Advanced Studies Institute Conference 5-7 July 2012: Montreal, Canada
Global Mental Health: Bridging the Perspectives of Cultural Psychiatry and Public Health
Challenges for mental health development in low and middle income countries
Suman Fernando
Prologue
As a background to my talk, I start with a quote from Laurence Kirmayer (2006) and then three anecdotes.
Slide 2:Dangers of Mental Health Development
And now the anecdotes.
Slide 3:Marketing diagnoses
You may have heard of camps for promoting health used I think for educating people about vaccination, treatments for tuberculosis etc. All very commendable. NGO operated camps on mental health have been held in several Asian and African countries I believe during the past few years. I know of one model used in Sri Lanka conducted by a British NGO. Initially, so-called community workers arrive in a village with short symptom checklists which they use to identify people (allegedly) ‘suffering’ from one or other psychiatric illness. Then these people are invited to a ‘camp’ where they are given a lecture by a psychiatrist outlining the remedies available for the different diagnoses, and invited to partake of the drugs displayed on a table, or given by injection. In some places I believe follow-up camps are held too.
The second anecdote is about something that happened in Sri Lanka in 2009 when I was helping with a public meeting to promote the idea of community care. We discovered that a rival meeting supported by the mental health directorate had been arranged - also on ‘community care’. Later I discovered what this was all about. An Australian NGO, which had linked up with some local professionals through various means, had sent a team to promote a scheme they were proposing which was to train people around the country in ‘community care’. This was a NGO that specialized in services for ‘depression’ and the training was essentially to teach people how to diagnose the illness of ‘depression’. A few weeks later, a local newspaper published its investigation into the NGO involved. Although it was non-profit making, many of the people on its management were heavily involved in pharmaceutical companies and some of the professionals on its board specialized in lecturing on behalf of these companies to promote particular antidepressants. Once this was exposed, the mental health directorate pulled out of supporting this scheme funded by the Australian NGO.
The third anecdote is about UK and Bangladesh. A mental health trust in UK discovered a few years ago that some British Bangladeshi people diagnosed with ‘mental illness’ were being sent for ‘treatment’ to Bangladesh by their relatives. When they enquired further in 2011 they found that one of the ‘community care’ facilities they were being sent to comprised a series of (what the person who visited the place described as)‘ware- houses’, where they were being given drugs appropriate to their diagnoses provided by a local pharmacy linked up with a drug firm.
I shall leave you to ponder on these stories in the knowledge that in many low and middle income countries there is no need for a prescription from a physician to buy most drugs – one just has to know its name – or the diagnosis for which it is marketed as a ‘remedy’.
Introduction
My aim is to look at practical issues - here and now - of how the welfare of people in low and middle income (LMI) countries can best be improved, focusing on mental health.
Slide 4:Mental Health. Attempts at universal definition
In one of its more enlightened publications WHO states that ‘mental health refers to a broad array of activities directly or indirectly related to the mental well-being component included in WHO's definition of health: "A state of complete physical, mental and social well-being, and not merely the absence of disease"’. In other words, ‘mental health’ is wider than the absence of mental illness, however ‘illness’ is defined.
Further, the understandings of mental health and illness are largely determined by the meanings people give to their experiences and feelings in a context of broader worldviews about the nature of the human condition - much of which is culturally determined – that is the culture of the majority of people not the culture of a particular professional or institutional group.
Slide 5:Cultural variation
For example, feelings may be expressed in terms of idioms that reflect habits and traditions arising from culture that have become imbued with meaning through usage; contextual factors and personal inclinations, the judgment of a particular idioms as normal or abnormal, adaptive or maladaptive, depending on socio-cultural constraints held in society and familiarity with alternative modes of expression; ‘illness experience is an intimate part of social systems of meaning and rules of behaviour’ that are culturally constructed; and cultural variations in concepts of the person (‘self’) are reflected in meanings of health and well-being – and mental health categories and concepts.
