HEALTH TRIBUNE Wednesday, October 11, 2000, Chandigarh, India

Leadership needed for mental health in India
October 10 was World Mental Health Day
By Dr Norman Sartorius
HE twentieth century has brought more insights in to psychiatry than any of the centuries preceding it. We have learnt a great deal about the structures and functioning of the brain. New and powerful methods of treatment and rehabilitation have become available. The importance of the social context of mental health and disease has become obvious and the interaction between people in illness and their physical and social environment is better understood.



Leadership needed for mental health in India
October 10 was World Mental Health Day
By Dr Norman Sartorius

THE twentieth century has brought more insights in to psychiatry than any of the centuries preceding it. We have learnt a great deal about the structures and functioning of the brain. New and powerful methods of treatment and rehabilitation have become available. The importance of the social context of mental health and disease has become obvious and the interaction between people in illness and their physical and social environment is better understood.

The advancement of knowledge has been far more spectacular than its application. At the beginning of the twenty-first century most people who suffer from mental illness will not have access to mental health care. Among those who have access to care relatively few receive appropriate treatment (Sartorius et al, 1993). Stigma and discrimination because of mental illness are still major obstacles to the development of mental health services, to the rehabilitation of those impaired by mental illness and to an investment into mental health research proportionate to the importance that it has both in developed and developing countries (Sartorius, 1997).

Recent reports confirming the enormous magnitude of mental health problems (WHO, 2000) and the weakness of health systems supposed to help those affected by mental illness make it obvious that it is necessary that governments — in developing and developed countries — decide which strategy will be used to cope with mental diseases and their consequences. Three strategies seem to be the most obvious choices for action: first, to significantly increase the resources given to mental health care, training and research; second, to redistribute tasks of health personnel and the resources currently available for health care in general; and third, to redefine mental health problems in such a manner that it will become possible to "share" the care for most of them to other social sectors, e.g. welfare, the churches, community organisations, families, consumers and so on.

In most countries, timid efforts to use all three strategies simultaneously can be observed: the earlier often used alternative — to turn a blind eye to all mental disorders and declare that they do not exist or, if they do, that their numbers are small and that their consequences for society are negligible — is becoming less and less acceptable and most countries will no longer use it. By now, there is so much evidence about the severity of mental health problems and about the availability of effective interventions to deal with these problems. So, the investments into the mental health care system have increased to a varying degree in a number of countries. In more countries it has been proposed to add training about the identification and treatment of mental disorders to the education of general health-care personnel. In many places, it has been suggested that the responsibility for mental health problems should be shared among the social sectors most concerned: terms like "empowerment of the consumer", "social responsibility for health" and others of the kind witness the latter trend.

Each of these three strategies alone could work quite well if strongly supported and the combination of the three would undoubtedly bring major benefits to the communities worldwide. Unfortunately, the support to all of them is at best lukewarm and usually goes very little further than declarations (Poitras and Bertolote, 2000). That this is so is not surprising.

The long tradition of neglect of mental health care and the powerful prejudice against mental illness and all that is connected with it (including the patients, psychiatrists, mental health institutions, treatments for (mental illness) will take a long time to change. The inertia of institutions created in colonial times also acted against any change: their modernisation is costly and requires modifications in structures of payment of personnel and in their daily routines.

Yet, despite these and other obstacles mental health programmes have been initiated and successfully developed in many developing countries. The introduction of mental health elements into the primary health-care system in Iran, the extension of mental health services into the rural areas in Ethiopia relying on a small but dedicated group of nurses trained in mental health, the remarkable work done by mental health assistants in Zambia, the village-care system in Nigeria, the outreach programmes in Senegal (Gureje and Alem, 2000), the programmes of promotion of mental health in the north of Pakistan (Mubbashar et al, 1986), and the programmes in Colombia (Climents et al, 1978), Bolivia and other countries in Latin America (Alarcon and Gaxiola, 2000) are some of the numerous examples that could be cited.

