ball and a heavy book for a bat. From another corner of the room, I could hear the sound of loud snoring.

Finally, Dr. Sreenivas came back. “No, no, don’t get up,” he said, as a few of us scrambled to our feet. “We have an interesting case. Only one of you can come.”

It wasn’t as if there was a huge rush to the door. I vaguely remember 2 of us standing up, and then the other person volunteered to sit this one out.

She was in her mid-30s, I estimated, and like many of the patients who came here, she was from a nearby village. She sat on the chair and looked straight through us. The man sitting next to her—the husband—stood up when we entered the room.

“What to do, Sir? Please. You have to help,” he said, speaking in Tamil.

I could understand Tamil, but spoke very little of it. Luckily for me, Dr. Sreenivas only expected me to observe the interview. He proceeded to piece together the story from the husband.

The wife did not say much, other than, “I cannot see,” after which she began to mutter unintelligibly, staring into space.

They’d been married for about a year, the husband said, and their life had been perfectly ordinary until a few weeks before. One night, he came back from the arrack shop, where he’d had his customary 3 sachets of the country-made liquor. What was that? Yes, he did drink every day, but what of it?

When he came back that night, and sat down for dinner, the rice was cold. He hit his wife because she should know better. Yes, yes, he should not have done that, but he did not hit her very hard. “Anyway, I don’t hit her every day, but once in a while only.”

When he slapped her this time, instead of heating up the food as she would usually do, she closed her eyes and began to chant some slokas from the Gita. He was about to raise his hand again when she looked at him, held out her palm, and blessed him. God promise, he could smell some jasmine even though there were no flowers in the room. What was going on? And then, he realized that a devi had come inside her—she had become a goddess.

So, for the next 5 days, he treated her as the goddess she was. He cooked for her, he performed poojas every morning, worshipping this divine being who graced his house, and as for the arrack shop, why, he had forgotten the way only.

His story was interrupted by a mewling sound from her. He jumped, but Dr. Sreenivas patted his hand. “Don’t worry,” he said. She lapsed into silence, and the man continued.

So, everyday he cooked for her and became an exemplary husband. “After all, a devi has to be treated like a devi.” On the fifth or sixth day, he could not remember which, he went out to the arrack shop again. “Just one packet I had, Doctor.” When he came back and went to pay her homage, she suddenly shrieked and slapped him on his face. Hard. She then began to use words that only he and his friends would use, especially when the cricket team was not playing well. “She does not know such bad words, Doctor.” He was stunned. Then he realized that he had been tricked. It was not a devi that had entered her being, but a pishachi, a she-devil. She was possessed by an evil spirit.

He touched a small cut on his face and showed us the blood on his hands in classic Bollywood fashion. “Look at my face; see what the pishachi did. Anyway, I brought her here because my neighbor, who is being a teacher, said this might be mental problems.”

“This is not her problem, but yours,” Dr. Sreenivas said gravely.

“Why, Sir? Why you are saying that?” “See here, Mister,” Dr. Sreenivas replied. “There is a saying in Kannada, ‘When you treat a woman well, she is an angel. Treat her badly, she is a devil.’ ”

Later, as a nurse helped the lady out of the room, Dr. Sreenivas explained the case to me. “Classic possession case with hysterical blindness. She has a conversion disorder. Now what I will do is give her some diazepam, then suggest to her that the devil will leave her and that she will be able to see again.”

I was impressed that she could be cured so easily, but Dr. Sreenivas misinterpreted the expression on my face. “Yes, yes, I know the books say this needs psychotherapy and all that, but we don’t have the resources. Not to worry, she will be alright, and more importantly, it will cure the husband also. Hopefully, the fellow will be scared enough so he will behave himself.”

A few hours later, I saw the patient leaving the hospital with her husband. He trailed behind her, slightly bent, as if he were cowering before a devil, or perhaps, bowing before a goddess.