Context of development
Slide 6:Context of development. Influences on MH development in LMI countries
The first thing to note is that whatever changes there have been culturally and in use of language, the world of consumption, economic interests and power politics still dominate the world scene- although perhaps less overtly than in the past. So we should try to guard against the dangers of the market economy and the influence of global corporations, determining the way development goes - mindful that these forces (i.e. economic interest and power-politics) affect (for example) what projects get funded or not, how research is conducted or not, putting pressures on professionals to go in a certain way in, determining what sort of system emerges in a given location. We need to beware that power games are played out through world organizations subtly dominated by (mainly) interests of particular nations - world organisations whose policies in implementation are often determined by the ‘experts’ they employ and the attitudes of ‘trainers’ going out from the first world to the third, whatever these organizations say in their official documents. Then there are the pharmaceutical companies – ‘pharma’ for short – which use various means for developing markets for their products. Low priority given for mental health development by many governments in LMI countries and their consequent dependence on NGOs that look to funding from agencies in high income countries which sometimes work to their agendas, rather than real needs of the people in LMI countries. And finally professionals are often still trained in styles of working (e.g. specialisms) more suited to developed western locations and so likely to go along with systems that may not suit the populations in LMI countries.
Then, there are the ground realities in LMI countries that mental health development has to confront.
Slide 7:Ground realities in LMI countries
Dr Jacob in South India who points out the importance of addressing poverty, public health infrastructure and inappropriate training and brain-drain. But it is equally necessary, in the world of global capitalism to address some of the other items on this list – for example the free marketing of psychotropic drugs against a background of whatever is sold as ‘scientific’ – and ostensibly ‘western’ – getting an easy run in the market-place; and the pervasive low grade corruption that leads to poor management of services to say the least. Also, we have to address the fact that the most urgent psycho-social issue in some LMI countries concerns the disruption resulting from armed conflict, natural and man-made disasters, and foreign invasions. Finally what is striking to many people is the maltreatment of people who are disturbed in behavior, both in hospitals and in the community – clearly much worse in LMI countries than it is in the West.
Process of mental health development
Development is a seductive word that suggests a necessary path of progress. In the postcolonial period it implied both social improvement and ‘catching up’. But the discourse has moved on considerably since then and much is made now of development, especially when applied to LMI countries, needing to be ethical and sustainable, unlike the ethos of most ‘development’ during colonialism.
Slide 8:Process of development
Ethical means that development is directly for the benefit of people of the country regarded as ‘self-defining subjects’ rather than ‘objects of concern’, people ‘entitled to choose their way of life themselves’ both as individuals and communities. And sustainable means it will carry on into the future fitting into the mainstream of social and political structures without being dependent on on-going input from other countries.
Slide 9:History of MH development
We know that the imposition in colonial times of western-type asylums did not really do much good and possibly helped towards under-development, if not actual suppression, of indigenous systems of mental health care. Of course the asylum approach has been abandoned in the West and we have seen considerable progress in the West towards addressing human rights violations in mental health facilities, although I think not much progress in combatting stigma. Perhaps asylums should never have been introduced in LMI countries, but many still function in these countries and require urgent attention, not least to prevent human rights violations. But in planning more general services, we need to be careful not make the same mistake we made about asylums - assuming that what is good enough for the West must be the best for every one – one might call it ‘the colonial attitude’.
Moreover, it is worth noting that serious doubts are being voiced today about the effectiveness of predominantly bio-medical psychiatry in Britain and North America, especially – in the UK particularly - for ethnic minorities of Asian and African backgrounds. Also, there are questions being asked in the US (for example) about the way medications are used in a frame of psychiatric models of ‘illnesses’ and theories of chemical imbalance of neurotransmitters in the brain. They are still minority voices (in terms of their power) but increasingly persuasive as exemplified by articles in the New York Review of Books and New York Times. And today’s minority opinion could well be established wisdom tomorrow. Like the asylum era, the current era of rigid diagnosis linked to early and prolonged medication may well be regretted before too long. Do we really want to risk getting the third world into this? So we have to be very wary indeed about enabling easy access to psychotropic drugs and promoting narrow, rigid systems of diagnosis.
Slide 10:Principles of mental health development in LMI countries
Developing mental health systems in LMI countries is not a simple matter of transferring established strategies commonly used in high income countries, irrespective of ground realities without taking on board what local people want. And mental health is not just a technical matter but is tied up with ways of life, values, and worldviews that vary significantly across cultures and societies.
A basic principle of development is that we have to start by looking at what happens currently and work from there. This is important not just to ensure social and cultural relevance of services and ownership by the people responsible for sustaining them, but also for cost-effectiveness – using the least resources to achieve the greatest gain. In most LMI countries, a variety of services are accessed by people – but usually only if they can afford to do so. A list drawn from a book by a Dutch psychologist researching in the central province of Sri Lanka is an example.
