WEBVTT

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I want you to imagine this for a moment.

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Two men, Rahul and Rajiv,

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living in the same neighborhood,

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from the same educational background, similar occupation,

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and they both turn up at their local accident emergency

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complaining of acute chest pain.

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Rahul is offered a cardiac procedure,

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but Rajiv is sent home.

NOTE Paragraph

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What might explain the difference in the experience

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of these two nearly identical men?

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Rajiv suffers from a mental illness.

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The difference in the quality of medical care

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received by people with mental illness is one of the reasons

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why they live shorter lives

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than people without mental illness.

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Even in the best-resourced countries in the world,

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this life expectancy gap is as much as 20 years.

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In the developing countries of the world, this gap

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is even larger.

NOTE Paragraph

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But of course, mental illnesses can kill in more direct ways

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as well. The most obvious example is suicide.

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It might surprise some of you here, as it did me,

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when I discovered that suicide is at the top of the list

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of the leading causes of death in young people

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in all countries in the world,

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including the poorest countries of the world.

NOTE Paragraph

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But beyond the impact of a health condition

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on life expectancy, we're also concerned

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about the quality of life lived.

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Now, in order for us to examine the overall impact

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of a health condition both on life expectancy

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as well as on the quality of life lived, we need to use

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a metric called the DALY,

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which stands for a Disability-Adjusted Life Year.

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Now when we do that, we discover some startling things

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about mental illness from a global perspective.

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We discover that, for example, mental illnesses are

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amongst the leading causes of disability around the world.

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Depression, for example, is the third-leading cause

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of disability, alongside conditions such as

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diarrhea and pneumonia in children.

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When you put all the mental illnesses together,

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they account for roughly 15 percent

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of the total global burden of disease.

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Indeed, mental illnesses are also very damaging

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to people's lives, but beyond just the burden of disease,

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let us consider the absolute numbers.

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The World Health Organization estimates

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that there are nearly four to five hundred million people

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living on our tiny planet

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who are affected by a mental illness.

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Now some of you here

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look a bit astonished by that number,

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but consider for a moment the incredible diversity

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of mental illnesses, from autism and intellectual disability

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in childhood, through to depression and anxiety,

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substance misuse and psychosis in adulthood,

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all the way through to dementia in old age,

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and I'm pretty sure that each and every one us

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present here today can think of at least one person,

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at least one person, who's affected by mental illness

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in our most intimate social networks.

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I see some nodding heads there.

NOTE Paragraph

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But beyond the staggering numbers,

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what's truly important from a global health point of view,

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what's truly worrying from a global health point of view,

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is that the vast majority of these affected individuals

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do not receive the care

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that we know can transform their lives, and remember,

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we do have robust evidence that a range of interventions,

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medicines, psychological interventions,

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and social interventions, can make a vast difference.

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And yet, even in the best-resourced countries,

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for example here in Europe, roughly 50 percent

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of affected people don't receive these interventions.

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In the sorts of countries I work in,

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that so-called treatment gap

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approaches an astonishing 90 percent.

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It isn't surprising, then, that if you should speak

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to anyone affected by a mental illness,

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the chances are that you will hear stories

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of hidden suffering, shame and discrimination

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in nearly every sector of their lives.

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But perhaps most heartbreaking of all

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are the stories of the abuse

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of even the most basic human rights,

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such as the young woman shown in this image here

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that are played out every day,

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sadly, even in the very institutions that were built to care

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for people with mental illnesses, the mental hospitals.

NOTE Paragraph

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It's this injustice that has really driven my mission

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to try to do a little bit to transform the lives

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of people affected by mental illness, and a particularly

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critical action that I focused on is to bridge the gulf

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between the knowledge we have that can transform lives,

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the knowledge of effective treatments, and how we actually

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use that knowledge in the everyday world.

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And an especially important challenge that I've had to face

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is the great shortage of mental health professionals,

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such as psychiatrists and psychologists,

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particularly in the developing world.

NOTE Paragraph

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Now I trained in medicine in India, and after that

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I chose psychiatry as my specialty, much to the dismay

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of my mother and all my family members who

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kind of thought neurosurgery would be

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a more respectable option for their brilliant son.

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Any case, I went on, I soldiered on with psychiatry,

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and found myself training in Britain in some of

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the best hospitals in this country. I was very privileged.

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I worked in a team of incredibly talented, compassionate,

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but most importantly, highly trained, specialized

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mental health professionals.

NOTE Paragraph

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Soon after my training, I found myself working

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first in Zimbabwe and then in India, and I was confronted

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by an altogether new reality.

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This was a reality of a world in which there were almost no

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mental health professionals at all.

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In Zimbabwe, for example, there were just about

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a dozen psychiatrists, most of whom lived and worked

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in Harare city, leaving only a couple

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to address the mental health care needs

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of nine million people living in the countryside.

NOTE Paragraph

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In India, I found the situation was not a lot better.

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To give you a perspective, if I had to translate

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the proportion of psychiatrists in the population

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that one might see in Britain to India,

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one might expect roughly 150,000 psychiatrists in India.

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In reality, take a guess.

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The actual number is about 3,000,

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about two percent of that number.

