The brief existence of the Indian section of the royal medico-psychological association: A historical note.

Specialists in psychiatry, in the Indian sub-continent, were trained in the UK in the early 20th century. Just before Independence, an Indian branch of the Royal Medical Psychological Association was established. Many issues of contemporary concern were discussed, as also plans for the further development of psychiatry in the region. Soon after the Second World War, and the Independence of India, the association was disbanded. However, a large number of psychiatrists from south Asia now live and work in the UK, and the Indian Psychiatric society and the Royal College continue to have close links.

INTRODUCTION

Mental health professionals from South Asia make a substantial proportion of the approximately 6000 psychiatrists in the UK,[1] and the close links between medical education, regulation, and services established during the pre-Independence era between India and the wider framework of Anglo-Saxon psychiatry continue. The historical analysis of this shared development still needs to be done.

THE ANTECEDENTS

Medical education in India has a long history, with medical schools being established in early 19th century, and gradually spreads throughout India. Provision of health care was initially part of the mandate of the East India Company in the territories it governed, and it was made the responsibility of local governments during the period of Crown rule.[2] Doctors trained in India were, however, ineligible to take up senior position in the medical services in the government, especially the management of public facilities such as lunatic asylums, within India, till the First World War.[3] The large number of (Indian) doctors in training who volunteered to serve during the First World War in UK, the work of the Indian medical officers during the War, and also the shortage of specialist staff made reform imperative, and feasible, for medical services, including psychiatric services. Indian doctors could now be appointed into positions of authority in the lunatic asylums (these were renamed mental hospitals in the decade following the war, as the first step toward reform) in British India. Postgraduate training in psychiatry at the Maudsley Hospital in London began soon after the WW1 to train psychiatrists for the Empire.[4] For almost a century before this, psychiatrists from all over Europe had trained in psychiatry and neurology in Germany, where Alzheimer, Nissl, and Kraepelin had established their preeminence. Furthermore, Kraeplin had just established an institute in Munich,[5] and it probably felt prudent to develop psychiatric training for the Empire in the UK, given the events of Europe in the preceding decades. Specialists in mental diseases from all over India; such as Frank Noronha from Mysore, Banarsi Das from Agra, and S. Venkat SubbaRao and A Purushottam from Madras, all came over to study at the Maudsley, and went back to work at, and manage, the various mental hospitals. By the time, Sir Edward Mapother visited the region in 1937, graduates from the Maudsley were scattered throughout the subcontinent and Ceylon, and issues of reform and further development were being vehemently discussed.[6]

In the short period of less than 20 years, a number of psychiatrists of Indian origin were trained in “academic” psychiatry and began to manage the mental hospitals, gradually displacing the earlier generation of medical men from the Indian Medical Service (IMS) who had till then been in positions of authority. Of these, Mapother was to comment caustically in his report of 1937, “it would be difficult for the most jingoistic to affirm that, in the matter of provision of mental disorder in India, the British ‘bearing of the white man's burden’ has been quite adequate (and) a refusal to look at the rest of the world with any hope of learning from it.” During meetings with various professionals, he got the impression that the government knew its time was up, and the IMS officers did not see the point in investing any more effort to make improvements of a permanent nature. In addition, many superintendents told him that they had less difficulty in getting help from provincial government rather than “in the days of more complete British control.”[7] Thus, both at a professional and political level, the Indian specialists had become conscious of the change in their stature and the need for recognition.

THE SETTING UP OF THE ASSOCIATION

In this context, the setting up of the Indian section of the Royal Medico-Psychological Association (RMPA) on January 23–24, 1939, marks an important development and a kind of self-assertion by the specialists in mental health in India. Its establishment had been first proposed in 1936 but had hit a stone wall. It was suggested, at that time, that membership be limited to those who had a formal qualification as a psychiatrist, then possible only by working in the UK, while those who had worked for long and exclusively in Indian mental hospitals were not eligible. This restricted the numbers to those who could afford to travel to the UK for this education or who could be sponsored by their local governments (as Noronha and many others were) and thus quite limited. This created considerable friction as Dr. Parsuram (from Madras) wrote to Dr. Banarsi Das that “scheme has to be dropped for the present till better circumstances prevail.”[8] Dr. Parasuram had written to Dr. Masefield seeking clarification on whether Indian doctors holding Indian degrees would be eligible for membership to the division, to which he got a reply that the society had discussed the issue in May 1936 and that registration in the UK under the medical act (1858) was necessary. The RMPA (the forerunner to the current Royal College of Psychiatry) itself had been formed only some years earlier and contained almost “all members of the medical profession dealing with nervous and mental disorders.”[9]

Despite this, Dr. Banarsi Das went ahead and suggested a core group of about 15–20 members. The first meeting was planned in 1938, but ill health of some members caused it to be postponed, and it was finally established in early 1939. As Dr. Das pointed out, the Indian division was the first overseas division, ahead of other self-governing dominions such as Canada, Australia, and South Africa. He also pointed out that India had more than 30 members while the number of psychiatrist in these dominions barely exceeded a dozen each. India was thus well poised to take the lead in this activity within the Empire. Banarsi Das also highlighted the neglect that had set in, as regards psychiatric services. While the best general hospitals in India could be compared to any in the west, the mental hospitals were an “embarrassment,” and the blame for this, he felt, was a “parsimonious allotment of funds.”[10]

