13.2 Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level

Posted Mon, 2012-04-02 08:12

Contents

Documents

Documents A65/10 and EB130/2012/REC/1, resolution EB130.R8

See also WHO's mhGAP Program

See WHO Watch comment at EB130

The issues before the Assembly

The Assembly is invited to note a report from the Secretariat on the global burden of mental disorders (A65/10) and to consider a resolution forwarded by the EB (resolution EB130.R8).

PHM pre debate comment

The Secretariat report provides a very useful overview of some of the problems associated with mental disorders globally.  It discusses the epidemiology, social and economic impact and strategies which can be implemented in the health and social sectors.

If the resolution is adopted and implemented it will make a huge difference to the lives of millions of individuals and families.  

However, there are some missed opportunities here also.

The paper notes the incidence of mental disorders associated with exposure to disasters but is silent on other important determinants of mental health, such as social exclusion, alienation, racism and gender inequities. There is no mention of the linkage between the widening socio-economic inequalities associated with neoliberal economic policies and the current financial crisis and the consequent weakening social solidarity and cohesion, powerful protective and supportive factors.

Poverty and social exclusion, intergenerational unemployment, experience of xenophobia among refugees or the experience of racism in minority settings can powerfully influence how people see themselves in the world and how they respond. These kinds of experiences can contribute to violence, substance abuse and chaotic parenting.

This weakness with respect to the social determinants of health illustrates the fragility of the DG’s ‘mainstreaming’ commitments with respect to SDH, gender equity, trade and health and the right to health.

The discussion of the integration of the medical and social sector and the importance of developing community-based mental health services (Par. 15 and par.22) are useful aspects of this report although there is no reference to primary health care as a strategy for service integration and community based services.   

The document is silent with respect to the medicalisation of mental health under the pressure of aggressive marketing of psychotherapeutic drugs by the pharmaceutical industry. The medicalisation of mental illness could have several negative consequences such as a change in the public conceptions of mental illness, an increasing individualisation of social problems and a progressive dislocation of responsibility for social problems. This consequently could create a huge barrier to the development of social approaches to prevention and treatment of mental disorders.

Report of Discussion at WHA65

At its 130th session in January 2012, the Executive Board adopted a draft resolution (EB130.R8) presented by India and cosponsored by US and Switzerland. WHA was today invited to consider it and to note a report from the Secretariat on the global burden of mental disorders.

India was the first country to take the floor affirming that mental health is a subject of the most urgent importance. Every countries recognized the magnitude of the global health problem presented by mental health and described the strategies they are implementing to deal with this issue.

Denmark, speaking on behalf of the EU, pointed out the importance of looking at the inequalities affecting people with mental health problems, since these disorders often lead to poverty, education drop-out and unemployment.

Recognizing that mental health is the result of factors mainly outside the health system, Canada, Costa Rica and other countries affirmed that a collaboration between health and social services is strongly needed. This perspective was reinforced also by some Latin American countries such as Chile, Ecuador and Colombia who asked for adopting a Primary Health Care approach through the development of community-based services.

Many Member States raised the issue of human rights violation and stigmatization of patients with mental health illnesses while others pointed out the importance of providing social services and legislation that guarantee the rights of people suffering from mental disorders.

Some African countries such as Zimbabwe and Burkina Faso highlighted the challenges they are facing in implementing effective interventions such as budgetary constrains and a tremendous lack of adequately trained human resources. The training of health professionals was backed also by many other countries.

Finally the Secretariat, pleased to see the level of interest among Member States and NGO, announced that all the comments will be considered in the development of a global mental health action plan that will be presented to the next WHA.

Concerning the draft of the resolution, it was adopted with some changes proposed by Thailand.

PHM post debate comment

The focus on  ‘a comprehensive, coordinated response from health and social sectors’ in the report presented to the WHA and in the resolution which was finally adopted is to be commended.

The MS accounts of their own mental health systems during the debate depict a wide variety in standards of care available to people with mental disorders. The resolution which was adopted commits WHO to support MS in focusing attention on mental health services and the interface between mental health care and social care and protection.

The resolution addresses a huge and complex problem which is everywhere resource starved. For WHO to make a significant contribution will require significant new resources at HQ, regional offices and in countries. The development of mental health services is part of health system strengthening generally which itself needs to be seen as part of sustainable and inclusive development.

In addressing the interface between mental health services and the social sector the main focus of the report and the resolution is on the social support needs of people with mental, neurological and drug misuse disorders. In this sense the focus was down stream. Neither in the report, nor the resolution nor the debate was there adequate recognition of the social determinants of social, emotional and spiritual well being and the significance of social, emotional and spiritual well being as a dimension of mental health.

The policy pre-occupation with ‘serious mental illness’ and the individualism of private psychiatry and counselling leaves the social determination of social, emotional and spiritual well being seriously neglected.  Yet the consequences of chronic anger, alienation, anxiety, depression and hopelessness on people’s lives can be profound and self-reproducing. Misuse of alcohol and drugs, interpersonal violence and dysfunctional parenting are powerful mediators through which these emotional disabilities are reproduced. In some degree there are inherited tendencies which may contribute to these disabilities but there are also powerful social determinants including: poverty, prolonged unemployment, racism, exclusion, xenophobia and inequality. The intergenerational harm associated with the interaction of these social pressures and emotional responses is profound. The economic costs in terms of lost productivity are huge.

In this context the apparent downgrading of WHO’s involvement in documenting, analysing and recommending around the social determinants of health is a cause for concern. Chronic anger or xenophobia are not simple problems and there are no magic bullets. They need to be addressed through public policy, supported by community sentiment. ‘Intervention’ involves giving weight to these issues in a myriad of different public policy decisions in transport, urban design, labour relations, cultural institutions.  The role of public health is to make these issues visible, to describe, to analyse and to demonstrate how public policy can make a difference. The work of the Commission on Social Determinants of Health had a profound impact on the policy conversation regarding these issues with a spreading impact into community consciousness.

The DG has adopted a policy of ‘mainstreaming’ issues such as the SDH and has affirmed strongly that she will take personal responsibility for ensuring that the SDH perspective is manifest across the work of the WHO. However, she has articulated no methodologies for planning, budgeting or accountability to support this commitment.