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MAY 1976

RADICAL PSYCHIATRY : PRINCIPLES
CLAUDE STEINER

is the art of soul healing.
Anyone
who practises the art is a psychiatrist. The practice
of psychiatry, usurped by the medical profession, is
in a sad state of disarray. Medicine has done nothing
to improve it; as practised today, medical psychiatry
is a step sideways, into pseudoscientism, from the
state of the art in the Middle Ages when it was the
province of elders and priests as well as physicians.
Psychiatry as it is predominantly practised today
needs to be changed radically, that is ‘ at the root ’.
Psychiatry is a political activity. Persons who
avail themselves of psychiatric aid are invariably in
the midst of power-structured relationships with one
or more other human beings. The psychiatrist has
an influence in the power arrangements of these
relationships. Psychiatrists pride themselves on being
* neutral ’ in their professional dealings. However,
when one person dominates or oppresses another, a
neutral participant, especially when he is seen as an
authority, becomes an enforcer of the domination
and his lack of activity becomes essentially political
and oppressive.
The classic and prime example of this fact is
found in psychiatry’s usual role in relation to women
where, at worst, psychiatrists promote oppressive sex
roles and at best remain neutral, therefore supportive
of them. The same is true of psychiatry’s traditional
role in relation to the young, black, and poor; in
every case psychiatry represents tacit support of the
oppressive status quo.
There are four types of psychiatrists. Alpha
psychiatrists are conservative or liberal in their politi­
cal consciousness and in their practice and methods
of psychiatry; the largest majority of medical psychiPSYCHIATRY

Go to the people

atrisls fall into this category. Beta psychiatrists are
conservative or liberal in their politics and radical in
their methods. Examples of this type are men like
Fritz Peris and Eric Berne and the human potenti­
alities psychiatrists, usually not physicians, who expand
the boundaries of psychiatric practice, but tend to be
unaware of the manner in which oppression is a
factor in psychic suffering and ignore the political
nature of their work. Gamma psychiatrists are
radical in their politics but conservative in their
practice. Examples of this are Laing and others
( as a special case, Szasz, whose awareness of the
politics of psychiatry is quite heightened ) who prac­
tise old, outmoded methods of therapy based on
Freudian or neo-Freudian theory with emphasis on
individual psychotherapy, ‘ depth
and 1 insight ’.
The fourth kind of psychiatrist is the radical psychi­
atrist, who is radical both politically and in his
psychiatric methods.
The first principle of radical psychiatry is that
in the absence of oppression, human beings will, due
to their basic nature or soul, which is preservative
of themselves and their species, live in harmony with
nature and each other. Oppression is the coercion
of all human alienation.
The condition of the human soul which makes
soul healing necessary is alienation. Alienation is a
feeling within a person that he is not part of the
human species, that she is dead or that everyone is
dead, that he does not deserve to live, or that some­
one wishes her to die. It may be helpful, in this
connection, to remember that
psychiatrists were
originally known as alienists, a fact that seems to
validate the notion that our forefathers know more

about psychiatry than we. Alienation is the essence
of all psychiatric conditions. This is the second
principle of radical psychiatry. Everything diagnosed
psychiatrically, unless clearly organic in origin, is a
form of alienation.

The third principle of radical psychiatry is that
all alienation is the result of oppression about which
the oppressed has been mystified or deceived.
By deception is meant the mystification of the
oppressed into believing that she is not oppressed or
that there are good reasons for her oppression. The
result is that the person instead of sensing his oppres­
sion and being angered by it decides that his ill feelings
are his own fault and his own responsibility. The
result of the acceptance of deception is that the person
will feel alienated. A good example of this is the
depressed youth who does not wish to participate in a
war, but is forced to do so and told that he’s doing
it for the benefit of his country, the benefit of his
brothers and sisters, or even for his own benefit. If
he neglects to see that he is oppressed in this situation
and comes to believe the mystifications about it, he will
then turn from someone who is angry at his oppression
to someone who is alienated and believes that he is
a coward. , Another example is the woman who,
angered by her husband’s domination, ceases to enjoy
sex with him. Again, if she fails to recognize her
oppression she will conclude that she is at fault; that
she is ‘ frigid
while if she becomes aware of the
source of her anger she will recognize that her loving
nature is intact.
Thus, the difference between alienation and anger
about one’s oppression is unawareness of deception.
Psychiatry has a great deal to do with the deception
of human beings about their oppression.
OPPRESSION + DECEPTION = ALIENATION
OPPRESSION + AWARENESS = ANGER

