Mental health for all by involving all
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0:00 - 0:03I want you to imagine this for a moment.
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0:03 - 0:06Two men, Rahul and Rajiv,
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0:06 - 0:08living in the same neighborhood,
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0:08 - 0:11from the same educational background, similar occupation,
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0:11 - 0:14and they both turn up at their local accident emergency
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0:14 - 0:17complaining of acute chest pain.
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0:17 - 0:20Rahul is offered a cardiac procedure,
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0:20 - 0:23but Rajiv is sent home.
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0:23 - 0:25What might explain the difference in the experience
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0:25 - 0:29of these two nearly identical men?
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0:29 - 0:32Rajiv suffers from a mental illness.
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0:32 - 0:35The difference in the quality of medical care
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0:35 - 0:38received by people with mental illness is one of the reasons
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0:38 - 0:40why they live shorter lives
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0:40 - 0:41than people without mental illness.
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0:41 - 0:44Even in the best-resourced countries in the world,
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0:44 - 0:49this life expectancy gap is as much as 20 years.
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0:49 - 0:51In the developing countries of the world, this gap
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0:51 - 0:53is even larger.
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0:53 - 0:56But of course, mental illnesses can kill in more direct ways
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0:56 - 1:00as well. The most obvious example is suicide.
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1:00 - 1:02It might surprise some of you here, as it did me,
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1:02 - 1:05when I discovered that suicide is at the top of the list
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1:05 - 1:08of the leading causes of death in young people
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1:08 - 1:09in all countries in the world,
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1:09 - 1:13including the poorest countries of the world.
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1:13 - 1:16But beyond the impact of a health condition
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1:16 - 1:18on life expectancy, we're also concerned
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1:18 - 1:21about the quality of life lived.
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1:21 - 1:23Now, in order for us to examine the overall impact
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1:23 - 1:25of a health condition both on life expectancy
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1:25 - 1:29as well as on the quality of life lived, we need to use
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1:29 - 1:30a metric called the DALY,
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1:30 - 1:34which stands for a Disability-Adjusted Life Year.
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1:34 - 1:37Now when we do that, we discover some startling things
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1:37 - 1:40about mental illness from a global perspective.
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1:40 - 1:43We discover that, for example, mental illnesses are
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1:43 - 1:47amongst the leading causes of disability around the world.
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1:47 - 1:50Depression, for example, is the third-leading cause
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1:50 - 1:53of disability, alongside conditions such as
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1:53 - 1:56diarrhea and pneumonia in children.
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1:56 - 1:59When you put all the mental illnesses together,
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1:59 - 2:01they account for roughly 15 percent
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2:01 - 2:04of the total global burden of disease.
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2:04 - 2:09Indeed, mental illnesses are also very damaging
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2:09 - 2:14to people's lives, but beyond just the burden of disease,
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2:14 - 2:17let us consider the absolute numbers.
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2:17 - 2:19The World Health Organization estimates
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2:19 - 2:22that there are nearly four to five hundred million people
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2:22 - 2:24living on our tiny planet
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2:24 - 2:26who are affected by a mental illness.
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2:26 - 2:27Now some of you here
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2:27 - 2:30look a bit astonished by that number,
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2:30 - 2:33but consider for a moment the incredible diversity
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2:33 - 2:36of mental illnesses, from autism and intellectual disability
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2:36 - 2:38in childhood, through to depression and anxiety,
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2:38 - 2:41substance misuse and psychosis in adulthood,
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2:41 - 2:42all the way through to dementia in old age,
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2:42 - 2:45and I'm pretty sure that each and every one us
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2:45 - 2:49present here today can think of at least one person,
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2:49 - 2:52at least one person, who's affected by mental illness
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2:52 - 2:56in our most intimate social networks.
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2:56 - 3:00I see some nodding heads there.
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3:00 - 3:03But beyond the staggering numbers,
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3:03 - 3:06what's truly important from a global health point of view,
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3:06 - 3:08what's truly worrying from a global health point of view,
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3:08 - 3:11is that the vast majority of these affected individuals
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3:11 - 3:13do not receive the care
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3:13 - 3:16that we know can transform their lives, and remember,
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3:16 - 3:19we do have robust evidence that a range of interventions,
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3:19 - 3:21medicines, psychological interventions,
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3:21 - 3:25and social interventions, can make a vast difference.
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3:25 - 3:27And yet, even in the best-resourced countries,
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3:27 - 3:30for example here in Europe, roughly 50 percent
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3:30 - 3:33of affected people don't receive these interventions.
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3:33 - 3:35In the sorts of countries I work in,
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3:35 - 3:38that so-called treatment gap
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3:38 - 3:42approaches an astonishing 90 percent.