NOTE Paragraph

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It became quickly apparent to me that I couldn't follow

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the sorts of mental health care models that I had been trained in,

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one that relied heavily on specialized, expensive

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mental health professionals to provide mental health care

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in countries like India and Zimbabwe.

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I had to think out of the box about some other model

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of care.

NOTE Paragraph

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It was then that I came across these books,

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and in these books I discovered the idea of task shifting

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in global health.

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The idea is actually quite simple. The idea is,

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when you're short of specialized health care professionals,

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use whoever is available in the community,

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train them to provide a range of health care interventions,

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and in these books I read inspiring examples,

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for example of how ordinary people had been trained

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to deliver babies,

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diagnose and treat early pneumonia, to great effect.

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And it struck me that if you could train ordinary people

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to deliver such complex health care interventions,

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then perhaps they could also do the same

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with mental health care.

NOTE Paragraph

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Well today, I'm very pleased to report to you

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that there have been many experiments in task shifting

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in mental health care across the developing world

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over the past decade, and I want to share with you

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the findings of three particular such experiments,

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all three of which focused on depression,

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the most common of all mental illnesses.

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In rural Uganda, Paul Bolton and his colleagues,

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using villagers, demonstrated that they could deliver

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interpersonal psychotherapy for depression

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and, using a randomized control design,

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showed that 90 percent of the people receiving

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this intervention recovered as compared

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to roughly 40 percent in the comparison villages.

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Similarly, using a randomized control trial in rural Pakistan,

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Atif Rahman and his colleagues showed

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that lady health visitors, who are community maternal

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health workers in Pakistan's health care system,

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could deliver cognitive behavior therapy for mothers

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who were depressed, again showing dramatic differences

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in the recovery rates. Roughly 75 percent of mothers

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recovered as compared to about 45 percent

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in the comparison villages.

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And in my own trial in Goa, in India, we again showed

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that lay counselors drawn from local communities

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could be trained to deliver psychosocial interventions

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for depression, anxiety, leading to 70 percent

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recovery rates as compared to 50 percent

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in the comparison primary health centers.

NOTE Paragraph

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Now, if I had to draw together all these different

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experiments in task shifting, and there have of course

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been many other examples, and try and identify

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what are the key lessons we can learn that makes

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for a successful task shifting operation,

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I have coined this particular acronym, SUNDAR.

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What SUNDAR stands for, in Hindi, is "attractive."

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It seems to me that there are five key lessons

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that I've shown on this slide that are critically important

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for effective task shifting.

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The first is that we need to simplify the message

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that we're using, stripping away all the jargon

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that medicine has invented around itself.

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We need to unpack complex health care interventions

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into smaller components that can be more easily

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transferred to less-trained individuals.

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We need to deliver health care, not in large institutions,

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but close to people's homes, and we need to deliver

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health care using whoever is available and affordable

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in our local communities.

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And importantly, we need to reallocate the few specialists

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who are available to perform roles

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such as capacity-building and supervision.

NOTE Paragraph

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Now for me, task shifting is an idea

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with truly global significance,

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because even though it has arisen out of the

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situation of the lack of resources that you find

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in developing countries, I think it has a lot of significance

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for better-resourced countries as well. Why is that?

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Well, in part, because health care in the developed world,

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the health care costs in the [developed] world,

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are rapidly spiraling out of control, and a huge chunk

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of those costs are human resource costs.

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But equally important is because health care has become

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so incredibly professionalized that it's become very remote

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and removed from local communities.

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For me, what's truly sundar about the idea of task shifting,

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though, isn't that it simply makes health care

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more accessible and affordable but that

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it is also fundamentally empowering.

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It empowers ordinary people to be more effective

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in caring for the health of others in their community,

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and in doing so, to become better guardians

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of their own health. Indeed, for me, task shifting

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is the ultimate example of the democratization

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of medical knowledge, and therefore, medical power.

NOTE Paragraph

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Just over 30 years ago, the nations of the world assembled

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at Alma-Ata and made this iconic declaration.

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Well, I think all of you can guess

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that 12 years on, we're still nowhere near that goal.

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Still, today, armed with that knowledge

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that ordinary people in the community

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can be trained and, with sufficient supervision and support,

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can deliver a range of health care interventions effectively,

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perhaps that promise is within reach now.

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Indeed, to implement the slogan of Health for All,

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we will need to involve all

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in that particular journey,

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and in the case of mental health, in particular we would

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need to involve people who are affected by mental illness

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and their caregivers.

NOTE Paragraph

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It is for this reason that, some years ago,

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the Movement for Global Mental Health was founded

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as a sort of a virtual platform upon which professionals

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like myself and people affected by mental illness

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could stand together, shoulder-to-shoulder,

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and advocate for the rights of people with mental illness

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to receive the care that we know can transform their lives,

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and to live a life with dignity.

NOTE Paragraph

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And in closing, when you have a moment of peace or quiet

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in these very busy few days or perhaps afterwards,

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spare a thought for that person you thought about

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who has a mental illness, or persons that you thought about

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who have mental illness,

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and dare to care for them. Thank you. (Applause)

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(Applause)