What, then, are the methods of radical psychiatry ?
The radical psychiatrist sees anyone who presents
himself with a psychiatric problem as being alienated,
that is being oppressed and deceived about his oppre­
ssion, for otherwise he would not seek psychiatric
succour.
All other theoretical considerations are
secondary to this one.
The basic formula of radical psychiatry is :

LIBERATION = AWARENESS + CONTACT
The formula implies that for liberation two
factors are necessary. On the one hand, awareness.
That is, awareness of oppression and the sources of
it.- This type of awareness is amply illustrated by the
writings of Laing and the writings by radical feminists
and blacks, and so on. However, this formula also
2

mplies that pure awareness of oppression does not
lead to liberation. Awareness of oppression leads to
anger and a wish to do something about one’s
oppression so that a person who becomes so aware
changes from one who is alienated to one who is
angry in the manner in which some black people and
women have become angry. Anger, therefore, is a
healthy first step in the process of liberation rather
than an ‘ irrationa ’, ‘ neurotic ’, or otherwise undesi­
rable reaction. But liberation requires contact as well
as awareness. That is to say, contact with other
human beings who, united, will move against the
oppression. This is why it is not possible to practise
radical psychiatry in an individual psychotherapy
context. An individual cannot move against his
oppression as an individual; he can only do so with
the support of a group of other human beings.
Thus it appears radical psychiatry is best practised
in groups because contact is necessary. Because people
seeking psychiatric help are alienated and therefore in
need of awareness a radical psychiatry group seems to
require a leader or leaders who will undertake to
guide the liberation process. To avoid the leader’s
oppression of group members each individual member
should propose a contract with the group that indi­
cates his wish to work on a specific problem. Libera­
tion from the leadei’s guidance is the ultimate
goal of radical psychiatry and is indicated by the
person’s exit from the group.

Contact occurs between people in a number of
different forms. Basically contact is human touch,
or strokes, as defined by Berner. But contact includes
also when people become aware of their oppression,
permission, and protection. Permission is just what the
word implies, a safe-conduct for a person to move
against his oppressor and to take care of business ’. This
permission needs to come from a person or persons
who at the moment feel stronger than the one who is
oppressed, usually the leader. Along with the permission,
the person who is to move against the oppression needs
to know that he will be protected against the likely
retaliation of the oppressor.
This, then, is the vital combination of elements
in radical psychiatry : awareness to act against decep­
tion and contact to act against alienation. It should
be reemphasized that neither awareness by itself nor
contact by itself will produce liberation.
As an
example, it is very clear that contact without aware­
ness is the essence of the therapeutic encounters of the
‘ human potentialities 9 movement. The potency of
human contact and its immediate production of well­
being, as found at Esalen and the present RAP
_______________ ( Turn to Page 8 )

Live among them

Is primary health care the new priority ?
Yes, but....
—Charles Elliott
( Continued from last issue )

We HAVE here, then, five areas of evidence that
I suggest we need to ponder rather carefully. To recap
briefly, these are :
1. Local communities tend to give health care low
priority.
2. They tend to make the ‘ wrong ’ choices when
given the opportunity to express their own
preferences in terms of delivery systems : at an
interpersonal level, they do not necessarily accept
medical equality.
3. Community-based health strategies have proved
extremely difficult to implement, partly (but only
partly) because frontline workers are rapidly
professionalized.
4. New health strategies may deliver health care to
more people, but tend to deliver an extremely low
quality of health care to the majority of those
people.
5. We have probably overestimated the effects of
disease on a community, and underestimated its
cultural and possibly physical adaptability to a
given burden of disease.

