0:00:00.433,0:00:03.204
I want you to imagine this for a moment.

0:00:03.204,0:00:06.099
Two men, Rahul and Rajiv,

0:00:06.099,0:00:07.957
living in the same neighborhood,

0:00:07.957,0:00:11.252
from the same educational background, similar occupation,

0:00:11.252,0:00:14.020
and they both turn up at their local accident emergency

0:00:14.020,0:00:16.836
complaining of acute chest pain.

0:00:16.836,0:00:19.960
Rahul is offered a cardiac procedure,

0:00:19.960,0:00:22.771
but Rajiv is sent home.

0:00:22.771,0:00:25.281
What might explain the difference in the experience

0:00:25.281,0:00:28.533
of these two nearly identical men?

0:00:28.533,0:00:32.020
Rajiv suffers from a mental illness.

0:00:32.020,0:00:35.119
The difference in the quality of medical care

0:00:35.119,0:00:37.980
received by people with mental illness is one of the reasons

0:00:37.980,0:00:39.895
why they live shorter lives

0:00:39.895,0:00:41.478
than people without mental illness.

0:00:41.478,0:00:44.148
Even in the best-resourced countries in the world,

0:00:44.148,0:00:48.918
this life expectancy gap is as much as 20 years.

0:00:48.918,0:00:50.843
In the developing countries of the world, this gap

0:00:50.843,0:00:53.468
is even larger.

0:00:53.468,0:00:56.327
But of course, mental illnesses can kill in more direct ways

0:00:56.327,0:00:59.688
as well. The most obvious example is suicide.

0:00:59.688,0:01:02.343
It might surprise some of you here, as it did me,

0:01:02.343,0:01:05.280
when I discovered that suicide is at the top of the list

0:01:05.280,0:01:07.845
of the leading causes of death in young people

0:01:07.845,0:01:09.493
in all countries in the world,

0:01:09.493,0:01:12.885
including the poorest countries of the world.

0:01:12.885,0:01:15.719
But beyond the impact of a health condition

0:01:15.719,0:01:18.089
on life expectancy, we're also concerned

0:01:18.089,0:01:20.783
about the quality of life lived.

0:01:20.783,0:01:23.032
Now, in order for us to examine the overall impact

0:01:23.032,0:01:25.405
of a health condition both on life expectancy

0:01:25.405,0:01:28.563
as well as on the quality of life lived, we need to use

0:01:28.563,0:01:29.949
a metric called the DALY,

0:01:29.949,0:01:34.236
which stands for a Disability-Adjusted Life Year.

0:01:34.236,0:01:36.757
Now when we do that, we discover some startling things

0:01:36.757,0:01:39.579
about mental illness from a global perspective.

0:01:39.579,0:01:42.843
We discover that, for example, mental illnesses are

0:01:42.843,0:01:47.431
amongst the leading causes of disability around the world.

0:01:47.431,0:01:50.166
Depression, for example, is the third-leading cause

0:01:50.166,0:01:53.138
of disability, alongside conditions such as

0:01:53.138,0:01:56.490
diarrhea and pneumonia in children.

0:01:56.490,0:01:58.594
When you put all the mental illnesses together,

0:01:58.594,0:02:00.856
they account for roughly 15 percent

0:02:00.856,0:02:04.062
of the total global burden of disease.

0:02:04.062,0:02:08.573
Indeed, mental illnesses are also very damaging

0:02:08.573,0:02:14.018
to people's lives, but beyond just the burden of disease,

0:02:14.018,0:02:16.730
let us consider the absolute numbers.

0:02:16.730,0:02:18.789
The World Health Organization estimates

0:02:18.789,0:02:21.894
that there are nearly four to five hundred million people

0:02:21.894,0:02:24.077
living on our tiny planet

0:02:24.077,0:02:25.738
who are affected by a mental illness.

