Brain Disorders and Madness, Past and Present: Book Reviews
By N.D. Wyteman
Committee on Nervous System Disorders in Developing Countries, Board on Global Health, Institute of Medicine (2001) Neurological, Psychiatric, and Developmental Disorders. Meeting the Challenge in the Developing World. Washington DC: National Academy Press. xv + 434 pp. Softback. isbn 0309071925. Full text also at: http://books.nap.edu/books/0309071925/html/
H.C. Erik Midelfort (1999) A History of Madness in Sixteenth Century Germany. Stanford, Ca.: Stanford University Press.
xvi + 438 pp. Softback. isbn 0804741697.
These two books document and scrutinise some of the more anguished sides of human experience across the world, with the medical and social responses of very varied communities and societies. They do so from sharply differing viewpoints. The first, from a highly qualified committee of international scientists backed by eminent consultants on specific topics, aims to review the literature, to sketch and quantify the state of knowledge about neurological, psychiatric and developmental disorders in all regions of the 'Developing World', and to recommend local and global responses by way of preventive, curative or therapeutic services. The second, from an experienced and painstaking social historian, studies the experience of 'madness' during one century in one country. Yet in hot pursuit of people and ideas, Erik Midelfort extends his century beyond the usual 100 years and the country beyond its geographical limits, since 16th century Germany gave birth to the Reformation, which had origins reaching far back and implications far forward across Europe. Midelfort's 'madness' extends across melancholy, religious and legal interpretations of witchcraft, mania, fools, folly and impaired cognition, and care institutions taking in poor people with any of these conditions but also with blindness or physical disabilities.
The first book is in many ways a magnificent effort, yet with some irritating drawbacks. A minor drawback is the lack of any handy tag, e.g. an author's name, by which to refer to it. Here it will be abbreviated as "Meeting the Challenge", since this stance is its main raison d'être. Most people who have ever worked in neurology, psychiatry or developmental disorders in developing countries will agree that they have been seriously neglected fields, often perceived by planners as a low-level, background nuisance like the smell of dustbins and drains, to which nobody knows a satisfactory answer other than keeping one's distance.
"Meeting the Challenge" aims to present a well-referenced case that six groups of brain disorders (developmental disorders, epilepsy, schizophrenia, bipolar disorder, depression, and stroke) currently affect a quarter of the world's population and account for 27% of all 'years lived with disability' in developing countries; that these problems are growing; that they exact a huge toll of long-term disability which has not been recognised because standard data do not adequately represent the duration and weight of the burden; and that much of this burden could be prevented in the first place or managed more competently using well tried drugs and techniques. Evidence supporting the case totals over 1,000 references to published research and reviews, from a wide range of health-related professionals working in all major regions of the Developing World.
Sloppy Editing, Sloppy Thinking
This evidence would carry more weight if there were always a close connection between the references cited and the assertions for which they are meant to be authorities. For example, that "iodine deficiency [in mothers] can lead to cognitive deficits [in their infants]" (p.35) has been demonstrated with increasing certainty by specific research in recent decades. It is odd to have it underpinned by reference 59, a study published in 1991 on iron deficiency in Costa Rican children (verified from Medline). That "Vitamin A deficiency can cause blindness [60]" has been established by research since the 1920s, but hardly by reference 60, which is the 10th revision of the WHO International statistical classification of diseases. On p.37, a "study in China showed that depression was nine times higher in women than in men.[92]" The precise meaning of this improbable claim is far from clear; but it is even less clear why it is supported by reference 92, a study on "The use of romal [presumably = formal] and informal health care by female adolescents in Nepal".
If these were isolated slips it would hardly be important; but they are not isolated. "Meeting the Challenge" has far too many errors of fact and assertion. Apart from further mis-referencing, and numerous typographical errors that could have been picked up by running a spell-checker over the final draft, there are logically and syntactically meaningless statements (e.g. on p.25); obviously ludicrous assertions (e.g. that the tobacco-related death toll by 2030 will be "a yearly loss of 10 billion lives", p.353 - how many technical reviewers and consultants skimmed past that one without blinking?); maps where the shading does not show the prevalence variation that it claims to show (e.g. p.124); confusion in labelling figures (e.g. Fig. 5-3 referring to 'vision disorders' on p.121 and 'blindness' on p.123), and other errors that would take too much space to describe.
Over-Confident Generalisations
Still more serious are the over-confident generalisations about "developing countries" and how their problems can be sorted out by modern expertise. On p.75, for example, a glib suggestion is based on "Experience even in resource-poor countries such as Botswana, Guinea Bissau and Tanzania..." Is the Committee on Nervous System Disorders aware that the per capita Gross National Product of these countries in 1999 was respectively US $3,240; $160; and $240; and their adult literacy rates were approximately 73%, 32% and 84%? A "robust national policy of primary care" is then attributed to this highly disparate and mutually distant trio of countries. Is the Committee aware that in Guinea Bissau one in five children dies before the age of five, the 12th highest rate in the world? (The rate in Botswana used to be of that order 40 years ago, and has been brought down to around 60 per 1000, though it is slowly rising as AIDS takes its toll of all health programs). This is not to denigrate the efforts made by Guinea Bissau with its modest resources. The competitor from Guinea Bissau at the Sydney Olympics, who had only recently learnt to swim but managed to get to the end of the pool, charmed the world by his cheerfulness and by not taking himself too seriously. Perhaps we are not meant to take the Committee too seriously when it plunges into the fluid swirl of sub-Saharan health politics.