Although different in style, most of these efforts have been linked to charismatic leaders rather than to structural and enduring changes of the health system. Also, most of these highly encouraging programmes have been limited to an area in the country or to a particular mode of service provision, for example, the use of nurse practitioners: the "export" of strategies and techniques developed for use in one setting to the totality of a country or a region was often difficult and when successful of short duration.

Support from international bodies sometimes helped to make full use of the national initiatives. The mental health programme of the World Health Organisation in its earliest times (Sartorius, 1980, 1983, 1988, 1989) made this area of work one of its priorities and, in addition to supporting national activities launched collaborative studies (Jablensky et al, 1992, Sartorius, 1993, Sartorius et al, 1993, 1996) that produced techniques for mental health work in primary health care as well as important results confirming the ubiquity of the problems and the feasibility of useful action in conditions of scarcity.

The report of the Primary Health-Care Conference in Alma Ata in 1978 listed mental health as an essential component of primary health care report and in the years that followed some of the countries did so in their national strategies (e.g. Thailand and Uganda).

However, considering the size of mental health problems and the omnipresent severe consequences of their continuing neglect the progress globally has to be marked as being slow and insufficient.

That mental health services in developing countries have changed at all is not accidental: while various factors might have been at play, in the main their change is the result of continuous and long-lasting efforts of a relatively small number of people, mainly from developing countries.

These pioneers and advocates of innovation have repeatedly demonstrated that mental illness is frequent and deleterious for poor and rich countries alike. They have developed mental health services in conditions of great scarcity of staff and other resources and shown that such services are effective in dealing with the most severe forms of mental illness.

They have managed to attract the attention of the health authorities to mental health problems and sometimes made the officials ashamed of services that they have been providing. They have carried out studies that were of top quality and published their results in leading international journals (Wig et al 1987a, Wig et al 1987b, Leff et al, 1987, 1990, Okasha et all 1993, Sartorius, 1997, 1998, Okasha and Karam, 1998, Srinivasa Murthy, 1998, Mubasshar et al, 1998, Wig, 2000) thus surprising the psychiatry in the developed world which was by and large convinced that psychiatrists in the third world are at best experienced clinicians and not able scientists as well as service providers.

These pathfinders were not alone in their effort. A number of their colleagues in developed countries, impressed by what could be done and by those who did it, rendered help and added credibility to the strategies of care provision that were invented in conditions of necessity but served well in all countries.

Chandigarh's Wig team
All of these facts are well known and do not surprise any longer. They are recalled here because they provide an adequate framework for a description of the work that Professor N.N. Wig has carried out on the international scene. As the Head of the first officially designated collaborating centre of the World Health Organisation in India and one of the first in the developing world Professor Wig assembled the experience and the results of work done in his own and in neighbouring countries and gave it visibility. The Chandigarh team, under his leadership, took part in several major international studies aiming to demonstrate that the provision of mental health-care as well as research of outstanding quality is possible even in conditions of great poverty and hardship. The excellence of the work of his centre and the results of numerous studies had an important impact on work in his own country and on others from which postgraduate students of psychiatry came to learn how to do psychiatry in the Third World.

All three of the strategies that were listed above begun to be used in India in which, for the first time in the early 1980's a small group of psychiatrists under his leadership drafted a national mental health plan. The plan led to a programme that has changed the mental health scene in India and gave new hopes not only to India but to other developing countries as well.

The apostolic effort in India was a rehearsal for the work that ensued. For a number of years Professor Wig helped by word and deed to develop strategies and policies for mental health care — as a WHO adviser, as a member of expert committees, as an informal counsellor. During his period of service in the Eastern Mediterranean Region of the World Health Organisation (1984-1991), he did for many countries of that region what he has done for his own country: worked with governments to help them in their mental health policy formulation; brought together mental health professionals to help them reach a consensus about the role of psychiatry in developing countries and to encourage them to continue their often lonely and discouraging efforts to change mental health systems in their countries; initiated research and advised colleagues in the countries of the region on how to do it; tried to enhance the understanding of mental health and to demonstrate the importance of mental health work to his colleagues in the World Health Organisation; maintained contacts with colleagues world-wide and remained an ardent advocate of the mental health programmes in the Third World (Wig, 1986).