0:02:25.738,0:02:27.457
Now some of you here

0:02:27.457,0:02:30.055
look a bit astonished by that number,

0:02:30.055,0:02:32.548
but consider for a moment the incredible diversity

0:02:32.548,0:02:35.702
of mental illnesses, from autism and intellectual disability

0:02:35.702,0:02:38.383
in childhood, through to depression and anxiety,

0:02:38.383,0:02:40.664
substance misuse and psychosis in adulthood,

0:02:40.664,0:02:42.300
all the way through to dementia in old age,

0:02:42.300,0:02:45.254
and I'm pretty sure that each and every one us

0:02:45.254,0:02:48.606
present here today can think of at least one person,

0:02:48.606,0:02:51.928
at least one person, who's affected by mental illness

0:02:51.928,0:02:56.359
in our most intimate social networks.

0:02:56.359,0:02:59.564
I see some nodding heads there.

0:02:59.564,0:03:02.534
But beyond the staggering numbers,

0:03:02.534,0:03:05.543
what's truly important from a global health point of view,

0:03:05.543,0:03:08.088
what's truly worrying from a global health point of view,

0:03:08.088,0:03:11.256
is that the vast majority of these affected individuals

0:03:11.256,0:03:13.265
do not receive the care

0:03:13.265,0:03:15.731
that we know can transform their lives, and remember,

0:03:15.731,0:03:18.792
we do have robust evidence that a range of interventions,

0:03:18.792,0:03:21.244
medicines, psychological interventions,

0:03:21.244,0:03:24.732
and social interventions, can make a vast difference.

0:03:24.732,0:03:26.983
And yet, even in the best-resourced countries,

0:03:26.983,0:03:29.918
for example here in Europe, roughly 50 percent

0:03:29.918,0:03:33.035
of affected people don't receive these interventions.

0:03:33.035,0:03:35.352
In the sorts of countries I work in,

0:03:35.352,0:03:37.502
that so-called treatment gap

0:03:37.502,0:03:42.389
approaches an astonishing 90 percent.

0:03:42.389,0:03:45.601
It isn't surprising, then, that if you should speak

0:03:45.601,0:03:48.032
to anyone affected by a mental illness,

0:03:48.032,0:03:50.844
the chances are that you will hear stories

0:03:50.844,0:03:54.894
of hidden suffering, shame and discrimination

0:03:54.894,0:03:57.843
in nearly every sector of their lives.

0:03:57.843,0:04:00.553
But perhaps most heartbreaking of all

0:04:00.553,0:04:03.242
are the stories of the abuse

0:04:03.242,0:04:05.774
of even the most basic human rights,

0:04:05.774,0:04:08.631
such as the young woman shown in this image here

0:04:08.631,0:04:10.695
that are played out every day,

0:04:10.695,0:04:14.639
sadly, even in the very institutions that were built to care

0:04:14.639,0:04:18.474
for people with mental illnesses, the mental hospitals.

0:04:18.474,0:04:21.502
It's this injustice that has really driven my mission

0:04:21.502,0:04:23.894
to try to do a little bit to transform the lives

0:04:23.894,0:04:26.640
of people affected by mental illness, and a particularly

0:04:26.640,0:04:30.489
critical action that I focused on is to bridge the gulf

0:04:30.489,0:04:33.275
between the knowledge we have that can transform lives,

0:04:33.275,0:04:35.717
the knowledge of effective treatments, and how we actually

0:04:35.717,0:04:39.139
use that knowledge in the everyday world.

0:04:39.139,0:04:42.298
And an especially important challenge that I've had to face

0:04:42.298,0:04:45.223
is the great shortage of mental health professionals,

0:04:45.223,0:04:46.895
such as psychiatrists and psychologists,

0:04:46.895,0:04:49.683
particularly in the developing world.

0:04:49.683,0:04:52.368
Now I trained in medicine in India, and after that

0:04:52.368,0:04:55.787
I chose psychiatry as my specialty, much to the dismay

0:04:55.787,0:04:58.015
of my mother and all my family members who

0:04:58.015,0:04:59.718
kind of thought neurosurgery would be

0:04:59.718,0:05:02.887
a more respectable option for their brilliant son.