Slide 11:Healing systems accessed by people in Kandyan regions of Sri Lanka
Clearly the mix would be different in other places. Most people are pragmatic, often accessing more than one system, if they can afford it, and their carers are able to support them (for there is little or no support available from the state). Indeed systems for supporting families may be one of the most effective ways of providing mental health care. Clearly there is a role for foreign agencies if only in kick-starting with funding, and by demonstrating what happens in high income countries that local people may wish to learn from. But it is important not to impose models of care that local people find culturally alien or models that may be discarded in the West before long anyway.
So where do we go from here?
Slide 12:Data about systems in LMI countries
The fact is that there is very little hard data to go on about the efficacy of systems of mental health indigenous to many LMI countries – religious, semi-religious or medical derived from (say) Ayurveda or African or pre-Columbian American ways of dealing with ‘mental’ problems , systems which suffer from under-development, not to speak of active suppression, over many years. And there is difficulty because problems that we see as being located in the ‘mind’, these problems are often seen in these cultures from holistic standpoints much broader than just ‘illness’ – what is ‘mental’(to us) is ‘beyond the mind-body split’ – ‘mental’ is out there not just in here inside our heads. Yet, there seems to be anecdotal evidence from user satisfaction about some indigenous medical / spiritual remedies for ‘illness’ - local knowledge that can be accessed if only we try.
Recently there have been a couple of significant studies in prestigious western journals (which I shall refer to later) – articles by Raguram et al., (2002) and by Halliburton (2004). Then there is WHO International Pilot Study of Schizophrenia (IPSS) of earlier times – the 1960s and 1970s. As you would know, the methodology of the IPSS was criticised (at the time it was carried out) because it failed to take on board ‘category fallacy’, namely imposing the ‘schizophrenia’ diagnosis as a measure of ill health; but surely we should take note of its finding that apparent outcomes for people seen as seriously mentally ill (in psychiatric terms) were actually better in non-western LMI settings where (at that time anyway) the bio-medical model for mental health problems was not very popularand psychotropic drugs were used sparingly if at all. I know that, more recently, this better outcome has been questioned, possibly because now, three decades later, psychotropic drugs are used more extensively than they used to be, and the model of ‘schizophrenia’ with its stigma and its image of genetic lifelong disability has spread in many LMI countries with ‘psycho-education’ programmes and other ways of imposing psychiatric thinking in their populations.
The first paper I mentioned, published in the British Medical Journal, was a study of healing at a Hindu temple in Tami Nadu (South India) known for helping people with mental health problems. The authors had elicited the views of both the patients and their carers about their experiences and also made psychiatric assessments (of the patients) on a standard scale before and after their stay at the temple. They found that most of the patients studied (a) suffered from psychotic illness (as per psychiatry) and (b) showed a degree of improvement (judged by reduction of psychiatric symptoms and their own expressed views), improvement that matched the sort of result that may be expected by through bio-medical therapy. As you may know, there are many healing centres in South Asia and possibly in other LMI countries; so there may be something to learn from these places, if they are studied sensitively.
Halliburton’s paper in Transcultural Psychiatry documented experiences of 100 people who had accessed treatment in three forms of therapy in Kerala (South India) – Ayurvedic, bio-medical psychiatry, and religious healing at one or other of three locations, namely a Hindu temple, a Muslin mosque and a Christian church, all of which had reputations for healing people who suffer from mental illness. All the patients had mixtures of symptoms which would give the diagnosis ‘schizophrenia’ or other severe mental disorder. Similar proportions of patients benefitted from each form of therapy, and several had changed from one to another until they derived benefit. This shopping around had resulted in a very high overall improvement rate. Incidentally I quoted this study in an article in the UK arguing for user-choice in our own British system.
Now, taking all this on board, what are the priorities and how best can they be addressed? Clearly, the first stage in development is to ask people on the ground, consult communities and other stakeholders. Qualitative studies that I was involved in during the McGill Trauma and Global Health Program of 2007 to 2011 ( indicated that the list of people and agencies to be consulted may be different according to location but would be something like that shown in the next slide.
Slide 13:Stakeholders for developing mental health services
Development should be bottom-up with people working in the field engaging in dialogue and consultation with local communities, including those with personal experience of mental health problems and people using mental health services; and liaising as much as possible with agencies and universities, both local and foreign, thereby drawing on whatever knowledge and expertise is appropriate and acceptable to local people.