BRIEFING Mental illness in Goa, India

Vikram Potei

While waiting for a delayed departure at Goa former relies entirely on the seasonal rains and airport recently, I engaged in conversation with a tends to be of a subsistence nature. The regular fellow frustrated passenger who happened to be export of manpower to the Middle East provides a an American tourist. Upon discovering that 1had steady source of valuable foreign exchange to spent eight months in Goa initiating a field study their families at home. The latest and arguably on common mental disorders in primary care most lucrative industry is, of course, tourism. clinics, she expressed amazement exclaiming After being a secret haunt of the flower-children "but surely there can't be mental problems in of the 1960s, Goa has emerged as a major this place. . . it's so beautiful and everyone seems destination for plane-loads of charter tourists so happy!". After a brief moment wondering from Europe. This flood has led to huge changes whether my companion was joking, I realised in lifestyle of Goans in the coastal belt of the state that my work in Goa could in itself seem a bit of a (unknown to most visitors, the rural essence of joke to colleagues and friends who associated Goa lies hidden away from the ocean beaches, in Goa with being a holiday destination. Not only is villages nestled between plains of paddy fields the view that living in an apparent paradise is fringed by coconut palms and frontiered by the somehow conducive to better mental health a forested hills of the Western Ghats). While the smokescreen, I had come to realise that mental inflow of cash dollars has seen a huge rise in illness was a considerable problem in this coast living standards, there are serious concerns al state. Perhaps this essay could be an about the impact of chaotic development on the opportunity to explain why. environment and the culture clash of tourists The youngest and smallest state of the Indian who may expose more flesh than is acceptable or republic, Goa's history is as chequered as any seek out pleasures of substances not familiar to ancient culture. After long periods under Hindu the traditional lifestyles built around fishing, and Muslim rule, 450 years of Portuguese coconut and paddy farming. domination ended with its liberation in 1961. Blessed as she is by her rich cultural heritage, Colonial influences have left an indelible mark enviable environment and comparatively high on Goan culture, making it very distinct from standard ofliving, my fellowpassengers' remarks that of its neighbouring Indian states. A third of may have seemed to be quite understandable. the population profess a Roman Catholic faith However, there are many signs that psychologi and the remainder are mainly Hindu. Despite cal disorder is at least as common in Goa, if not numerous differences between the cultures of more, than in apparently less salubrious parts of the two groups, for example in their food and India or abroad. The Institute of Psychiatry & clothing habits, Goa has witnessed one of the Human Behaviour in Panjim city is the central most harmonious coexistences of religions in psychiatric hospital of Goa and has about 275 Indian history. The local language, Konkani, can beds. With a population of about 1.2 million, this be written in both the Romanic script preferred means that Goa has an average of one psychia by Catholics and the Devanagari script preferred tric bed per 4500 population, a ratio impressively by Hindus. Since independence, Goa has seen a higher than the mean for India which stands at relatively stable political climate which has 1:20000. The average admission rate is in the fostered enormous improvement in its living region of 2500 per annum, which reflects that standards; in the 1992 Family Health Survey, about one in 300 adult Goans are admitted to the Goa scored near the top of the league of Indian hospital every year. Given the fact that the states on a range of indicators of health. For admission rate represents only the very tip of example, the infant mortality rate was 20 per the iceberg of mental disorder in most countries, 1000 live births (as compared with 79 for India) and that in India in particular, only those with and literacy rates in women are 67% (as severe behavioural disturbances are brought to compared with 39% for India) (Population Re psychiatric hospitals, this figure is a worrying search Centre, 1995). marker of the potential scale of morbidity in the Its economy is based on agriculture, fishing, community. Although there are few epidemiolo- mining, the export of Goan labour and tourism. gical data on mental disorder in Goa, there is Agriculture and fishing provides employment to anecdotal evidence that learning disabilities and the majority of Goans, although much of the major mental illnesses, such as schizophrenia.