I have argued that each of these could provide
evidence, ( which I have deliberately not rehearsed in
detail ), that PHC strategy alone does not deliver us
from the kind of professional domination we all
associate with hospital-based curative services. This
is not, not to say that PHC is a blind alley, or
wrong or a mistake. Please let us be clear about
that. It is to say that an overly naive espousal of
PHC strategy, without a readiness to face deeper
issues, is likely to result in bitter disappointment.
For, to anticipate a moment, PHC strategy depends
upon fallen man ( both as healer and would-behealed ) and therefore upon fallen institutions. It,
like everything else, is cast in an environment of
original sin. This is a theme to which we must return.
For the present let us limit the discussion to one
central point.
The CMC and its many friends have been
wholly justified in declaring war -on the medical
ideology of the middle sixties. The question I am
asking is whether, in producing a substitute ideology,
we are not in danger of doing the same violence to
people and to communities, (though perhaps for higher
motives), as did the people and institutions with which
Love them

we have been struggling. Is there not a danger that
the new set of ideas becomes as dominating, as
dehumanized, as ultimately demonic as the old set of
ideas ? If we really seek to respond to the situation
as it is, to respect the whole personality of the
community and individuals within it, might we not
come out with a very different set of assumptions,
strategies and tactics-and might not those assumptions,
strategies and tactics have very little, at least overtly,
to do with what we have traditionally regarded as
health care ?
Ill. This takes me on to a new point, and a
second hard question. The question can be put like
this: Is community health care as readily institutiona­
lized as any other social service ? Precisely because
the PHC emphasis has already, become widely accepted
( if not yet widely implemented), there is surly a
danger that it will suffer from a hardening of the adminisrative arteries and a blunting of sensitivity that
will change it from a potential asset to a certain
liability.
If one looks at the literature on community servi­
ces in general, (and person-directed community servi­
ces in the United States and the United Kingdom
in particular), one is impressed by the ease with
which an institution subverts the end for which it was
created as a means into a means by which its own
end can be justified.
Within the last six years,
many studies have revealed how, in our own Western
countries, services that were established to deal with
‘ the hard cases ’ have become extremely adept at de­
veloping administrative rules whereby the really hard
cases are excluded,
with the result that the
service becomes available to the less hard, the more
easily managed, the more administratively safe.
I see no reason to assume that this tendency is
confined to one particular culture or one particular
kind of organization. It seems to me to stem much
more from the nature of fallen man and, when put
together with the five bits of evidence I adduced for
the first question, it does seem to me to suggest that
even PHC stands in great danger of developing an
institutionalized hierarchy of beneficiaries which will
systematically exclude those who stand in the greatest
need of health care-and in whose name the original
moral impetus of PHC was originally generated.
This administrative distortion I. see as an internal
threat : it is parallelled and indeed aggravated by an
external threat. That threat is the tendency for gov­
ernments to see the provision of health care as Part
of the Process by which the government itself is legi­
timized. To some extent, this is true of all social ser­
vices; and to some extent, it is a proper and healthful
3

response of government of to popular pressure. The
danger arises because different social groups are capa­
ble of threatening governments to different degrees.
Different social groups can therefore demand different
levels of tribute; and health care is one form that
tribute can take. Put at its crudest, this tends to suggest
that once PHC develops its own intitutional momen­
tum and its own administrative rigidities, we may well
find that it is subject to the same distributional biases
as was the curative, hospital-based, ‘ undemocratic ’
structure of health care. Whenever and wherever there
are resources to be distributed, they will be distributed
in response to political pressures. The changing of the
health package (in its widest sense ) does not much
affect that basic fact of political life.

Here I think we glimpse something that the
CMC has always emphasized, even if sometimes
obliquely—namely, that health and salvation are
mutually interdependent in every human society,
irrespective of culture, political allegiance or level of
gross national product ( GNP). That interdependence
is worked out, not only at the individual level, but
also at the macro or social level. The personality of
professional and patient is determined by what a
passing generation of theologians called the state
of grace, and the social milieu in which the persona­
lity is formed and lived. Thus, salvation does not,
cannot and must never be allowed to have a purely
personal reference. Salvation is a social process as
well as an individual liberation.

