Mental health for all by involving all Vikram Patel

I want you to imagine this for a moment

two men Rahul and Rajiv living in the

same neighborhood from the same

educational background similar

occupation and they both turn up at

their local accident emergency

complaining of acute chest pain Rahul is

offered a cardiac procedure but Rajiv is

sent home what might explain the

difference in the experience of these

two nearly identical men Rajiv

suffers from a mental illness the

difference in the quality of medical

care received by people with mental

illness is one of the reasons why they

live shorter lives than people without

mental illness even in the best resource

countries in the world this life

expectancy gap is as much as twenty

years in the developing countries the

world this gap is even larger

but of course mental illnesses can kill

in more direct ways as well the most

obvious example is suicide it might

surprise some of you here as it did me

when I discovered that suicide is at the

top of the list of the leading cause of

death in young people in all countries

of the world including the poorest

countries of the world but beyond the

impact of a health condition on life

expectancy we’re also concerned about

the quality of life lived now in order

for us to examine the overall impact of

a health condition both our life

expectancy as well as on the quality of

life lived we need to use a metric

called a dolly which stands for a

disability adjusted life here now when

we do that we discover some startling

things about mental illness from a

global perspective we discover that for

example mental illnesses are amongst the

leading causes of disability around the

world depression for example is a third

leading cause of disability alongside

conditions such as diarrhea and

pneumonia and children when you put all

the mental illnesses together they

account for roughly 15% of the total

global burden of disease

did mental illnesses are also very

damaging to people’s lives but beyond

just the burden of disease let us

consider the absolute numbers the World

Health Organization estimates that there

are nearly four to five hundred million

people living on our tiny planet who are

affected by mental illness now some of

you here look a bit astonished by that

number but consider for a moment the

incredible diversity of mental illnesses

from autism and intellectual disability

in childhood through to depression

anxiety substance misuse and psychosis

and adulthood all the way through to

dementia and old age and I’m pretty sure

that each and every one of us present

here today can think of at least one

person at least one person who is

affected by mental illness in our most

intimate social networks I see some

nodding heads there but beyond the

staggering numbers what’s truly

important from a global health point of

view what’s truly worrying from a global

health point of view is that the vast

majority of these affected individuals

do not receive the care that we know can

transform their lives and remember we do

have robust evidence that a range of

interventions medicines psychological

interventions and social interventions

can make a vast difference and yet even

in the best resource countries for

example here in Europe roughly 50% of

affected people don’t receive these

interventions in the sorts of countries

I work in that so-called treatment gap

approaches an astonishing 90% it isn’t

surprising then that if you should speak

to anyone affected by mental illness the

chances are that you will hear stories

of hidden suffering shame and

discrimination in nearly every sector of

their lives but perhaps most

heartbreaking of all are the stories of

the abuse of even the most basic human

rights such as the young woman shown in

this image here that are played out

every day sadly even in the very

institutions that were built to care for

people with mental illnesses the mental

hospitals

it’s this injustice that has really

driven my mission to try and do a little

bit to transform the lives of people

affected by mental illness Anna at a

particularly critical action that I

focused on is to bridge the gulf between

the knowledge we have that can transform

lives the knowledge of effective

treatments and how we actually use that

knowledge in the everyday world and an

especially important challenge that I’ve

had to face is the great shortage of

mental health professionals such as

psychiatrists and psychologists

particularly in the developing world

now I trained in medicine in India and

after that I chose psychiatry as my

specialty

much to the dismay of my mother and all

my family members who can’t afford

neurosurgery would be a more respectable

option for their brilliant son any case

I went on I soldiered on with psychiatry

and found myself training in Britain and

some of the best hospitals in this

country I was very privileged I worked

in a team of incredibly talented

compassionate but most importantly

highly trained specialized mental health

professionals soon after my training I

found myself working first in Zimbabwe

and then in India and I was confronted

by an altogether new reality this was a

reality of a world in which there were

almost no mental health professionals at

all in Zimbabwe for example there were

just about a dozen psychiatrists most of

whom lived and worked in Harare City

leaving only a couple to address the

mental health care needs of nine million

people living in the countryside in

India I found a situation was not a lot

better to give you a perspective if I

had to translate the proportion of

psychiatrists in the population that one

might see in Britain to India one might

expect roughly 150,000 psychiatrists in

India in reality

take a guess the actual number is about

3,000 about two percent of that number

it became quickly apparent to be that I