Professor Wig's wisdom and knowledge did not only influence the work of the World Health Organisation. He has also been active in non-governmental organisations dealing with psychiatry and mental health. Among those, the World Psychiatrist Association received his particular support over many years, most recently as a member of the Steering Committee of an important international programme against stigma and discrimination because of schizophrenia that the World Psychiatric Association has initiated.

The latter choice is not random but the result of a careful selection of an area in which an investment of time and energy is most likely to be useful: there is little doubt about the fact that stigma and discrimination because of mental illness are among the most important remaining obstacles to an increase of priority given to programmes directed to their treatment and care.

The recent reports of the World Bank and the World Health Organisation have helped to dispel doubts about the enormous magnitude and seriousness of mental health problems: that action despite this remains sporadic and anaemic results from the negative attitudes and reluctance to invest significant amounts of resources into programmes that deal with a stigmatised condition and it is in this area that a major investment of mental energy and effort are now necessary (Sartorius, 1998).

The description of what Naren(dra N.) Wig did over some 40 years of his active career is not meant to be comprehensive nor a curriculum vitae. It is offered here as a case study, an example of a person from a developing country who has over many years used all of his remarkable qualities to promote a new understanding of mental health and of mental health services in all countries, regardless of their religion, ethnic definition, level of industrial development and previous experience. The contribution that he, a pioneer of new mental health programmes, has made was vital to the development of new ways of going about mental health in the Third World. The work is far from finished but a beginning has been made. It is to be hoped that the path that Professor Wig has taken and shown will be used by others, with as much vigour, knowledge, modesty and selflessness as he had done it. If that happens, the developing world will reach the level of mental health-care that its populations need and so amply deserve.

Dr Norman Sartorius is Professor Emeritus of Psychiatry, University of Geneva, Switzerland; a former Director, Mental Health, World Health Organisation, Geneva; and a past-President of the World Psychiatrist Association. 


The Open Window

October 15 is White Cane Day

Out of a total global blind population of nearly 20 million, India has the misfortune of having 10 million. While 80% of these less fortunate are curable, there is an acute dearth of qualified ophthalmologists, or, for many reasons, these patients have no access to the centres of sight restoration. While a few NGOs do organise eye camps, mostly in and around urban areas, the state health-care services have no organised regular mobile eye-care facilities for the rural and remote areas. Therefore, there seems to be a permanent statistical stagnation at 80% of even the curable blind sons and daughters of Mother India. Please read an illuminating article by Brig (Dr) M.L. Kataria next week.

Laser-boosted drugs

Jeanne Tester is the first Hamilton area patient to receive a new light-sensitive drug that treats the most severe form of macular degeneration, the leading cause of blindness in people over 50.

The medication, Visudyne (verteporfin), is injected with a dye into the arm of patients with age-related macular degeneration (AMD). Ten minutes later, the drug is activated by laser light for 83 seconds.

It took just 15 minutes for the 79-year-old Dundas grandmother to have her nearly blind right eye treated (at a cost of $2,500).

The Ontario health plan does not cover Visudyne because the drug, is awaiting Health Canada's approval.

—Courtesy: Regional Institute of Health, Chandigarh

Blood banking in India

Blood transfusion services in most of the developed countries have made tremendous progress. However, the scenario in the south-east Asian countries in general and India in particular is dismal. The reports of international agencies suggest that this programme has received considerable impetus during the last two decades. But this is a small consolation observes Prof J.G. Jolly. His wide-ranging views have been scheduled for publication in the next edition of Health Tribune.

Cancer — many risks: S.M. Bose

The danger of AIDS as a killer disease is looming large on the horizon but it is cancer which is actually taking a very heavy toll at present. The cause of AIDS is known and one can take precautions to a large extent to avoid the diseases. But unfortunately, the exact cause of cancer is not yet well known. There are some risk factors which are known as contributing to the causation of cancer, e.g, smoking, radiation, genetic factors etc. and there are many factors which have been incriminated for this. Some of the less known factors will be described by Prof S.M. Bose in these columns next Wednesday.