Taken together, then, the internal and the external
pressures on the community health care strategy will
at the very least much moderate the effectiveness
of that strategy in reaching the poorest and the most
powerless.

The question remains : in operational terms, how
can we make real this dawning perception that, in
all our societies, rich quite as much as (perhaps even
more than) poor, the processes of being healthy and
making others healthy have to them a dimension com­
pletely ignored by traditional thinking, - a dimension
that acknowledges that the people ( both healer and
healed ) and the institutions are in continuous need of
liberation, renewal and at-one-ment—a need that the
biblical tradition call salvation, but which could of­
ten be equally well translated wholesomcness, or hea­
lthfulness ? In developed and underdeveloped countries,
how do we bring healing and wholeness, not only to
the sick, but to those who purport to cure the sick ?
When we do that, what are the implications for the
relationship between the practitioner and the patient,
the curer and the cured ? This will doubtlessly need
much further investigation, but one implication is
clear. That relationship ceases to be a relationship
between the sick and the healthy. It becomes rather
a relationship between two people or groups both
of which know that they are less than whole and
both of which are seeking to find a greater degree
of wholeness.

IV. So far, I have asked questions about :
(a) the extent to which PHC has become a new
form of professional domination, and

(b) the extent to which it has been, is being and
will be institutionalized in a way that prevents
it from ^effectively reaching those who need it
most.
If these are valid questions, we have to ask:
What then ? What can be done ? What, particularly,
can be the reaction of the CMC or its successors ?
Part of the answer is already clear. In discussing
both of the basic questions I have tried to ask. I
suggested that what one is up against is man as he
is. Because one is up against man as he is, one is
also up against institutions as they are, mirrors and
magnifying glasses of man’s moral and cultural
ambiguities. Both as dispensers and recipients of
health care, men-in-community are severely limited
in their ability to give or receive health. The funda­
mental problem that faces us, therefore, is to enlarge
that ability.
The process by which that is done can be ascri­
bed a variety of different labels according to ideolo­
gical or eth’cal positions. It can be called conscientization. It can be called liberation. It can be called
cultural revolution. Or it can be called salvation.
I’m not suggesting that these are either the same or
even roughly equivalent: I am suggesting that we are
all looking for ways in which the delivery of health
care does not become subverted into the protection
of a profession; and for ways in which the receiving
of health care does not become distorted into a process
by which my neighbour is robbed. _____
4

1 know that some of what I have said is conten­
tious and may spark challenge and even fundamental
disagreement. So be it. But at the risk of seeming to
confound confusion, let me make one final comment.
If what I have said is even roughly right, there is
clearly a limit to the extent to which the CMC, the
Christian Medical Commission, can collaborate with
agencies which deny to the concept of health the element
of transcendental wholeness as expressed in the last
paragraph. It is possible that some of these agencies
will see that the physician is as much in need of
healing as the sick. The real question will be : Where
will the agencies look for the spiritual resources for
_______
( Turn to Page 8 )