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3:42 - 3:46It isn't surprising, then, that if you should speak
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3:46 - 3:48to anyone affected by a mental illness,
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3:48 - 3:51the chances are that you will hear stories
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3:51 - 3:55of hidden suffering, shame and discrimination
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3:55 - 3:58in nearly every sector of their lives.
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3:58 - 4:01But perhaps most heartbreaking of all
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4:01 - 4:03are the stories of the abuse
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4:03 - 4:06of even the most basic human rights,
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4:06 - 4:09such as the young woman shown in this image here
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4:09 - 4:11that are played out every day,
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4:11 - 4:15sadly, even in the very institutions that were built to care
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4:15 - 4:18for people with mental illnesses, the mental hospitals.
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4:18 - 4:22It's this injustice that has really driven my mission
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4:22 - 4:24to try to do a little bit to transform the lives
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4:24 - 4:27of people affected by mental illness, and a particularly
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4:27 - 4:30critical action that I focused on is to bridge the gulf
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4:30 - 4:33between the knowledge we have that can transform lives,
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4:33 - 4:36the knowledge of effective treatments, and how we actually
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4:36 - 4:39use that knowledge in the everyday world.
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4:39 - 4:42And an especially important challenge that I've had to face
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4:42 - 4:45is the great shortage of mental health professionals,
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4:45 - 4:47such as psychiatrists and psychologists,
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4:47 - 4:50particularly in the developing world.
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4:50 - 4:52Now I trained in medicine in India, and after that
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4:52 - 4:56I chose psychiatry as my specialty, much to the dismay
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4:56 - 4:58of my mother and all my family members who
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4:58 - 5:00kind of thought neurosurgery would be
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5:00 - 5:03a more respectable option for their brilliant son.
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5:03 - 5:06Any case, I went on, I soldiered on with psychiatry,
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5:06 - 5:08and found myself training in Britain in some of
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5:08 - 5:10the best hospitals in this country. I was very privileged.
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5:10 - 5:14I worked in a team of incredibly talented, compassionate,
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5:14 - 5:17but most importantly, highly trained, specialized
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5:17 - 5:19mental health professionals.
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5:19 - 5:21Soon after my training, I found myself working
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5:21 - 5:24first in Zimbabwe and then in India, and I was confronted
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5:24 - 5:27by an altogether new reality.
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5:27 - 5:30This was a reality of a world in which there were almost no
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5:30 - 5:32mental health professionals at all.
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5:32 - 5:34In Zimbabwe, for example, there were just about
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5:34 - 5:37a dozen psychiatrists, most of whom lived and worked
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5:37 - 5:39in Harare city, leaving only a couple
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5:39 - 5:42to address the mental health care needs
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5:42 - 5:46of nine million people living in the countryside.
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5:46 - 5:49In India, I found the situation was not a lot better.
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5:49 - 5:52To give you a perspective, if I had to translate
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5:52 - 5:54the proportion of psychiatrists in the population
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5:54 - 5:56that one might see in Britain to India,
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5:56 - 6:02one might expect roughly 150,000 psychiatrists in India.
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6:02 - 6:05In reality, take a guess.
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6:05 - 6:07The actual number is about 3,000,
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6:07 - 6:10about two percent of that number.
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6:10 - 6:12It became quickly apparent to me that I couldn't follow
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6:12 - 6:15the sorts of mental health care models that I had been trained in,
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6:15 - 6:18one that relied heavily on specialized, expensive
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6:18 - 6:21mental health professionals to provide mental health care
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6:21 - 6:23in countries like India and Zimbabwe.
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6:23 - 6:26I had to think out of the box about some other model
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6:26 - 6:28of care.
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6:28 - 6:31It was then that I came across these books,
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6:31 - 6:34and in these books I discovered the idea of task shifting
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6:34 - 6:36in global health.
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6:36 - 6:38The idea is actually quite simple. The idea is,
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6:38 - 6:41when you're short of specialized health care professionals,
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6:41 - 6:44use whoever is available in the community,
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6:44 - 6:47train them to provide a range of health care interventions,
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6:47 - 6:50and in these books I read inspiring examples,
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6:50 - 6:53for example of how ordinary people had been trained
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6:53 - 6:54to deliver babies,
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6:54 - 6:58diagnose and treat early pneumonia, to great effect.
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6:58 - 7:01And it struck me that if you could train ordinary people
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7:01 - 7:03to deliver such complex health care interventions,
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7:03 - 7:05then perhaps they could also do the same
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7:05 - 7:07with mental health care.
