Friday, December 26, 2008

Psychiatric Ethics in Mumbai

Because of (a) my clinical specialty (psychiatry) and (b) the fact that I'll be spending time in Mumbai next month, the headline "Psychiatrists work overtime with traumatized in Mumbai" in yesterday's Boston Globe caught my eye.

Here's the gist of the story:
"Since the gruesome Mumbai terrorist attacks, mental health specialists have been in big demand here.

But India, with 1.1 billion people, has only 4,000 psychiatrists, and efforts to provide adequate professional help for those traumatized by the rampage that left more than 170 dead and hundreds wounded is proving a daunting task.

Psychiatrists say it's not unusual to arrive at rural clinics and find 300 people waiting to see them. Each patient receives a scant few minutes of attention. Many give up and go in search of more traditional forms of assistance.

Evening "relaxation and breathing" workshops, for example, are being held in the immediate environs of the Chabad Jewish center that came under prolonged attack late last month and in other neighborhoods around Mumbai.

"We help ease people's tension through breathing techniques," said Ami Patel, an instructor with the Art of Living Foundation, which offers the sessions. "And people appreciate the feeling that someone cares."

...Mumbai psychiatrist Anukant Mittal is a case in point. He shuttles among city hospitals, suburban clinics, and primitive rural facilities, all part of a catchment area of 26 million people.

On any given day, Mittal sees patients ranging from chief executives of high-tech multinationals, who pay $50 per visit, to illiterate villagers wearing nothing but strips of cloth over their loins, and pay a subsidized 5-cent fee.

Rural residents sometimes turn instead to a shaman for help.

'You know very well they're going to go from your clinic to a witch doctor who will do black magic,' Mittal said. "So you have to say: 'I know you're going to need someone to exorcise this, but at the same time don't stop taking my medicine.'"

...Psychiatrists must grapple with their own anger, which can hamper their ability to help others. Recognizing this, hundreds of counseling professionals across India started an e-mail 'anger discussion group.'

'Psychiatrists are human, too, so we express our anger and try to heal ourselves,' said Harish Shetty, a social psychiatrist with Mumbai's Hiranandani Hospital.

'It's not always politically correct to admit anger, but in our epics, the Ramayana and Mahabharata, good kills evil,' Shetty said. 'It's part of our ethos.'"
For me, three aspects of the story exemplify admirable medical ethics.

First, Dr. Mittal's comment to his patient - "I know you're going to need someone to exorcise this, but at the same time don't stop taking my medicine" - embodies cultural awareness at its best. He recognizes his patient's beliefs, sees how they can be integrated with the treatment he is recommending, and presents a respectful synthesis of traditional healing and allopathic medicine.

Second, when "hundreds of counseling professionals across India started an e-mail 'anger discussion group'" we're seeing the kind of self awareness and self discipline that all health care professionals should apply. Whatever area of health care we're in, our attitudes and values are part of the clinical equation, and we have to do all we can to make sure they don't distort the care we offer.

Finally, Dr. Shetty's citing of the Ramayana and Mahabharata places health care where it belongs - in the context of wider culture. Practicing evidence-based medicine is a necessary part of excellent practice, but isn't sufficient in itself.

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