Placeholder Image

Subtitles section Play video

  • Translator: Joseph Geni Reviewer: Morton Bast

  • 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-resourced countries in the world,

  • this life expectancy gap is as much as 20 years.

  • In the developing countries of 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 causes of death in young people

  • in all countries in 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 on life expectancy

  • as well as on the quality of life lived, we need to use

  • a metric called the DALY,

  • which stands for a Disability-Adjusted Life Year.

  • 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 the third-leading cause

  • of disability, alongside conditions such as

  • diarrhea and pneumonia in children.

  • When you put all the mental illnesses together,

  • they account for roughly 15 percent

  • of the total global burden of disease.

  • Indeed, 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 a 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 and anxiety,

  • substance misuse and psychosis in adulthood,

  • all the way through to dementia in old age,

  • and I'm pretty sure that each and every one us

  • present here today can think of at least one person,

  • at least one person, who's 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-resourced countries,

  • for example here in Europe, roughly 50 percent

  • 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 percent.

  • It isn't surprising, then, that if you should speak

  • to anyone affected by a 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 to do a little bit to transform the lives

  • of people affected by mental illness, and 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

  • kind of thought 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 in 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 the 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 me that I couldn't follow

  • the sorts of mental health care models that I had been trained in,

  • one that relied heavily on specialized, expensive

  • mental health 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,

  • train 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 task 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,

  • Atif Rahman 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 counselors drawn from local communities

  • could be trained to deliver psychosocial interventions

  • for depression, 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 in task shifting, and there have of course

  • been many other examples, and try and identify

  • what are the key lessons we can learn that makes

  • for a successful task shifting operation,

  • I have coined this particular acronym, SUNDAR.

  • 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 task 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 health care interventions

  • into smaller components that can be more easily

  • transferred to less-trained individuals.

  • We need to deliver health care, not in large institutions,

  • but close to people's homes, and we need to deliver

  • health care 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.

  • Now for me, task 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 health care in the developed world,

  • the health care costs in the [developed] 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 it's become very remote

  • and removed from local communities.

  • For me, what's truly sundar about the idea of task 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, for me, task shifting

  • is the ultimate example of the democratization

  • of medical knowledge, and therefore, medical power.

  • Just over 30 years ago, the nations of the world assembled

  • at Alma-Ata 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 deliver 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 in 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,

  • and 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 or quiet

  • in these very busy few days or perhaps afterwards,

  • spare a thought for that person you thought about

  • who has a mental illness, or persons that you thought about