He was a bigger boy, as we used to say back then in Barbados. This meant that although we attended the same school in the early 1950s, and we were aware of each other's existence, we were not buddies or any form of close friends. He would be called my senior, an artful way of establishing a hierarchy that was quite functional in those days of British colonial life. So he and I did not play on the same cricket or football teams, and we would not have been seen in the same circle of friends.
It was about 20 years later, around 1976, when I encountered him again. I was a resident in psychiatry, and I decided to attend a post-Annual Meeting conference that the American Psychiatric Association used to sponsor in the old days. The Annual Meeting had taken place in Miami, and this post-convention seminar was being held in Puerto Rico, an island I had never visited before. I was walking through the lobby of the hotel when I heard hearty, deep-throated laughter interspersed with Caribbean-accented conversation. I hesitated momentarily and then thought I recognized him. I approached tentatively and quickly realized that this was a face I knew from my days at grammar school. I may have quickly mentioned my own name, but I know I emphasized my eldest brother's name. I had followed the tradition of connecting myself to an older brother, and the link was made. We did not talk long then. There would be time enough over the next several decades for me to appreciate fully the breadth of his career and the profound impact he would make throughout the West Indies. At that time, Dr. George Mahy had already served a stint as medical superintendent of The Mental Hospital in Barbados and he was established as a specialist psychiatrist in the British and Caribbean contexts. I did not know then that we would carry out a number of professional activities together and that he would distinguish himself as a practitioner of forensic psychiatry throughout the English-speaking Caribbean.
Psychiatry was not a premier medical specialty in the era when the West Indian islands were under the governance of the British. Each island struggled with the care of its citizens whom the community considered to be in need of psychiatric care. In Barbados, those individuals were housed at a facility referred to as Jenkins, no doubt because it was located on what used to be the Jenkinsville estate. I remember friends from my neighborhood having the task of visiting relatives who were at Jenkins. These friends' mothers advised them strictly not to put their real names on the register when they went to visit someone at the psychiatric facility. The point was that my friends were not to let on that they had relatives who were under care at Jenkins. This attitude toward the psychiatrically ill persisted for years, and it is easy to see why. There were few voices from the medical profession or the lay community available to speak on behalf of the group of psychiatric patients.
A politically astute psychiatrist named Michael Beaubrun took up a position in 1965 at the Medical School of the University College of the West Indies (later to become the University of the West Indies) in Jamaica. He attracted a group of physicians around him and managed their professional development with a clever eye to the future, both with respect to his charges' personal maturation and to the longitudinal development of psychiatric care in the Caribbean. Dr. George Mahy was one of Professor Beaubrun's stellar protégés. Under the professor's tutelage, Mahy got his early grounding in Jamaica. Then he went off to Scotland to round out his training, an arrangement obviously established by Beaubrun. Dr. Mahy gained his British specialist qualifications in psychiatry in 1970 and then became a founding member of the Royal College of Psychiatry in 1972. This was an important step. Possession of specialty certification would allow him access to certain positions once he returned to a Caribbean that was then in the midst of struggles for post-colonial independence. It was important that the new generation of indigenous physicians be able to claim that they had sat and passed the specialty examinations conducted by the former colonial masters. In other words, the new cadre of doctors could legitimately claim that they were well trained.
Over the next decades, George Mahy would consult to many of the island governments in the region, to the Pan American Health Organization, and to numerous other nongovernmental groups trying to carry out mental health initiatives in the West Indies. His prominence, coupled with the paucity of available psychiatric expertise in the region, would lead to his becoming progressively involved in forensic psychiatry. This was bound to happen.
In the Caribbean, individuals regularly have their first encounter with mental health authorities as a result of behavior that necessitated a response from the police. During my own stint of consulting to the government of Grenada, I was struck by how frequently psychotic individuals attracted attention by standing in the middle of a road and impeding traffic while they muttered to themselves. Or they picked up small stones and threw them at passers-by while shouting insults. Inevitably, the police were called and had to intervene. In some cases, criminal complaints were lodged against these persons. But often it was the psychiatrist who influenced the final disposition of the matter. So, Caribbean psychiatrists, partly because of the geographic limitations of their island activity, have for a long time been involved in informal jail diversion programs.
Administrators of the islands' jails must eventually turn to a psychiatrist for help and advice in caring for their charges. I have accompanied George Mahy to these facilities in Barbados, Grenada, and St. Kitts. During these visits, he was impressive as he manipulated his cultural connections to the patients in ways that would have been difficult in many other settings. They called him “Doc,” with a tone of affection that bordered on the reverent, while he glided among them quietly and smoothly, belying his imposing muscular physique.