Serve them

Book Review

HEALTH OR “ HEALTH SERVICES ” ?
We have for review two books on the same subject—
health—that supplement each other. The Care of
Health in Communities ( Macmillan, dollar 8.95 )
is by Nancy Milio, the registered nurse who spent a
year or two working in a “ mom and tots ” center
in the ghetto area of Detroit—getting it going, making
it work—and then telling the story of this adventure
in 9226 Kercheval (1970). The Detroit experience
became the foundation for
wide investigation.
Miss Milio went back to school, did research, and
wrote the present general report on health services
throughout the United States. Quite evidently,
The
Care of Health in Communities is the result of a
deeply felt need to understand why there are so many
practical obstacles in the way of anyone who tries to
work personally and effectively to help the poor and
disadvantaged. Access for Outcasts, Miss Milio’s
subtitle, gives the motive and theme of this work.
The other book—not yet published in this country
(U.S.A.) still; a draft circulated for comment and criti­
cism—will be the American edition of Ivan Illich’s
Medical Nemesis, which has already appeared in
England in briefer form. This book is the best
example yet of Illich’s extraordinary capacity for
effective generalization. The impressive documentation
supporting his judgments suggests that he and his
colleagues have read every criticism in print of the
modern practice of medicine.
Illich’s fundamental
claim is that during the expansion of the social
processes and structures of a civilization dominated
by industrialism, a point is reached where activities
originating as services begin to have a reverse effect.
They begin to harm people instead of helping them.
The damage is both subjective and objective. The
reader is directed to proof of the damage in Illich’s
numerous footnotes. His text deals with psychological
subversion, and the cutting edge of most of his
generalizations is at this level. He contends that when
individual responsibility is diminished by the require­
ments of technological systems, people lend to deny
themselves the very possibility of healthful lives.
Health, he suggests, is the spontaneous result when
normal human beings cope resourcefully with a normal
environment, matching their capacities with the natural
limitations and obstacles in life.
Such statements have obvious metaphysical impli­
cations. They also have great intuitive appeal.
Medical Nemesis represents Illich’s effort to demon­
strate that the facts of modern experience at every
significant level support this analysis. Here we are
able to give only a few of his generalizations :

Learn from them

Increasing and irreparable damage accom­
panies present industrial expansion in all sectors.
In medicine this damage appears as iatrogenesis
(physician-caused ills ).
Iatrogenesis is clinical
when pain, sickness and death result from medical
care; it is social when health policies reinforce an
industrial organization which generates ill health;
it is structural when medically sponsored behaviour
and delusions restrict the vital autonomy of
people by undermining their competence in gro­
wing up, caring for each other and aging, or
when medical intervention disables personal res­
ponses to pain, disability, impairment, anguish
and death.
Most of the remedies now proposed by the
social engineers and economists to reduce iatro­
genesis include a further increase of medical
controls.
These so-called remedies generate
second-order iatrogenic ills on each of the three
critical levels.
The most profound iatrogenic effects of the
medical technostructure are a result of its non­
technical functions, by which it supports the increa­
sing institutionalization of values. The technical and
non-technical consequences of instutional medicine
coalesce and generate a new kind of suffe­
ring : anesthetized, impotent and solitary survival
in a world turned into a hospital ward. Medical
nemesis is the experience of people who are
largely deprived of any autonomous ability to
cope with nature, neighbours and dreams, and who
are technically maintained within environmental,
social and symbolic systems. Medical nemesis
cannot be measured, but its experience can be
shared. The intensity with which it is experienced
will depend upon the independence, vitality and
relatedness of each individual.

What is Illich’s ideal ?
briefly :

The following states it

The level of public health cjrresponds to the
degree to which the means and responsibility for
coping with illness are distributed among the total
population. This ability to cope can be enhanced
but never replaced by medical intervention or by
the hygienic characteristics of the environment.
That society which can reduce professional inter­
vention to the minimum will provide the best co­
nditions for health. The greater the potential for
autonomous adaptation to self, to others and the

environment, the less management of adaptation
will be needed or tolerated.
The weakness of Medical Nemesis is certainly
not in Ivan Illich’s diagnosis, but in his remedy—he
wants to limit medical monopolies by law, and to
give legislative encouragement to people to evolve
their own forms of health service and care of the
sick. Why should this be a weakness ? Because
Illich, despite the avalanche of facts he has assembled,
is making a philosophic criticism. At root he is
recommending a changed attitude of mind—better
ways for humans to think about themselves, their
capacities, and their needs. You don’t change minds
with legislation. Changed minds may cause better
legislation, but a vast number of minds have to
change before the laws can be substantially improved.
Only a dictator or an autocracy is able to change
the laws in advance of a strong current of public
opinion.