The Cost of Medicine


It is obvious that the patient is dying. She is 92 years old with “multiple medical problems”—so many that my tired intern mind can barely list them on morning rounds. “History of metastatic colon cancer, diabetes, advanced dementia, congestive heart failure. . .” But the family wants everything done—so we do our job efficiently and thoroughly. The attending physician recommends an MRI to clarify the diagnosis of the patient’s sudden limb weakness, and I write the order down, then initial it. It feels routine now, this mundane ordering of expensive tests with no questions asked about cost. No more do I feel the sense of wonder and amazement that suffused me when I first started working as a physician in the United States. Like “Medical Disneyland”—as many diagnostic and therapeutic rides as you want. And no lines in this amusement park, Sir! So I ordered them all, the MRIs, the CTs, the PET scans—this was larger-than-life medicine.

But for some reason today, as I order the scan and look into the hazy eyes of this 92-year-old lady with a dying body that all these thousands of dollars will not save, I think back to the boy.

While a medical student in India, I was on call one night in the ER (or “casualty,” as it is known in India), asleep soundly in a room that I was sharing with the intern, when we were awakened by loud knocking on the door. The government hospital could not afford pagers, so the system of choice was Ramappa, the orderly, who was sent to wake up physicians whenever there was an admission. The method was a bit alarming, especially at two in the morning, but it was foolproof—there was no “but my pager didn’t go off.” I woke up with my face and scalp itching. A few mosquitoes had made their way through little rents in the mosquito net and now in the dim light I could see them hovering around, replete and sluggish.

“What is it?” the intern asks sleepily.

“One boy has come to casualty, Doctor. He feels sick and wants medicine.” Ramappa had a talent for giving us no information at all yet managing to sound like he was imparting details that were clinically crucial.

We go to the casualty where a boy sits in the corner wearing a ragged cotton shirt a few sizes too big and blue shorts, the color beaten out of them. His bony legs are dry and scarred and his bare feet do not reach the ground as he sits on the stone bench. His hair is wispy brown, his eyes sad, and his belly protrudes below prominent ribs. This small front room is used as a waiting room but also, when things are busy, as an examination room or sometimes even for minor surgical procedures. There is no door—it was never designed for one with its wide archways and open windows—and the smell of disinfectant is not as strong here in the cool night air. Moths fuss around the bright lamp on the roof and there is the soft clatter of a bandicoot scurrying along the rafters. In the adjoining room, separated from this one only by a small corridor, coarse jute rope restrains a man to one of ten beds. He is screaming loudly in a psychotic rage induced by the atropine administered as an antidote to the insecticides he swallowed earlier today.

“Love problem, Doctor,” Ramappa had told me earlier.

On another bed sits Shivarama, the other orderly, who has been assigned to watch over the restrained man.

The boy just sits there looking at the moths. Now Shivarama lights a leisurely beedi—an Indian hand-rolled cigarette—and watches us as we try to talk to the boy over the screams.

He tells us he is from a nearby village and has run away from home to the city after his stepmother beat him again for the fourth time this week.

I see bruises on his arms, his chest, and his back— black and red, they look like he has been playing Holi—the festival where people throw colored powders on each other to celebrate the first day of harvest season.

“I have sugar problem, Doctor,” he says. The intern tells me to take care of this and goes to the next cubicle— another man has just been carried in after being hit by a speeding truck.

“I was taking injections for high sugar in my blood,” he continues in fluent Hindi, “and then my mother died 2 months ago and my father married again. She has two children, so there is no money for injections now.” He looks vacantly at the red-oxide floor. “I have been vomiting the whole day, Doctor, and now I feel like I will faint.”

I examine him gently, afraid to push and prod too hard, his bones seem fragile and brittle with malnutrition. I feel his pulse—it is rapid and thready. His mouth is parched and he has the sick sweet breath of diabetic ketoacidosis.

“Do you get enough food to eat?” I ask.

“She says it is better to keep the food for healthy children, Sir. So my stepbrother and stepsister get most of the food. Anyway, it will be all wasted if I eat because very soon I will die from sugar disease.”

As I examine him, I ask him how old he is.

“Eighteen,” he says.

The fountain of youth for this boy is disease and malnutrition— his growth stunted and his development arrested, he looks about twelve.