Brief Nod to Traditional Healers
When it comes to "Integrating Brain Disorders Into Health Care Systems" (pp. 57-94), a brief nod is given in the direction of Traditional Healers, who are the main providers of low-cost, accessible care in many countries. The cited literature is mainly about how these practitioners can be "used" to deliver imported solutions, while protecting patients from "intrinsically harmful traditional practices". There is no mention of any harm done to people with mental disorders by orthodox medical practitioners and pharmaceutical companies during the past two centuries in Europe and North America. The latter experiences should have generated some caution in the mental health export field - indeed, many western medical anthropologists have become more modest in their estimates of the comparative advantages of 'modern' and 'traditional African or Asian' mental health practices. Yet "Meeting the Challenge" is relentlessly modernist and metropolitan, displaying little understanding of the complexities of life in the peripheral villages and suburbs where two thirds of the world live. Apparently the 'correct' response is not to try to understand 'these people', but to get out there and change their lives; with their consent if it can be obtained fairly rapidly, or without consultation if they turn out to be slow learners.
The Gap
The gap between well-meaning experts meeting in air-conditioned offices in New York, London, Nairobi or Bangkok, and the people 'out there' in the pre-electric villages and slums for whom the experts try to formulate plans and make brisk pronouncements of priorities, seems almost unbridgeable. The vast range and complexity of lives and cultures 'out there' cannot honestly be crammed into the sort of neat solutions and development packaging that "Meeting the Challenge" suggests. There have been endless high-powered committees taking evidence and formulating hopeful or grandiose plans for the Third World throughout the 20th century. Social and economic changes have indeed taken place over decades, but seldom in the directions recommended. Where positive self-help has been mobilised in the health development field, it has often been the result of determined individuals with the capacity to inspire others, who worked sufficiently near the grass roots to be able to hear the people for whom they were planning, and to respect their cultures and customs. Yet 30 years of painful progress is already being rolled back by HIV/AIDS and population pressures, while the prospects for a less inequitable balance of world trade remain extremely poor.
People-friendly development seldom results from grand plans by anonymous committees. When nobody is personally responsible for making a plan or taking a decision, nobody is likely to feel the personal responsibility for making it work and tidying up the mistakes. If the immensely prestigious Committee on NSD ever asks itself how it came to issue this error-strewn book without caring even to run a spell-checker over it, its members might learn a useful lesson on the gap between intention, grand plan, and Third World delivery.
However it must again be said that, with all its curious flaws, "Meeting the Challenge" is a formidable attempt to compile material from around the world and to trace patterns and possible ways forward. The compilers must be congratulated on the excellent Mbangu mask on the cover, depicting a face half tranquil, half distorted by the pangs of severe disorder. A revised edition,with at least the obvious flaws removed and perhaps with a little post-11th September reflection on respectful mutual interactions between significantly different cultures, must now be awaited.
German Madness and Sanity
It is very unfair for the efforts of a single historical researcher to be compared with the product of a Committee of scholars with global purview and huge library resources at its disposal. Naturally, the single researcher runs rings round such a Committee. Professor Midelfort had the advantage of accumulating and testing his materials through some 25 years of research, teaching and publication. He was also writing about a world on which the dust had had four centuries to settle, yet a world well documented as printing was in its early and exuberant days, an expanding world in which the geographical discoveries were being matched by cosmological upheavals of Copernican dimensions, a dangerous world where Western Christendom was rending itself into warring parts while the Ottoman Turks flexed powerful muscles just over the horizon.
Midelfort also had the good fortune that someone had already produced the stratospheric 'grand overview' of European early modern madness, i.e. Michel Foucault's rewrite of a doctoral thesis that he had first tried at Uppsala but which had not impressed the hard-boiled Swedes. After refurbishing it in Paris, Foucault had Folie et déraison: histoire de la folie à l'âge classique accepted at the Sorbonne as a kind of history of constructions of madness (surveyed by the academic deity from his mountain-top beyond time and space, thus liberated from the need to provide the tedious 'factual' underpinning required of serious historical work). As Foucault's originality of perception has lost some of its freshness while his historical clangers continue to provide amusement, the challenge has been to write solid, meaty histories of early modern madness that convey a sense of the many ways in which it was lived, perceived and responded to, while being rooted in primary sources rather than conjured by feats of clairvoyance.
This challenge Midelfort is widely considered to have met, deftly weaving his lively chapters from contemporary materials in German, Latin, French and English while taking into account the views of subsequent commentators and illuminating various controversies. "Madness was ... a diverse experience in sixteenth-century Germany, one that ill comports with schemes that simplify and try to characterise the age with just a few bold strokes of the pen." (p.387) Responses to madness were equally diverse, and conflicting trends were at work throughout the century. Physical aetiologies of madness had their place, along with complex religious, philosophical and psychological explanations. To describe this complexity in its own terms, Midelfort has made great efforts to enter the conceptual worlds of those times.
One gets an impression that the 16th century German pastor, physician, lawyer or courtier (and perhaps also their diligent 20th century cultural historian) could have had an understanding of what brain disorders mean in the lives of ordinary people in present-day Tanzania, China or Peru, equal to or greater than the understanding displayed by the international scientists who compiled the book already described. Certainly the former did not have the latter's depth and power of technical knowledge, sifted and refined by the past three centuries of medical research and debate. Yet it remains predictable that the modern technical fixes will not have much success in developing countries until the scientists learn to blend them more appropriately into the conceptual worlds of the people targeted. For that task, Midelfort's book opens many windows.
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