At the inaugural meeting in January 1939, at the Mental Hospital, Lahore (now in Pakistan), hosted by Lt. Col. Lodge-Patch, IMS, the developments in psychiatry in Punjab, its prospects in Australia, the management of mental defectives, and the role of medical psychology, as well as managing neuropsychiatric clinics were discussed in detail. The hidden hand of the Maudsley can perhaps be discerned in all this, as in that hospital, neuropsychiatric clinics had been established, and psychology and physiology were actively encouraged, and a wider discourse within the British Empire was possible when doctors from all over met while training in the UK. The other concerns were overcrowding in mental hospitals, and their reform; the (in) adequate training of medical students in psychiatry, as also other staff and nurses for psychiatric care, amendment of lunacy laws, and optimum designs for single cells in mental hospitals. Other than the last, the other issues continue to be discussed, with almost equal fervor, till now.

The meeting was held in the lawns of the Mental Hospital (January can be quite cold in Lahore), and later that evening dined on, among other dishes, “Poulet en Karri et Pelau” (less officiously, chicken curry and rice!). Members included British and Indian officers from the IMS (Lodge Patch, Moore-Taylor, Kennedy, Dhunjibhoy, and others) as also those in civil service (Banarsi Das) while the Royal College was represented by CJ Thomas. A silver badge and other official accoutrements were presented to the Indian division from the RMPA.

THE SECOND WORLD WAR, INDEPENDENCE, AND AFTER

World War II began a few months later in September 1939, and organization work took a back seat. However, larger things were afoot in the subcontinent. Moore-Taylor had several meetings with Prof. Edward Mapother in London and used these discussions to outline reforms in psychiatric services as part of the suggestions made by the Bhore Committee (the Indian equivalent of Nye-Beveridge plans, which outlined the blueprint for health care in soon-to-be independent India, and envisaged an National Health Service [NHS] kind of service).[11] In addition, psychiatrists from Germany who had moved to the UK under the Rockefeller program (W Mayer-Gross, Lieberman) during or before the World War established close links with Indian psychiatrists who were training there, and this would, in turn, have an impact on postgraduate training in India.[12]

Things remained in a flux during the war, and the politics of the subcontinent changed dramatically soon after. Col Moore-Taylor, who had been instrumental in steering the reform process, retired when India became independent. As early as April 1947, Moore-Taylor had written to a colleague that he had “unofficial information that a move was on to foot to institute an Indian Association and that the Indian Division (of the RMPA) would die a natural death. Anything ‘Royal’ is not regarded with favor (sic) in India these days.”[13] The General Secretary in London requested that due to the “present political situation” that the association is dissolved. The Indian Psychiatric Society was thus formed, with Col RB Davis, IMS, as its first President. However, as Dr. Roy, the last secretary of the Indian Division, wrote, “my personal view that it was a mistake to have a new society formed so early and particularly its dissociation from the RMPA” and went on to affirm that he was not severing his connection with the RMPA, echoing the view of Dr. Davis that most members of the Indian Psychiatric Society will remain members of the RMPA amidst “hopes that the relations between the two will always be the most cordial.”[14]

EPILOGUE

This back and forth approach of the professionals in India, trained in hospitals in the UK, and familiar with medical practice in the English-speaking world, influenced the nature of medical services in India. Following suggestions made by Lord Adrian Hill, Sir Dalrymple-Champneys, Henry Sigerist, and others, postgraduate training facilities were established immediately upon independence.[15] The All India Institutes of Medical Sciences (AIIMS) and the All India Institute of Mental Health (AIIMH) were established by 1954, and while the Diploma in Psychiatric Medicine course at the AIIMH was patterned closely upon that at the Maudsley, the MD program at the AIIMS was more oriented toward a general hospital psychiatry and dynamic psychotherapy. The training in psychiatry, at the early departments, thus closely resembled that expected of practicing mental health professionals in the UK or the USA.

However, unlike Australia and Canada, the countries of the Indian subcontinent, soon after Independence, were faced with partition and population migration, the disbanding of the IMS, crippling financial readjustments, devaluation of currency, several wars, and near famine situations in the first two decades of their existence. All this made any hope of a comprehensive, universal health-care system become a chimera, and medical graduates found themselves unsuited to the kinds of services that were being developed. They emigrated in large numbers (the NHS alone has almost 40,000 doctors from the region among the 250,000 odd members on its registers).

However, there was no systematic attempt to improve the mental hospitals or develop community services (as was being done in the UK by the 1960s). The lack of professional opportunities and the apocryphal “Cinderella” approach to psychiatric services worsened the situation. India, which could once claim to be ahead of other countries in the erstwhile British Empire, like Australia and Canada, now lags far behind. As these countries, and the USA established more organized services for psychiatric care, even more psychiatrists from the subcontinent moved there.[16]

This has produced a piquant situation. Psychiatrists from the “third world” are now completely adept at understanding the psychological problems of the “ first world”[17] while many first world psychiatrists continue to advise the “third world,” for solutions for the people living there. More often than not, this includes suggestions to develop entirely “local” models for care while doctors from the region are expected to fit into a globalized cosmopolitan framework of psychiatry. These tensions within local and global, in service delivery, as well as in professional roles are still constantly debated.

Financial support and sponsorship

The work was supported by a grant from the Wellcome Trust, UK, Turning the Pages, 096493/Z/11/Z.

Conflicts of interest

There are no conflicts of interest.