I check his blood sugar. It is 664. I cannot check his electrolytes because the lab has run out of supplies tonight. “My sugar is high, no?” He looks at me. “If I did not have the disease I could drink sweet, sweet juice every day isn’t it, Doctor? My mother used to give me the juice of fresh oranges sometimes, before she died. . . .”

I nod absently, worried about his condition. He is obviously in urgent need of fluids and insulin. “I am going to take him to the ward to get him admitted,” I call out to the intern. There is no one to help us with a stretcher so we walk to the adult ward, the boy shuffling next to me in exhaustion and thirst. When we get to the ward, the clerk tells me the ward is full. I can see, over his shoulder, people crammed into every available bed, some accommodated on mattresses in the narrow corridors.

I decide to take the boy to the pediatrics ward. “Say you are sixteen,” I tell the boy. I know admission criteria are strictly enforced and only patients under eighteen years of age are admitted.

“How old are you?” the admissions clerk asks the boy.

“He is sixteen,” I tell the clerk. “No, I want the boy to tell.”

The clerk glares at me, then turns to the boy again. “How old are you, I say?”

“Uh . . .” His big black eyes are wide with nervousness and fear of this big-city clerk and big strange hospital building.

“Answer my question, I say!” the clerk points a pen at the boy, irritated by this delay in the proceedings.

“I am eighteen, Sir,” the boy says softly.

“Then no admission. Sorry Doctor, you are bringing adult person here, we can’t admit him. He is adult,” the clerk says pointing the pen at the boy again.

I know that here, in these aging government hospitals that take care of India’s poor, bureaucracy reigns supreme. But I am angry with the clerk for enforcing petty rules when someone’s life is at stake.

“Listen here, this boy needs treatment soon, otherwise he will definitely die. There is no place in the adult ward and that’s why I brought him here.”

But the clerk shakes his head again. “No, no admission here, he is adult.”

“I don’t care if he is an adult!” I say, feeling frustrated and powerless. “If you don’t admit him I will speak to the medical superintendent and tell him that you denied admission to a critically ill patient.”

“You can speak to medical superintendent, he will say the same thing,” the clerk shrugs. “Either the boy will die, Sir, or if I admit him then the next child will die because we won’t have any place in wards.” He looks at the boy a little more sympathetically. “What can I say, Doctor, there are always more people than beds here. Sorry.”

We walk back in silence toward the casualty, which is near the main gate of the hospital. The long, paved road is quiet, the darkness punctuated by soft lamps on the side. There are occasional sounds of crows—they are waking up and soon it will be morning. The boy walks slowly, not talking, now and then wiping snot from his nose with a sleeve of his long ragged cotton shirt.

When we get to the gate, I hand him all the money I have in my pocket—50 rupees—about $1. He knows this will be enough only for a day’s supply of insulin, but his eyes light up and he takes the money with a soft “thank you.”

There is nothing else I can do. I watch him make his way through the big iron gates, past the waiting rickshaws outside. He waits for a bus to lumber past and then carefully, painfully, crosses the road. I watch him until he disappears into the shadows.

I feel sad and dejected and this surprises me. I see disease and suffering all the time—every day people die for lack of money for medicines and tests. So this unaccustomed sorrow feels strange, but, like a long forgotten blanket, it begins to comfort me. Any feeling, even sorrow, is a respite from the numbness I wasn’t even aware of until today. Then I realize that the soothing warmth of my sadness comes from this boy’s despair. The selfishness of this confuses and disconcerts me, so I put it out of my mind and head back to the room to get some sleep before Ramappa knocks on the door again.

Later that day a body is brought to the morgue by a police constable.

“We found him outside lying in the gully, Sir. It seems he drank many glasses of juice in that shop outside. Where he got the money from, I don’t know, poor beggar.”

I look at the boy. His legs are still scarred and his body is still bruised, but with his eyes closed and the smell of oranges clinging to him, he seems, finally, at peace.

Now, I sit in this air-conditioned ward next to shiny computers and smooth new tables. I try not to think of the boy as I order this test for a 92-year-old lady with a dying mind and a dying body, a $2000 test that would buy lots and lots of insulin.