0:05:02.887,0:05:05.621
Any case, I went on, I soldiered on with psychiatry,

0:05:05.621,0:05:07.916
and found myself training in Britain in some of

0:05:07.916,0:05:10.291
the best hospitals in this country. I was very privileged.

0:05:10.291,0:05:13.834
I worked in a team of incredibly talented, compassionate,

0:05:13.834,0:05:17.085
but most importantly, highly trained, specialized

0:05:17.085,0:05:19.276
mental health professionals.

0:05:19.276,0:05:21.248
Soon after my training, I found myself working

0:05:21.248,0:05:23.691
first in Zimbabwe and then in India, and I was confronted

0:05:23.691,0:05:26.551
by an altogether new reality.

0:05:26.551,0:05:29.897
This was a reality of a world in which there were almost no

0:05:29.897,0:05:32.262
mental health professionals at all.

0:05:32.262,0:05:34.296
In Zimbabwe, for example, there were just about

0:05:34.296,0:05:37.356
a dozen psychiatrists, most of whom lived and worked

0:05:37.356,0:05:39.482
in Harare city, leaving only a couple

0:05:39.482,0:05:41.875
to address the mental health care needs

0:05:41.875,0:05:45.543
of nine million people living in the countryside.

0:05:45.543,0:05:49.160
In India, I found the situation was not a lot better.

0:05:49.160,0:05:51.583
To give you a perspective, if I had to translate

0:05:51.583,0:05:53.791
the proportion of psychiatrists in the population

0:05:53.791,0:05:56.173
that one might see in Britain to India,

0:05:56.173,0:06:01.782
one might expect roughly 150,000 psychiatrists in India.

0:06:01.782,0:06:04.813
In reality, take a guess.

0:06:04.813,0:06:07.378
The actual number is about 3,000,

0:06:07.378,0:06:09.842
about two percent of that number.

0:06:09.842,0:06:12.339
It became quickly apparent to me that I couldn't follow

0:06:12.339,0:06:15.400
the sorts of mental health care models that I had been trained in,

0:06:15.400,0:06:18.339
one that relied heavily on specialized, expensive

0:06:18.339,0:06:20.871
mental health professionals to provide mental health care

0:06:20.871,0:06:23.331
in countries like India and Zimbabwe.

0:06:23.331,0:06:25.984
I had to think out of the box about some other model

0:06:25.984,0:06:27.607
of care.

0:06:27.607,0:06:30.720
It was then that I came across these books,

0:06:30.720,0:06:33.963
and in these books I discovered the idea of task shifting

0:06:33.963,0:06:36.031
in global health.

0:06:36.031,0:06:38.307
The idea is actually quite simple. The idea is,

0:06:38.307,0:06:41.321
when you're short of specialized health care professionals,

0:06:41.321,0:06:44.370
use whoever is available in the community,

0:06:44.370,0:06:47.307
train them to provide a range of health care interventions,

0:06:47.307,0:06:50.175
and in these books I read inspiring examples,

0:06:50.175,0:06:53.111
for example of how ordinary people had been trained

0:06:53.111,0:06:54.464
to deliver babies,

0:06:54.464,0:06:58.095
diagnose and treat early pneumonia, to great effect.

0:06:58.095,0:07:00.846
And it struck me that if you could train ordinary people

0:07:00.846,0:07:03.070
to deliver such complex health care interventions,

0:07:03.070,0:07:05.143
then perhaps they could also do the same

0:07:05.143,0:07:07.135
with mental health care.

0:07:07.135,0:07:10.004
Well today, I'm very pleased to report to you

0:07:10.004,0:07:13.116
that there have been many experiments in task shifting

0:07:13.116,0:07:15.887
in mental health care across the developing world

0:07:15.887,0:07:17.950
over the past decade, and I want to share with you

0:07:17.950,0:07:20.647
the findings of three particular such experiments,

0:07:20.647,0:07:22.734
all three of which focused on depression,

0:07:22.734,0:07:25.169
the most common of all mental illnesses.

