Vikram Patel - Mental Health For All by Involving All - TED Talk

31/01/2021 Vikram Patel: Mental health for all by involving all | TED Talk
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English transcription by Joseph Geni.
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Vikram Patel · TEDGlobal 2012
Mental health for all by involving all
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English
Translated by Joseph Geni
Reviewed by Morton Bast
00 03
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
https://www.ted.com/talks/vikram_patel_mental_health_for_all_by_involving_all/transcript?language=en 1/8
cardiac procedure, but Rajiv is sent home.
00 26
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.
00 56
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.
01 16
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.
03 03
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.
04 21
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.
04 53
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.
05 22
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
31/01/2021
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Vikram Patel: Mental health for all by involving all | TED Talk
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.
05 49
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.
06 13
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.
06 31
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.
07 10
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.
08 29
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.
09 31
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.
therefore, medical power.
10 39
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.
11 21
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.
11 44
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 who have mental illness, and dare to care for them.
Thank you. (Applause) (Applause)
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