A Passage to India

One of the opportunities afforded the APA president is to visit other countries as a guest at their psychiatric society meetings. My most recent trip took me to Kolkata (formerly Calcutta), India, where I was the plenary speaker at the annual meeting of the Indian Psychiatric Society (IPS).

As I’ve gotten to know our international colleagues, I’ve learned that we have much in common, share the same altruistic motivations, and struggle with similar challenges to providing compassionate and high-quality care to our patients. Also, I’ve always had an interest in the health and mental health care systems of other countries. I’ve published on the Swiss mental health care system, and, as a fourth-year medical student, I chose to do an elective at the Maudsley Institute in London, where I experienced the National Health Service. Observing how care is delivered in other nations helps me to better appreciate the challenges and opportunities we face in this country.

Through conversations with Indian psychiatrists as well as my tour guides and drivers, I learned a fair amount about the Indian health care system. India has a population of 1.3 billion people, the second most populous country in the world. About 4% of the country’s GDP is spent on health care versus 18% in the United States. Everyone has access to the government-mandated insurance program, which is state based. Care is delivered in government hospitals or clinics. Those who want to receive specialty or higher quality care at private hospitals or from private doctors can purchase insurance or, for those who can afford it, pay out of pocket. With the Indian economy booming, the government has begun to invest more resources in health care, but there are long waiting lists, especially for elective procedures, and quality-of-care issues given the high demand for services.

To focus on psychiatric care, there are only 9,000 psychiatrists in all of India—that’s fewer than 1 psychiatrist per 100,000 people. In this country, there are 14 psychiatrists per 100,000 people, which is about a third less than countries like France and Germany. When I first arrived at the IPS meeting in Kolkata, I was waylaid by a reporter who asked my opinion regarding a psychiatrist being required to treat 600 patients a day. It’s inconceivable that any physician would be expected to care for so many patients in a day; in fact, an annual caseload of 600 patients is substantial. If one assumes that 5% of the population has serious psychiatric disorders, that would represent 65 million patients, or over 7,000 patients for every psychiatrist in India.

Family structures are very strong in India, and multiple generations live together, especially in the middle and upper classes. It’s likely that many more of the people with serious mental illness are cared for in their homes and by local physicians, who are mostly in primary care and provide medication, than in hospitals. Hospitals are reserved for the most acutely ill and for those who no longer can be cared for by their families.

As many people have private health insurance, there are private psychiatric hospitals where patients can be cared for by psychiatrists. One of my tour guides told me that his brother had received treatment with lithium carbonate for bipolar disorder at such a hospital and was doing well. (Unfortunately, I did not have the opportunity to visit any psychiatric hospitals.)

While psychiatric care in our country is superior to that in India in many ways and accessible to a far larger proportion of the population, it is imperative that while we fight our battles at home to improve our mental health system, APA continues to join with our colleagues in other nations to achieve similar goals and to share our expertise. We can do no less as citizens of the world. ■