Dr. Mahy joined the Faculty of Medicine of the University of the West Indies in 1982. He has long been associated with the campus located in Barbados, where he rose to the rank of Vice-Dean. An intriguing area of his scholarship has been the phenomenon of suicide. His work has drawn attention to the problem of maintaining accurate statistics about suicide in the different territories. Facts about the prevalence of suicide and attempted suicide have been difficult to obtain because, for a long time, it has been illegal for one to try to take his own life. In addition, the stigmatizing shame attached to the action of harming oneself has prevented families from discussing these problems openly. But Dr. Mahy has been an early voice in pointing out the vulnerabilities of certain groups to the profound demoralization that may lead to suicide. He has also shed light on the unique context of Caribbean culture that facilitates the use of agricultural poisons in suicide rather than firearms or gas stoves that are commonly used in other countries.
Multiple conversations with Dr. Mahy have clarified for me the powerful roles played by Caribbean culture in the practice of general psychiatry and particularly in forensic psychiatry. In general, the Caribbean territories are quite small, although Trinidad, Jamaica, Belize, and Guyana are notable exceptions. In addition, there are not significant numbers of psychiatrists, and forensic psychiatry is still not fully appreciated. Unlike the United States, there is no love of lawsuits. For one thing, this means in practice that there is a paucity of ethics complaints lodged against physicians. But just as important, were an ethics complaint to be brought, it would not be an easy matter to find a forensic psychiatrist to testify as an expert witness against the physician and on behalf of the complainant. Similarly, in the arena of civil law, such suits are relatively rare, and the need for experts is not pressing. When the need arises, experts can be obtained from another territory so as to minimize the problem of conflict of interest. This is not to suggest that people in the Caribbean are unaware that the law can be used to correct civil wrongs. Some years ago in Barbados, a clergyman sued his bishop, and the case was covered widely, as it was appealed all the way to the Privy Council in England. Nevertheless, as Dr. Mahy has taught me well, individuals who win such suits still have to live in the community where everybody knows everyone else. The daily necessity of interacting with one's neighbors, a term meant to encompass everybody on the small island, diminishes the likelihood that a litigious character will flourish and prosper. Unfortunately, even lawyers and experts who participate in the suit may be tainted by the brush of unpopularity.
The criminal context is also influenced by the dimension of culture. Dr. Mahy has reminded me time and again that he has yet to appear in court in a battle of the experts. Whether engaged by the defense or the prosecution, he is always the only expert to appear in a given case. This situation obviously highlights the importance of cross-examination. But, too, it emphasizes the significance of all that an experienced expert like George Mahy has to say. In a recent case of a woman with known epilepsy who killed her child, he was used as an expert to discuss the subject of sane and insane automatism and its relationship to the woman's documented history of post-ictal bizarre behavior. He recommended that the woman be confined in an appropriate place where medical personnel could observe her and where she could be examined by a neurologist and undergo further tests to determine the extent and severity of her seizure disorder. His contributions here were clearly enhanced by the unique cultural context of the Caribbean. In addition, the esteem he enjoyed in the criminal courts and his status among psychiatric practitioners enhanced his ability to be helpful in an arena where justice was being sought. Dr. Mahy also explained that simply seeking a decision of not guilty by reason of insanity would have been pointless, as most Caribbean territories still use the McNaughten rule.
He and I discussed at some length the future of forensic psychiatry in his island, Barbados. It was evident that he took delight in informing me about one of his star students, Dr. Maisha Emmanuel. She has just accepted the post of Lecturer in Psychiatry at the University of the West Indies in Barbados. In addition, she has acquired a British master's of forensic psychiatry degree and will therefore likely be the first psychiatrist in the Caribbean to have formal university training in the sub-specialty. So Dr. Mahy looks forward eagerly to the beginning of this new era in Caribbean forensic psychiatry.
I have, from time to time, allowed myself to be persuaded that in Europe and the United States we are at the forefront of developing ideas in forensic psychiatry. A thoughtful discussion with George Mahy always dispels that notion. I recall our discussing what to do with dangerous psychiatric patients on small Caribbean islands where there is simply no secure hospital facility in which to house them. No funds were available to construct a secure institution, nor would it have been a wise use of resources to construct and staff such a facility to house only a handful of these patients. It took me a while to process the numerous reasons advanced fluently and cogently by my colleague to buttress his recommendation that the prison could be humanely used. He also helped me to understand how easy it is to corrupt the principles of physicians in the context of politics, something that so many of us in the United States struggling with the goings-on at Guantanamo have difficulty appreciating. But George Mahy had somewhat of an inside seat during the revolution in Grenada and he knows of what we all are capable, physician or not.
In 2003, on the recommendation of his island's prime minister, the British government awarded George Mahy the prestigious CBE (Commander of the Most Excellent Order of the British Empire).This honor, just short of a knighthood, recognized his decades of contributions to general psychiatry and forensic psychiatry in the English-speaking Caribbean. His wife, a well-known high-school teacher of French, and children must have been delighted at such international recognition of their husband and father. I could not have known then, 50 years ago, that this youngster in short khaki pants would grow to be a man celebrated by Her Majesty, the Queen of England.
George E. Mahy, FRCPsych, CBE
- American Academy of Psychiatry and the Law
