Getting it straight

Will mental health finally get the attention it deserves? Hala Sakr reviews this year's World Health Report
For the first time in its history, the World Health Organisation (WHO) has dedicated both World Health Day, on 7 April 2001, and its annual World Health Report, released on 4 October, to a single topic: mental health. The new report, entitled "Mental Health: New Understanding, New Hope," marks the climax of a year-long campaign by WHO to raise awareness of the importance of mental health.
"WHO is making a simple statement: that mental health -- neglected for far too long -- is crucial to the overall well- being of individuals, societies and countries, and must be universally regarded in a new light," commented WHO Director- General Gro Harlem Brundtland.
Ensuring that people are better informed and more understanding of mental illness is a clear goal of the WHO report. The report lays out a new understanding of mental health and mental illness as present in all societies and treatable, like physical illnesses. Based on a wealth of knowledge -- particularly information gathered over the last five decades -- the report shows how genetic, biological, social and environmental factors can collide to cause illness, both mental and physical.
The report comes at a critical time as a growing sense of fear, insecurity and confusion is rampant in the wake of the terrorist attacks on the United States. The ongoing conflict casts a heavy shadow on the mental well-being of humanity as a whole, but particularly on strained and heated regions like the Eastern Mediterranean. The threats to mental health cited by the World Health Report are all common in this region and growing. "In many places, we are facing man-made disasters like war, refugee crises, internal and external migration and occupation," remarked Hussein Geziary, regional director of the WHO Eastern Mediterranean regional office (EMRO).
The close relation between poverty -- quite prevalent in the region -- and mental illness is highlighted by the new report. Relentless exposure to stressful and unsafe living conditions, exploitation and poor general health render the poor more vulnerable to mental disorders. Lack of access to treatment only exacerbates the problem. Without treatment, illness becomes more severe and debilitating and thus, a rarely broken vicious cycle between poverty and mental disorders is established. "We know that poor people are bound to remain poor if they lack physical and human security," notes Brundtland. "This means that freedom from terror, violence and disease are critical foundations for poverty reduction, human well-being and a secure future for our world."
A technical paper focusing on controlling violence was taken up by the 48th session of the WHO regional committee for the Eastern Mediterranean, held in Saudi Arabia from 30 September to 3 October 2001. The paper described violence as a general phenomenon that is not restricted to a particular group or class. Defined as a social and health burden, violence materialises in different forms, from war, to suicide, to murder -- the main causes of morbidity and mortality in the region. Stereotyping certain groups based on religion, gender or race invites violence against these people, in turn creating an atmosphere that breeds social -- and mental -- problems. Asked by Al-Ahram Weekly about the role of WHO in the practical reduction of such attitudes, Brundtland explained that as a United Nations agency, WHO is naturally against the use of negative images and works to eliminate racist and anti- religious sentiments. She conceded, however, that WHO is "not the world's policeman, and cannot stop people from expressing violence and aggression or using destructive remarks." She stressed that this is a general challenge to humanity. "Our global community is being tested as never before ... We must continue to work together to tackle the great problems that affect the future of humanity and sustain the impetus for freedom and democracy so that all people can live and grow together," she said.
Mental health problems are becoming dramatically more prevalent. According to WHO. One person out of every four will suffer from mental illness at one point of his or her life. Mental illness has thus taken its place among the top causes of disease and disability worldwide. Major depression ranks fourth among the 10 leading causes behind the global burden of disease.
The WHO report notes that 450 million people suffer from mental or neurological disorders or psycho-social problems, such as those related to substance abuse. This is an increase of 50 million from the figure offered by WHO as recently as January of this year. The difference, says Ahmed Mohit, regional adviser for mental health and substance abuse at EMRO, is to be expected. "This figure is at best a good estimate. What is clear is that, whatever figure we use, the fact remains that the number of people suffering from mental health problems is underestimated."
Also highlighted by the report is the increase in substance abuse as a major health risk particularly with the escalation of injected drug abuse and the associated hazards of blood-borne diseases such as HIV/AIDS and hepatitis. "Substance abuse has the potential to become one of the gravest economic and development problems in this region," says Mohit. "Almost no country in the region is immune to it."