Illich may feel that his thought will remain
utopian unless he proposes a political remedy for the
ills he defines so well. But truly utopian programs
arc best initiated by numerous small-scale experiments,
persistently repeated until they finally take root.
Law-making is now in the hands of a collection of
second-rate, secular grand inquisitors whose methods
are all infected with
their spiritual
ancestor’s
assumptions. Entrusted to their hands, reforms aimed
at self-reliance and increased individual responsibility
will inevitably be turned around and made to have
an opposite effect.

Illich’s genius lies in showing what is wrong with
4he Zeitgeist of the industrial age. He reveals its
self-defeating Faustian delusions and gives chapter
and verse on where the defeats are taking place.
What is the Zeitgeist ? It is spirit and mood,
embodying both conscious and unconscious over-all
value judgments about our lives and what is good. But
men are more than any Zeitgeist. They are not
entirely its creatures. They are not totally occupied
by the generalization of their common weaknesses.
In every doctor who submits to the imperatives of
technological medicine there is still a human being
who may be uneasy, who may sense that something
is seriously wrong. The Prometheus who is subdued
is not defeated. The Zeitgeist reflects the action, not
the potentiality, .of the age. Law-making, as a means,
belongs to the past, not the future.
Nancy Milio, one could say, looks at world
health care, and especially health care in the United
States, from the point of view of what can be done
in spite of Zeitgeist, of which she seems well aware.

6

While Illich works at changing the polarity of human
thinking, Nancy Milio considers what we may be able
to do, in the meantime, out in the field. Mostly, of
course, her book lists the limitations on health care—
what is wrong. Inevitably, the Zeitgeist threatens
her positive recommendations. In one place she says :
Without public awareness of the very different
consequences of numerous proposals all of which
are labeled “ national health insurance, ” there is
likely to be little consumer response to Cong­
ressional moves.
Without definitive public
response, Congressional approaches are likely to
follow familiar paths, with the result that changes
will not alter current prerogatives very much,
outcasts will gain little and the health of the
American majority is not likely to improve.
Creating such a truly democratic responsive­
ness would meet with many impediments, beyond
finding sources for the funds that would be
needed. Among them is the fact that health
professionals—who are assumed to be experts on
health—are often unaware, or narrowly aware as
a result of their training and other reasons, of
the big picture, of the context in which they
work. In effect, they are more concerned about
health services than health.
Further, most health care providers are part
of large groups and associations. Thus group
decisions and organizational priorities arc likely
to take precedence over personal doubts, to stifle
questions, to close options to new ways. And
soon the newer—and sometimes more open—
health personnel accept the same constraints and
rewards as their mentors. Personal intention to
do good and perform well takes or retains prio­
rity over the critical examination of the effects
of collective actions. Were it otherwise, organized
health professionals would probably have signi­
ficant policy making influence toward support for
the health-deriving social changes that would make
personal health services more effective.

True to her purpose, Nancy Milio concludes by
giving three examples of improved access that has
already been achieved—programs in Orissa, India, in
Amsterdam, Holland, and in Edinburgh, Scotland.
The State of Orissa, “with all its difficulties, is doing
what others have only talked about.” Here parapro­
fessionals are reaching into outlying villages of
Harijans ( 'untouchables,” of whom there are four
million in Orissa), and training local practical nurses
and midwives. An extraordinary woman in Amster­
dam is accomplishing similar effective contact with
Surinam Blacks whD have migrated to Holland, and
Start with what they know

have been long neglected there. In Edinburgh the
people of a low-income district have themselves organi­
zed a day nursery and health program and generated
a community spirit which animates a variety of other
activities—housing rehabilitation, and recreation for
both young and old—with the result that “ those who
were to be organized have become the organizers,
those who are outcast are together working to open
and enter the decision-making that sets their options
for living.” A book entirely devoted to such initia­
tive and achievements would make fine reading.
Courtesy, ‘ MANAS ’ Feb. 11, 1976,

Dear Friend,
Is this a readers’ bulletin ?

