Delivering quality primary care to large populations is always challenging, and that is certainly the case in India. While the sheer magnitude of patients can create difficulties, not all challenges are about logistics. Sometimes patient health-seeking behaviour leads to delays in obtaining medical help for reasons that have more to do with culture, social practice and religious belief. When primary care is accessed via busy state-run outpatient departments there is often little time for the physician to investigate causes behind a patient’s condition, and these factors can adversely affect patient outcomes. We consider the case of a woman with somatic symptoms seemingly triggered by psychological stresses associated with social norms and familial cultural expectations. These expectations conflict with her personal and professional aspirations, and although she eventually receives psychiatric help and her problems are addressed, initially, psycho-social factors underlying her condition posed a hurdle in terms of accessing appropriate medical care. While for many people culture, belief and social norms exert a stabilising, positive influence, in situations where someone’s personal expectations differ significantly from accepted social norms, individual autonomy can be directly challenged, and in which case, something has to give. The result of such challenges can negatively impact on health and well-being, and for patients with immature defence mechanisms for dealing with inner conflict, such an experience can be damaging and ensuing somatic disturbances are often difficult to treat. Patients with culture-bound symptoms are not uncommon within primary care in India or in other Asian countries and communities. We argue that such cases need to be properly understood if satisfactory patient outcomes are to be achieved. While some causes are structural, having to do with how healthcare is accessed and delivered, others are about cultural values, social practices and beliefs. We note how some young adult women are adversely affected and discuss some of the ethical issues that arise.
India is a country with a diverse range of cultures, ethnicities, religions and languages. While in many ways this is a source of richness and strength, cultural influences sometimes give rise to challenges in the context of managing commonly presenting illnesses. Physicians caring for patients expect to take account of psychological, social and environmental factors that underlie some of the problems with which patients present in general practice, particularly where there are concerns about mental health. But in cases where physical manifestations seem to stem from deep-seated influences relating to socio-cultural norms and expectations, some conditions can prove difficult to treat. In our view, interconnections between socio-cultural factors and health need to be better acknowledged and warrant exploration in the hope of making it easier to achieve best practice and improve patient outcomes. Against this background we consider a case from India involving a young woman who presents late with an underlying psychiatric disorder, paying particular attention to ethical, cultural and social aspects of her care.
As a nation India faces a number of challenges in trying to meet population needs for quality healthcare. For instance, in primary health clinics and state-run community hospitals the length of an average consultation is just a few minutes, which makes it hard to take account of underlying socio-economic and psycho-social factors. The short consultation means that it is difficult to investigate adverse factors impacting on patients’ physical and psychological well-being. However, on the positive side, primary healthcare offered by city and district hospitals and by rural primary health centres generally succeed in offering basic treatment with no cost to the patient. The focus in primary care clinics is usually on immunization, treatment of common illnesses, prevention of malnutrition, and providing pregnancy, childbirth and postnatal care; patients needing specialised care (and/or having more complicated illnesses) are referred to secondary and tertiary care centres, which may have district, state or national teaching hospital status.
GPs tend to have well-established connections with such centres enabling them to make suitable referrals, especially in urban areas; patients in turn have long-standing connections with GPs, sometimes extending over generations. Broadly speaking, healthcare in India is divided between private and state-funded and between rural and urban centres, and these divergent limbs form part of a complex system that tries to cater for the needs of a vast population. On the one hand it succeeds in catering for large numbers of patients providing basic care for uncomplicated ailments; on the other hand compromises have to be made regarding quality of care, especially when treating illnesses that demand resource-intensive standards of care.
Some people have the chance to access quality, private insurance-based healthcare, but others are excluded due to lack of affordability. Imbalances arise between the private and state-funded health sectors, and these are both significant and growing . While the Indian system relies on a mix of primary health village centres and government hospitals to provide free medical care for the general population, private hospitals cater more for urban, higher socio-economic strata in society. The public system seeks to make healthcare accessible to all sectors of the population and it was structured with this in mind. However, the system does not always function in the way that was originally intended due to problems such as poor standards of literacy, overt political and religious influences, an ever-expanding population, and poor doctor to patient ratios.
