want you to imagine this for a moment two men rahul and rajiv living in the same neighborhood from the same educationalbackground 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 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 mentalillness is one of the reasons why they live shorter lives than people without mentalillness even in the best resourced countries in the world this life expectancy gap is as much as twenty years
in the developing countries of the world this gap is even larger
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
but beyond the impact of a health condition on life expectancy we 're also concerned about the quality of life lived
now when we do that we discover some startling things about mentalillness 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 fifteen 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 mentalillness now some of you here look a bit astonished by that number
but consider for a moment the incrediblediversity 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 mentalillness in our most intimate social networks
i see some nodding heads there 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 fifty 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 ninety percent
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
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 mentalillness 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
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 incrediblytalentedcompassionate but most importantly highly trained specialized mental health professionals
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 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
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 one hundred and fifty thousand psychiatrists
in india in reality
take a guess
i had to think out of the box
about some other model of care 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
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 ninety percent of the people receiving this intervention recovered as compared to roughly forty 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 communitymaternal 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 seventy five percent of mothers recovered
as compared to about forty five 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 depressionanxiety leading to seventy percent recovery rates as compared to fifty percent in the comparisonprimary health centers
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
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 thereforemedical power
just over thirty 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 twelve 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
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 mentalillness and their caregivers
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 mentalillness could stand together shoulder to shoulder and advocate for the rights of people with mentalillness to receive the care that we know can transform their lives
and to live a life with dignity and in closing
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