Inspite of the fact that 1 was very much involved
in planning the various issues of the bulletin, when it
comes in print, 1 can’t help feeling that there should
be more people participating in writing for it. The
first two issuse have become a JNU affair which
perhaps is not a very healthy sign. I suggest if we
could in future invite members to contribute on
certain specific problems ( which we have selected ).

In the second Bulletin I am attracted by Shri
Bapalal Vaidya’s comment.
’* There is a need to
liberate people from the grip of the doctors ”, It
appears that according to him Ayurveda has the
answer but is being thwarted by the 1CMR in its own
interest. While I fully agree that indigenous medicine
is not getting the kind of attention it deserves 1 also
want to express my doubts about his hope that if
funds were provided Aurvedic medicine will come to
the rescue of the people. I suspect that the same
reasons which obscure the preventive aspect of allopa­
thic medicine will continue to operate on the teaching
and practice of Aurvedic medicine and till we realise
this, no amount of shifts from one system of
medicine to other will make any sense.
—Imrana Qadcer, JNU, New Delhi.
Who is the culprit ?
It was interesting to go through ‘ The Myth of
the Protein Gap ’. Dr. JayaRao has accused vested
interest of some countries having surplus protien
resources for the myth. If it is true-and there are
enough experiences in other fields to believe that it
must be true-then it raises some serious and subtle

question about our scientists and their so-called
research activities.
Are those scientists who per­
petuated, supported and highlighted the so-called
protein gap a party to vested interests ? Or were
they fool enough to be misguided ? If so, it means
that scientists may be trapped and used by vested
Build upon what they have

interests. This is important because it is possible in
a number of other fields also; these vested interests
must be exploiting the scientists and ultimately the
masses in the name of scientific truth. Not only
masses are exploited individually but scarce national
resources in terms of man and material are misspent.
Wrong programmes are launched and authentic and
false health education is imparted. Then people have
to unlearn the compulsory miseducation imparted in
order to accept new education. Not only that, any
sensible person would hesitate to take the job of
health educator, when there are many chances of
miseducating the people. This unlearning requires
tremendous effort and it means wastage of national
resources. If this wastage is translated in crude
language it is a question of bread or death for a
common man in developing countries. Who is respon­
sible for this ? Can scientists shun their responsibility
in the name of science and research ? If it is due to
an honest and sincere mistake in research itself then
they may.
But if it is planned by vested interest
and scientists are being played with in their hands, it is
not only unpardonable but scientists should be taken
to task. They have a social responsibility to scrutinise
the information put to them, either individually or
collectively.
Would anyone open the myths of
pharmaceutical concepts ?
—A. B. Patel, Kheda.
The protein gap

The article ‘ The Myth of The Protein Gap ’
appeared in last issue made a stimulating reading.
I came across an exhaustive review article on ‘ The
Protein Gap ’ in ‘ Nature ’ Vol. 258 November 13
1975 by Waterlow and Payne. I cannot resist myself
to quote few passages from it, which may incite
other readers to go through it.

“ In 1968 the UN Advisory Committee on the
Application of Science and Technology to Development
presented a report to UNESCO with the title “ Inter­
national action to avert the impending protein crisis.”
Numerous recommendations were made about methods
of increasing protein supplies, the production of high
protein foods and the exploitation of unconventional
sources of protein to fill the “protein gap’’. Seven
years later there is a strong body of opinion that
this is an incorrect statement of the problem : that
what the world with its expanding population has to
face is primarily a food gap or an energy gap and
not a protein gap.
McLaren, in his stimulating
article “ The great protein fiasco ”, has summarised
the history of this preoccupation with protein and in
particular the reasoning by which the UN agencies
came to identify protein as the weak point in the