Nearly two-thirds of people with a known mental illness never seek medical assistance. According to Benedetto Saraceno, WHO director for mental health, more than 80 per cent of people in the world with epilepsy are not receiving treatment. Less than 25 per cent of people with depression or schizophrenia are receiving treatment. The stigma attached to mental illness, discrimination against people diagnosed with mental problems, and the neglect by governments and social leaders are the main factors that prevent people from getting the care and treatment they need.
The report outlines various solutions to mental health problems, highlighting the importance of prevention and early intervention with effective drug therapy to minimise the need for separate care. Access to "affordable" treatment for the poor was also stressed. "Affordable", notes EMRO's Mohit, means that people of little means will have the "buying power to receive an agreed- upon minimum level of service for psychotic patients through different mechanisms such as free medication, medical or social insurance, community services... etc."
Among the recommendations made by the report is that governments shift using large, segregated mental institutions to community health care centres. It is urged that mental health care be integrated into primary and general health care systems. Geziary of EMRO points out that the Eastern Mediterranean region has had a pioneering role in this approach. Starting with Fayoum, in Egypt, as early as the mid-1980s, the drive to subsume mental health within the larger context of general health care has spread throughout the region.
In Egypt, mental health is high on the agenda of the Ministry of Health. "The only way to promote mental health is to include it within the general health system," affirms Ahmed Okasha, president-elect of the World Psychiatric Association (WPA) and director of the WHO collaborating Centre for Training and Research, Cairo. "An increase in the number of psychiatrists or psychiatric beds in mental or general hospitals can only treat the mentally ill, but not promote mental health," he explained, stressing the acute difference between the issue of mental illness and mental health. "Mental health means providing optimum environment and care to individuals to work and to be able to love in a responsible way."
In some countries, like Egypt and Yemen, WHO has sponsored special programmes for the integration of mental health within primary health care. Between 1998 and 1999, WHO collaborated with Ma'amoura State Mental Hospital through the programme "Nations for Mental Health". Some 250 physicians and 75 nurses in rural and urban areas of Alexandria were trained in early detection, treatment and follow-up of mental health problems, as well as in referral of mental illness cases. Consequently, the number of mental illness cases admitted into Ma'amoura Mental Hospital declined notably. According to Kamal Al-Fawal, head of the hospital at the time, the experiment was supposed to be a pilot study for further and more widespread application. "Unfortunately, this did not happen," Al-Fawal said, "probably due to financial and administrative causes."
Insufficient human resources pose a further challenge. In the Eastern Mediterranean region, the ratio of psychiatrists to people is less than one for every 100,000. The pace of training is slow and no one can predict if an increase in psychiatrists can keep up with the increase in population. Mohit of EMRO agrees that the obstacles are formidable. "We have to be realistic," he says. "Integration needs new ways of thinking." What is important, he added, is to start somewhere. "We do not expect countries to provide care for all the population. The first important step is to accept the idea that mental health is an integral part of health and that mental health services are possible and effective."
The WHO report underlines the need for reform of mental health policies, services and legislation. Currently, more than 40 per cent of countries worldwide have no mental health policy at all, and over 30 per cent have no mental health programme. Around 25 per cent of the countries have no mental heath legislation. More than 33 per cent of countries allocate less than one per cent of their budgets to mental health, with another 33 per cent spending just one per cent of their budgets on mental health.
"We should consider the enormous economic loss due to the non-treatment of mental disorders -- the burden on families and communities and the days of work lost," notes Saraceno of WHO. "The cost for the world of [failing to] treat mental disorders is probably higher than the cost of treating them," he added.
Increasing awareness by all means possible -- publications, television programming, religious institutions and the arts -- is a top priority, as misinformation is so abundant about mental health and illness. The report stresses that action must be taken to monitor, remove and prevent the use of negative imagery and even story- lines in television and film that reinforce stereotypes.
The EMRO has already brought media and mental health professionals together to discuss this topic twice this year, once in early April in celebration of World Health Day and again from 9 to 11 October to mark the launch of the World Health Report. WHO has also developed a five-year global action programme (GAP), which focuses on helping countries to translate WHO's recommendations into action.
Derek Yach, executive director of WHO, maintains that the new report is "a message of hope" that signals a change of tides in the way people are looking at mental health, thanks to better knowledge. "Through advocacy and media work, we can destigmatise the problem that is keeping too many people in the shadow," says Yach.
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