couldn’t follow the sorts of mental

health care models that I have been

trained in one that relied heavily on

specialized expensive mental her

professionals to provide mental health

care in countries like India and

Zimbabwe I had to think out of the box

about some other model of care it was

then that I came across these books

and in these books I discovered the idea

of task-shifting

in global health the idea is actually

quite simple the idea is when you’re

short of specialized health care

professionals use whoever is available

in the community trained them to provide

a range of health care interventions and

in these books I read inspiring examples

for example of how ordinary people had

been trained to deliver babies diagnose

and treat early pneumonia to great

effect and it struck me that if you

could train ordinary people to deliver

such complex health care interventions

then perhaps they could also do the same

with mental health care well today I’m

very pleased to report to you that there

have been many experiments in tar

shifting in mental health care across

the developing world over the past

decade and I want to share with you the

findings of three particular such

experiments all three of which focused

on depression the most common of all

mental illnesses in rural Uganda Paul

Bolton and his colleagues using

villagers demonstrated that they could

deliver interpersonal psychotherapy for

depression and using a randomized

control design showed that 90 percent of

the people receiving this intervention

recovered as compared to roughly 40

percent in the comparison villages

similarly using a randomized control

trial in rural Pakistan Aarti Freeman

and his colleagues showed that lady

health visitors who are community

maternal health workers in Pakistan’s

health care system could deliver

cognitive behavior therapy for mothers

who were depressed again showing

dramatic differences in the recovery

rates roughly 75 percent of mothers

recovered as compared to about 45

percent in the comparison villages and

in my own trial in Goa in India we again

showed that lay counsellors drawn from

local communities could be trained to

deliver psychosocial interventions for

depression and anxiety leading to 70

percent recovery rates as compared to 50

percent in the comparison primary health

centers now if I had to draw together

all these different experiments and are

shifting and there of course been many

other examples and try and identify what

are the key lessons we can learn that

makes for a successful tar shifting

operation I’ve coined this particular

acronym thunder what sundar stands for

in Hindi

is attractive it seems to me that there

are five key lessons that I’ve shown on

this slide that are critically important

for effective tar shifting the first is

that we need to simplify the message

that we’re using stripping away all the

jargon that medicine has invented around

itself

we need to unpack complex healthcare

interventions into smaller components

that can be more easily transferred to

less strained individuals we need to

deliver healthcare not in large

institutions but close to people’s homes

and we need to deliver healthcare using

whoever is available and affordable in

our local communities and importantly we

need to reallocate the few specialists

who are available to perform roles such

as capacity building and supervision but

for me tar shifting is an idea with

truly global significance because even

though it has arisen out of the

situation of the lack of resources that

you find in developing countries I think

it has a lot of significance for better

resourced countries as well why is that

well in part because healthcare in the

developed world the health care costs in

the developing world are rapidly

spiraling out of control and a huge

chunk of those costs are human resource

costs but equally important is because

health care has become so incredibly

professionalized that has become very

remote and removed from local

communities for me what’s truly sundar

about the idea of tar shifting though

isn’t that it simply makes health care

more accessible and affordable but that

it is also fundamentally empowering it

empowers ordinary people to be more

effective in caring for the health of

others in their community and in doing

so to become better guardians of their

own health indeed from ATAR shifting is

the ultimate example of the

democratization of medical knowledge and

therefore medical power just over 30

years ago in the nations of the world

assembled in alma mater and made this

iconic declaration well I think all of

you can guess that 12 years on we’re

still nowhere near that goal

still today armed with that knowledge

that ordinary people in the community

can be trained and with sufficient

supervision and support can

liver a range of health care

interventions effectively perhaps that

promise is within reach now indeed to

implement the slogan of health for all

we will need to involve all in that

particular journey and the case of

mental health in particular we would

need to involve people who are affected

by mental illness and their caregivers

it is for this reason that some years

ago the movement for global mental

health was founded as a sort of a

virtual platform upon which

professionals like myself and people

affected by mental illness could stand

together shoulder to shoulder an

advocate for the rights of people with

mental illness to receive the care that

we know can transform their lives and to

live a life with dignity and in closing

when you have a moment of peace acquired

in these a very busy few days or perhaps

afterwards spare a thought for the

person you thought about who has a

mental illness or persons that you

thought about who have mental illness

and their to care for them thank you

you