Psychiatric Bulletin (1997), 21, 299-301 299 BRIEFING

appear to be frequent. This is an intriguing issue short-lived and are associated with stimulant and may be linked to the 400 years of relative misuse. isolation from the neighbouring Indian popula We have recently completed a study of com tion. Consanguineous marriages are not uncom mon mental disorders such as depression and mon; according to the 1992 survey. 14% of anxiety in attenders at two government primary marriages were consanguineous with such mar care clinics in Goa. Such disorders were frequent riages being acceptable to both religious com (more than 40% of attenders scored above the munities. Indeed, intrafamily marriages were cut-off score of a psychiatric interview) and were often a choice in Goa for numerous reasons, strongly associated with female gender and one being to avoid the splitting of family wealth poverty. Recurrent themes from this and other and property, since Portuguese inheritance laws studies showed that other than alcoholism, provided for equal partitioning between all poverty and loneliness were exacting a severe siblings irrespective of gender (unlike the rest of toll on the mental health of Goans and that India where the male offspring often have greater women were particularly vulnerable. Despite the rights). relatively better position of women in Goan Alcohol has always been an integral part of society, poverty may affect their health as much Goan lifestyle. Traditional brews derived from the as women in other parts of India, since tradi cashew fruit and coconut are popular tipples. tional gender roles often discriminate against Tavernas, pubs and bars abound in the state, women in a variety of ways, for example by which has the somewhat dubious distinction of dictating the pattern of food distribution in the having the lowest taxes on alcohol in India. household (Shira, 1992). Further, loneliness is Unfortunately though, this drinking is not with particularly a female companion since it is often out its damaging effects. Recent reports in a related to absent men working overseas or leading daily recorded a huge increase in outside Goa in jobs which are either not available cirrhosis deaths in Goa Medical College; the or do not pay as well in Goa. Primary health staggering toll of death and injury on Goan roads centre (PHC) doctors make a brave effort to is also partly attributable to alcohol. Ethno recognise psychological morbidity but confess graphic studies with primary care clinic staff to feeling overawed by the prospects of acknowl and traditional healers and priests have repeat edging disorders of which they understand very edly brought up alcohol as one of the key little, and providing treatments about which they problems leading to the breakdown of the fabric know even less. Thus, as in many PHCs around of family and community life. Domestic violence India, patients are provided with a medley of is frequently associated with male drinking. Yet, symptomatic drugs, vitamin injections, and for a other than isolated efforts for detoxification and few, benzodiazepines. counselling, there are no public health initiatives Goa is indeed a paradise. Its culture is a to examine the extent of problem drinking nor to dynamic blend of Indian and Portuguese flavours ameliorate its effects. Instead of billboards and its people are warm and welcoming. How advertising the dangers of drink-driving, the ever, it would be naïveto extend this superficial highways of Goa are littered with blatant (and homily to mean that mental health is assured. illegal) liquor advertisements. Paradise it may be for those who arrive for two Drug misuse, in particular cannabis, opiates weeks to escape the winter cold of Europe or the and more recently, LSD and esctasy, is of chaos of urban India, but for those who live here concern in the coastal areas where tourism is the struggles, aspirations, concerns and life the main industry. To date, despite the apparent events remain as significant as for any other scale of the problem, there are no reliable community. Perhaps, therein lies a lesson for epidemiological data on the extent of problem me; psychological disorder is truly universal. drinking or drug misuse and their impact on the How we classify it or what we call it may vary health and economy of Goa. From a public health considerably, but no one can deny the essence of perspective, drug misuse is far less common suffering: not even a package holiday company than problem drinking, but it attracts much nor an anthropologist's vision of paradise. more public attention and government condem nation. Perhaps as with many problems in India, it is easier to blame a foreign influence for the ills of society. Nevertheless, the concerns are real, although anecdotal evidence suggests a shift from the more worrying use of opiates in the 1980s to the recreational use of stimulants in the 1990s. There is a steady trickle of European Acknowledgements tourists brought usually by the police to the The project in Goa is supported by Wellcome Institute of Psychiatry and Human Behaviour Health Services Project Grant 045281/Z/95/Z. I (IPHB) with drug-induced psychoses; most are am grateful to Gauri Divan for her comments.

300 Patel BRIEFING

References Vikram Patel, Clinical Research Fellow. Institute POPULATIONRESEARCHCENTRE,Jss INSTITUTEOFECONOMIC of Psychiatry, London and Institute of Psychiatry RESEARCHANDINTERNATIONALINSTITUTEFORPOPULATION and Human Behaviour, Goa, India SCIENCES(1995) National Family Health Survey (MCH and Family Planning!. Goa 1992-3. Bombay: PRC. Dharwad & UPS. SHIVA.M. (1992) Women & Health. In State of India's Health Correspondence: Section of Epidemiology and (ed. A. Mukhopadhyay), pp. 265-302. New Delhi: General Practice, Institute of Psychiatry, Voluntary Health Association of India. DeCrespigny Park. London SE5 8AF

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