Within the vast catalog of mental illnesses, there are few more debilitating than schizophrenia. The disease both distorts and impoverishes reality through a combination of “positive” symptoms, or symptoms that impose excess sensations and behaviors on reality (hallucinations, delusions, repetitive movements, disorganized thinking), and “negative” symptoms, or symptoms that detract from someone’s normal experience of and functioning in reality (dulled emotional responses, social withdrawal, inability to experience pleasure).

It is also a deadly illness. The onslaught of symptoms often cripples the sufferer’s ability to care for themselves. Passive neglect of health, poor coping habits, such as alcohol and drug misuse and a vastly increased risk of suicide contribute to a death rate among people with schizophrenia between two and three times higher than the general population.

Treating mental illness in the developing world is already difficult, beset by underfunding (less than 25 cents annually per person in low-income countries) and inadequate distribution of health care personnel (less than two psychiatrists per 100,000 people in many countries). 

Some challenges schizophrenia poses for the developing world are tied to these preexisting conditions. Others are unique to the disease itself.

Conflicting Visions

The so-called “outcomes paradox” is a major hurdle. Beginning in the 1960s, the World Health Organization (WHO) undertook a series of studies comparing the health outcomes of schizophrenia patients in developing countries, such as Colombia, India and Nigeria, and developed countries, such as The United States, Denmark and Taiwan. Surprisingly, patients fared better in the developing world than in wealthier nations, experiencing less social impairment and higher rates of remission and recovery, and all with far less antipsychotic-drug therapy, a standard first-line treatment in the developed world.

These findings were attributed to several factors, and subsequent studies have untangled and complicated the paradox. The third and last of the WHO studies, known as the International Study of Schizophrenia (ISoS), surveyed patients from the previous study after 15 and 25 years and attributed the paradox to the social and cultural conditions in which the patients received treatment, stressing the importance of early intervention with a combination of social and pharmacological therapy. 

The many years of work done by Dr. Vikram Patel, chair of Harvard’s Department of Global Health and Social Medicine, illuminate the bulk of this paradox and the path towards successfully and sustainably treating schizophrenia in the developing world. His 2008 analysis of 23 studies in low and middle-income countries showed wild variance in the incidence and severity of chronic schizophrenia across nations and time — a thicket of conflicting data further obscuring the underlay of the paradox. For instance, 4.5% of patients in India experienced chronic illness over five years, as opposed to 51.7% of twelve years in China. Many of the patients ricocheted between better and worse health outcomes and everything in between over the course of the analyzed studies, with disability and social outcomes for patients also varying widely by nationality.

A Clearer Path

Untangling this mystery is by no means superfluous to the here-and-now needs of the mentally ill poor. Still, in a 2007 paper co-authored by Patel, he outlines an approach that draws upon established knowledge about health care when it has to be built from the ground up. First comes identifying those in need, provided by networks of people familiar with the health of people in their community. Next, skilled health practitioners must provide treatment that focuses not only on the symptoms of schizophrenia but also on the overall physical health of each patient, which is so often affected by the illness. These efforts must take root within communities strengthened to cope with such a severe affliction. The empowerment of community health workers and the families and individuals they serve is key, supporting them with opportunities for paid employment and equitable systems of health care financing (voucher systems, insurance plans, fixed-monthly payments).

Many organizations around the world have taken up this mantle of community care and empowerment. The Schizophrenia Research Organization (SCARF), an Indian NGO based in Chennai, Tamil Nadu, socially reintegrates its patients by providing them with livestock, supporting their small businesses and providing rural patients with access to health care using telemedicine.

BasicNeeds, founded in 2000 by English entrepreneur Chris Underhill and recently merged with Christian disability foundation CBM UK, is one of the world’s most widespread and well-organized examples of community care. Its model of psychosocial support has already helped over 650,000 people in 12 countries throughout Africa and Asia. 

In their 2015 annual report, Dr. Syvanna Phompanya, a Laotian general practitioner working with BasicNeeds in Vientiane province, recounts a dramatic example of the healing work accomplished in his nation:

“One of my patients suffering from schizophrenia lived in a cage for 15 years. With regular medication and treatment, his symptoms have reduced, and he no longer lives in the cage. I’m so delighted with his progress and to see him living with his family. I’m pleased with the mental health work done in my district hospital, and I’m thrilled to be working in the area as there are a limited number of professionals in this field.”

– John Merino
Photo: Pixabay