0:07:25.169,0:07:28.511
In rural Uganda, Paul Bolton and his colleagues,

0:07:28.511,0:07:32.355
using villagers, demonstrated that they could deliver

0:07:32.355,0:07:34.710
interpersonal psychotherapy for depression

0:07:34.710,0:07:37.382
and, using a randomized control design,

0:07:37.382,0:07:39.627
showed that 90 percent of the people receiving

0:07:39.627,0:07:41.587
this intervention recovered as compared

0:07:41.587,0:07:45.128
to roughly 40 percent in the comparison villages.

0:07:45.128,0:07:49.268
Similarly, using a randomized control trial in rural Pakistan,

0:07:49.268,0:07:51.608
Atif Rahman and his colleagues showed

0:07:51.608,0:07:54.343
that lady health visitors, who are community maternal

0:07:54.343,0:07:57.132
health workers in Pakistan's health care system,

0:07:57.132,0:07:59.349
could deliver cognitive behavior therapy for mothers

0:07:59.349,0:08:01.857
who were depressed, again showing dramatic differences

0:08:01.857,0:08:04.704
in the recovery rates. Roughly 75 percent of mothers

0:08:04.704,0:08:07.269
recovered as compared to about 45 percent

0:08:07.269,0:08:09.553
in the comparison villages.

0:08:09.553,0:08:12.639
And in my own trial in Goa, in India, we again showed

0:08:12.639,0:08:15.167
that lay counselors drawn from local communities

0:08:15.167,0:08:17.851
could be trained to deliver psychosocial interventions

0:08:17.851,0:08:20.433
for depression, anxiety, leading to 70 percent

0:08:20.433,0:08:22.516
recovery rates as compared to 50 percent

0:08:22.516,0:08:25.722
in the comparison primary health centers.

0:08:25.722,0:08:27.691
Now, if I had to draw together all these different

0:08:27.691,0:08:30.223
experiments in task shifting, and there have of course

0:08:30.223,0:08:32.597
been many other examples, and try and identify

0:08:32.597,0:08:34.615
what are the key lessons we can learn that makes

0:08:34.615,0:08:37.693
for a successful task shifting operation,

0:08:37.693,0:08:41.549
I have coined this particular acronym, SUNDAR.

0:08:41.549,0:08:45.783
What SUNDAR stands for, in Hindi, is "attractive."

0:08:45.783,0:08:47.998
It seems to me that there are five key lessons

0:08:47.998,0:08:50.597
that I've shown on this slide that are critically important

0:08:50.597,0:08:52.780
for effective task shifting.

0:08:52.780,0:08:55.806
The first is that we need to simplify the message

0:08:55.806,0:08:58.190
that we're using, stripping away all the jargon

0:08:58.190,0:09:01.511
that medicine has invented around itself.

0:09:01.511,0:09:04.468
We need to unpack complex health care interventions

0:09:04.468,0:09:06.696
into smaller components that can be more easily

0:09:06.696,0:09:09.351
transferred to less-trained individuals.

0:09:09.351,0:09:11.918
We need to deliver health care, not in large institutions,

0:09:11.918,0:09:14.144
but close to people's homes, and we need to deliver

0:09:14.144,0:09:16.916
health care using whoever is available and affordable

0:09:16.916,0:09:19.297
in our local communities.

0:09:19.297,0:09:22.177
And importantly, we need to reallocate the few specialists

0:09:22.177,0:09:24.245
who are available to perform roles

0:09:24.245,0:09:27.723
such as capacity-building and supervision.