These factors can combine to form a vicious circle, and the healthcare system often lacks the necessary resources to enable proper provision of inpatient facilities, including basic essential medical equipment or help with transport for patients coming from more remote geographical locations. Patients from these areas experience additional barriers in terms of accessing quality, affordable, local care. Hindrances have to do with politics as well as geography, and on account of relatively low standards of education there is often a general lack of awareness about family planning.
Culture, Belief and Health
Against this background we consider the role played by culture and belief and how they can impact on patient outcomes. Belief systems and moral values are intrinsic to human life, and for many people cultural and religious considerations exert strong, positive influences on their lives. But norms bound by culture and belief can also negatively impact on people in terms of mental and physical well-being. Culture-bound syndromes are not uncommon within primary care in India and Asian communities more generally, with cases arising that display psychiatric and associated somatic symptoms . Recognising that there is an element of controversy surrounding the diagnosis,  an example we wish to consider is that of dissociative trance or possession-like state, most commonly encountered amongst young adult women. Dissociative trance or possession states capture the essence of the problems we are addressing, and we offer the following case as a way of exploring them further.
‘S’ is a 23 year-old female who presents with episodes of anxiety, accompanied by feelings of impending doom, shortness of breath, palpitations, and loss of sensation in her limbs lasting for 15-20 minutes. Symptoms are accompanied by a shift in consciousness whereby ‘ancestral spirits’ appear to take control over her body and personal identity. This experience is accompanied by violent behaviour, a change in voice and irrelevant speech content, as well as general weaknesses, body aches and decreased appetite. Anxieties appear to result in somatic symptoms with autonomic instability. However, S is reluctant to seek psychiatric help, partly because of the stigma attached to this kind of therapy.
Family levels of education range from illiteracy to having full secondary education; the family is closely-knit and conforms to conventional societal norms. S is well-educated and a graduate with ambitious plans for further study; however, these are interrupted when she becomes engaged as part of an arranged marriage. She experiences a number of problems and has no recollection of episodes involving ‘possession and dissociative trance'; eventually a decision is made to consult the local religious healer, whom the family has been seeing for generations. S is taken to a temple where rituals are carried out to ‘drive out spirits from her body’. Her symptoms improve but only for a matter of days. The family eventually seeks help and advice from the GP for S’s abnormal behaviour, and the GP makes a referral to a local psychiatrist. S and her family are open to psychotherapy, although it requires motivation and persuasion in order to try and break the cycle of events; in total, the delay in seeking qualified help amounts to six to eight months, largely by reason of family beliefs and S’s lack of insight into her illness.
Eventually she is treated and her psychological stressors are identified, namely that S was unwilling to get married and felt unable to convey this to her parents or express her desire to do further studies; S felt it would be disrespectful towards her parents to talk openly about such matters. At the consultation it was thought that subconsciously she was using denial and dissociation to cope with stresses arising from her internal conflict. She is eventually admitted to a local hospital for psychiatric observation and ‘distraction therapy’.
Gradually, psycho-educative sessions involving both patient and the family are undertaken to clear away apparent misconceptions about healing rituals, while at the same time stressing the importance of seeking out and complying with professional treatment and advice. Without being disrespectful to values and sentiments of the parents, the focus gradually shifts towards S’s long-term professional ambition. The advice given is for her not to marry until she feels that she is ready.
Upon further psychiatric evaluation S is found to have ‘histrionic personality traits and immature maladaptive defence mechanisms’ for coping with family rules based on strict societal norms and expectations. After a week of observation as an inpatient no further episodes of abnormal behaviour are seen. Subsequently S receives regular psychotherapy as an outpatient and makes a steady improvement.[contact-form]