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bulletin : May 1976

world’s nutritional defences.
It all began with
kwashiorkor.
“ When Williams described kwashiorkor in young
children- in Ghana some forty years ago, she diagnosed
it as a nutritional disease, adding cautiously “....in
which some amino acid or protein deficiency cannot
be excluded ”.
The children who developed the
disease did so after weaning, when they were fed on
starchy porridges rather low in protein, and they were
cured by milk. It took some time for the diagnosis
of protein deficiency to be generally accepted; in
earlier accounts, particularly from Latin America, the
presence of oedema and skin lesions in many cases
led to the suggestion of a multiple vitamin deficiency.
For the last 25 yrs, however, the view has been fairly
generally held that the two extremes in the spectrum
of childhood malnutrition - kwashiorkor and marasmus
-represent conditions in which the main limiting
factor is protein on the one hand, energy on the
other. This satisfying hypothesis is epitomised in the
title of a book published in Wfti-Calorie Deficiencies
and protein Deficiencies.
The chain of arguments which leads from these
early clinical studies to the concept of the protein
gap as a worldwide problem rest on three premises :
that kwashiorkor is indeed a manifestation of protein
deficiency; that it is very common in the developing
world; and that wherever kwashiorkor occurs milder
forms of protein deficiency must be widespread,
affecting far more children than those who develop
the severe disease. This is the ‘ tip of the iceberg ’
theory. All three premises need to be examined.
“ Is kwashiorkor a result of protein deficiency ?
The evidence is to a large extent circumstantial.
Retrospective dietary histories are of limited value
because the illness itself causes a fall in appetite and
thus a reduced intake of all nutrients. The most
powerful evidence of cause and effect in nutritional
work-the therapeutic test-is not practicable, because
a sick child cannot be fed protein alone. In a prospe­
ctive study of children in a poor community no
quantitative or qualitative differences in the diet were
found between children who developed kwashiorkor
and those who became marasmic. Gopalan therefore
suggested that it is not the diet which determines the
clinical picture, but the way in which the subject
adapts or fails to adapt.
Is kwashiorkor common ? The WHO and FAO
conducted a survey in Africa about childhood malnu­

trition in 1952. Their report concluded that : “ Kwash­
iorkor is the most serious and widespread nutritional
disorder known to medical and nutritional science ”.
McLaren has pointed out that this judgement, based
largely on rural Africa, ignores large areas of the
world where marasmuus is by far the commonest
form of malnutrition.
“ Is there evidence of widespread protein deficiency
in the absence of clinical disease ? Estimates of WHO
that in many countries 20-40% of childern are mode­
rately or severely malnourished are in most cases
based on a deficit in weight for age. This growth
failure is, of course, a nonspecific effect of malnutri­
tion. It is possible that more information may be
obtained by analysing separately two component of
growth failure : inadequate gain in weight and inade­
quate gain in length or height.
The search for
specific biochemical indicators of protein deficiency
has been going on for many years.
Whilehead has
concluded that the most sensitive index of impending
kwashiorkor is a decrease in serum albumin concen­
tration. It remains to be proved, however, that this
change is indeed a specific effect of protein deficiency.
The third approach is by comparision of intakes with
requirements. Before going on to this we have to
consider the basis on which requirements have been
estimated, since they are often considered not to be
realistic, or little better than guesses.
—D. P. Shah, Bombay.
Radical

Psychiatry....

( Continued)

Centre, is rightfully eyed with suspicion by therapists
in the Movement because without awareness human
contact has a capacity to pacify and reinforce the
mystification of the oppressed. It is equally clear
that pure awareness, whether it be psychoanalytic or
political, does not aid the individual in overcoming
oppression since the overcoming oppression requires
the banding together of the oopressed.

Courtesy, ' The Radical Therapist ’
Is

primary

health

Care....

(Continued)

the healing of the physician ? The Christian answer
is ( more or less) clear. Can we devise experiments
which show those resources in action ? Or perhaps
they are already at hand ?
( Concluded ]
Courtesy, ‘ Contact
August ’75.

Editorial Committee: imrana qadeer, prakash bombatkar, satish tibrewala, kamala jayarao, mira sadgopal, abhaya bang, george
isaac, sathi devi, bhoomi kumar j., suhas jaju, lalit khanra, ashvin patel (Editor)
title design : puma, nid, ahmedabad 9

Edited and Published by - Ashvin J. Patel for Medico Friend Circle from 21 Nirman Society, Vadodara-390005.
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