0:09:27.723,0:09:30.055
Now for me, task shifting is an idea

0:09:30.055,0:09:33.014
with truly global significance,

0:09:33.014,0:09:35.547
because even though it has arisen out of the

0:09:35.547,0:09:39.045
situation of the lack of resources that you find

0:09:39.045,0:09:42.004
in developing countries, I think it has a lot of significance

0:09:42.004,0:09:44.885
for better-resourced countries as well. Why is that?

0:09:44.885,0:09:48.405
Well, in part, because health care in the developed world,

0:09:48.405,0:09:50.880
the health care costs in the [developed] world,

0:09:50.880,0:09:53.457
are rapidly spiraling out of control, and a huge chunk

0:09:53.457,0:09:56.877
of those costs are human resource costs.

0:09:56.877,0:09:59.363
But equally important is because health care has become

0:09:59.363,0:10:03.200
so incredibly professionalized that it's become very remote

0:10:03.200,0:10:05.955
and removed from local communities.

0:10:05.955,0:10:09.677
For me, what's truly sundar about the idea of task shifting,

0:10:09.677,0:10:11.323
though, isn't that it simply makes health care

0:10:11.323,0:10:14.481
more accessible and affordable but that

0:10:14.481,0:10:17.037
it is also fundamentally empowering.

0:10:17.037,0:10:20.669
It empowers ordinary people to be more effective

0:10:20.669,0:10:23.492
in caring for the health of others in their community,

0:10:23.492,0:10:24.981
and in doing so, to become better guardians

0:10:24.981,0:10:28.263
of their own health. Indeed, for me, task shifting

0:10:28.263,0:10:30.950
is the ultimate example of the democratization

0:10:30.950,0:10:36.199
of medical knowledge, and therefore, medical power.

0:10:36.199,0:10:39.650
Just over 30 years ago, the nations of the world assembled

0:10:39.650,0:10:42.623
at Alma-Ata and made this iconic declaration.

0:10:42.623,0:10:44.228
Well, I think all of you can guess

0:10:44.228,0:10:47.943
that 12 years on, we're still nowhere near that goal.

0:10:47.943,0:10:50.608
Still, today, armed with that knowledge

0:10:50.608,0:10:53.264
that ordinary people in the community

0:10:53.264,0:10:56.427
can be trained and, with sufficient supervision and support,

0:10:56.427,0:10:59.699
can deliver a range of health care interventions effectively,

0:10:59.699,0:11:03.580
perhaps that promise is within reach now.

0:11:03.580,0:11:07.224
Indeed, to implement the slogan of Health for All,

0:11:07.224,0:11:09.010
we will need to involve all

0:11:09.010,0:11:10.669
in that particular journey,

0:11:10.669,0:11:13.615
and in the case of mental health, in particular we would

0:11:13.615,0:11:16.518
need to involve people who are affected by mental illness

0:11:16.518,0:11:17.972
and their caregivers.

0:11:17.972,0:11:20.508
It is for this reason that, some years ago,

0:11:20.508,0:11:22.426
the Movement for Global Mental Health was founded

0:11:22.426,0:11:26.449
as a sort of a virtual platform upon which professionals

0:11:26.449,0:11:29.256
like myself and people affected by mental illness

0:11:29.256,0:11:31.968
could stand together, shoulder-to-shoulder,

0:11:31.968,0:11:34.454
and advocate for the rights of people with mental illness

0:11:34.454,0:11:37.671
to receive the care that we know can transform their lives,

0:11:37.671,0:11:40.680
and to live a life with dignity.

0:11:40.680,0:11:44.197
And in closing, when you have a moment of peace or quiet

0:11:44.197,0:11:47.023
in these very busy few days or perhaps afterwards,

0:11:47.023,0:11:49.777
spare a thought for that person you thought about

0:11:49.777,0:11:52.354
who has a mental illness, or persons that you thought about

0:11:52.354,0:11:53.942
who have mental illness,

0:11:53.942,0:11:57.746
and dare to care for them. Thank you. (Applause)

0:11:57.746,0:12:01.810
(Applause)