The co-occurrence of EDs and OCD presents specific treatment challenges. The severity of illness is an important factor to consider when treating this presentation as it can impact treatment planning and prognosis. Having this comorbidity decreases the rates of treatment completion for OCD. The degree of insight is also crucial when considering treatment and outcomes. A prior treatment history can also impact compliance and outcome in several ways for both EDs and OCD. Clinicians have no control over any type of messaging or interventions that patients were exposed to by other providers, and bad treatment can be worse than no treatment at all as it leaves more for the new clinician to “undo” to optimize outcomes. Religious and cultural variables should be taken into consideration and managed in the most ethical and culturally sensitive manner. Families and social support are crucial for the treatment process, particularly for adolescent and young adult patients. When these supports are lacking or problematic, it can create additional challenges for the clinician and may require adjustments to the treatment plan as issues arise.

Chapter 10 discusses the beginnings of vaccination in India. From Bombay in June 1802, the practice was extended to Ceylon (Sri Lanka), Madras and Calcutta by the end of the year. Medical men in the service of the East India Company made the running, but civil and military governors provided strong support for the establishment of the practice. Children under vaccination were often used to deliver the vaccine, Indians were trained and paid for their work in vaccinating and systems were devised to maintain the supply of vaccine. The new prophylaxis was taken up in the European enclaves, but won some acceptance, too, among the Indian and Sinhalese, especially in Madras. Intrusive measures caused resentment and arm-to-arm transmission raised concerns about pollution. Still, the tally of vaccinations probably reached one million in the first five years of the practice. By this stage, too, India was serving as a hub for the spread of the practice in all directions.