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7:07 - 7:10Well today, I'm very pleased to report to you
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7:10 - 7:13that there have been many experiments in task shifting
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7:13 - 7:16in mental health care across the developing world
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7:16 - 7:18over the past decade, and I want to share with you
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7:18 - 7:21the findings of three particular such experiments,
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7:21 - 7:23all three of which focused on depression,
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7:23 - 7:25the most common of all mental illnesses.
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7:25 - 7:29In rural Uganda, Paul Bolton and his colleagues,
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7:29 - 7:32using villagers, demonstrated that they could deliver
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7:32 - 7:35interpersonal psychotherapy for depression
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7:35 - 7:37and, using a randomized control design,
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7:37 - 7:40showed that 90 percent of the people receiving
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7:40 - 7:42this intervention recovered as compared
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7:42 - 7:45to roughly 40 percent in the comparison villages.
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7:45 - 7:49Similarly, using a randomized control trial in rural Pakistan,
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7:49 - 7:52Atif Rahman and his colleagues showed
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7:52 - 7:54that lady health visitors, who are community maternal
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7:54 - 7:57health workers in Pakistan's health care system,
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7:57 - 7:59could deliver cognitive behavior therapy for mothers
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7:59 - 8:02who were depressed, again showing dramatic differences
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8:02 - 8:05in the recovery rates. Roughly 75 percent of mothers
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8:05 - 8:07recovered as compared to about 45 percent
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8:07 - 8:10in the comparison villages.
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8:10 - 8:13And in my own trial in Goa, in India, we again showed
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8:13 - 8:15that lay counselors drawn from local communities
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8:15 - 8:18could be trained to deliver psychosocial interventions
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8:18 - 8:20for depression, anxiety, leading to 70 percent
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8:20 - 8:23recovery rates as compared to 50 percent
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8:23 - 8:26in the comparison primary health centers.
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8:26 - 8:28Now, if I had to draw together all these different
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8:28 - 8:30experiments in task shifting, and there have of course
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8:30 - 8:33been many other examples, and try and identify
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8:33 - 8:35what are the key lessons we can learn that makes
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8:35 - 8:38for a successful task shifting operation,
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8:38 - 8:42I have coined this particular acronym, SUNDAR.
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8:42 - 8:46What SUNDAR stands for, in Hindi, is "attractive."
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8:46 - 8:48It seems to me that there are five key lessons
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8:48 - 8:51that I've shown on this slide that are critically important
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8:51 - 8:53for effective task shifting.
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8:53 - 8:56The first is that we need to simplify the message
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8:56 - 8:58that we're using, stripping away all the jargon
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8:58 - 9:02that medicine has invented around itself.
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9:02 - 9:04We need to unpack complex health care interventions
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9:04 - 9:07into smaller components that can be more easily
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9:07 - 9:09transferred to less-trained individuals.
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9:09 - 9:12We need to deliver health care, not in large institutions,
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9:12 - 9:14but close to people's homes, and we need to deliver
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9:14 - 9:17health care using whoever is available and affordable
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9:17 - 9:19in our local communities.
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9:19 - 9:22And importantly, we need to reallocate the few specialists
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9:22 - 9:24who are available to perform roles
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9:24 - 9:28such as capacity-building and supervision.
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9:28 - 9:30Now for me, task shifting is an idea
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9:30 - 9:33with truly global significance,
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9:33 - 9:36because even though it has arisen out of the
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9:36 - 9:39situation of the lack of resources that you find
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9:39 - 9:42in developing countries, I think it has a lot of significance
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9:42 - 9:45for better-resourced countries as well. Why is that?
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9:45 - 9:48Well, in part, because health care in the developed world,
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9:48 - 9:51the health care costs in the [developed] world,
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9:51 - 9:53are rapidly spiraling out of control, and a huge chunk
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9:53 - 9:57of those costs are human resource costs.
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9:57 - 9:59But equally important is because health care has become
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9:59 - 10:03so incredibly professionalized that it's become very remote
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10:03 - 10:06and removed from local communities.
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10:06 - 10:10For me, what's truly sundar about the idea of task shifting,
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10:10 - 10:11though, isn't that it simply makes health care
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10:11 - 10:14more accessible and affordable but that
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10:14 - 10:17it is also fundamentally empowering.
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10:17 - 10:21It empowers ordinary people to be more effective
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10:21 - 10:23in caring for the health of others in their community,
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10:23 - 10:25and in doing so, to become better guardians
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10:25 - 10:28of their own health. Indeed, for me, task shifting
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10:28 - 10:31is the ultimate example of the democratization
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10:31 - 10:36of medical knowledge, and therefore, medical power.
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10:36 - 10:40Just over 30 years ago, the nations of the world assembled
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10:40 - 10:43at Alma-Ata and made this iconic declaration.
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10:43 - 10:44Well, I think all of you can guess
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10:44 - 10:48that 12 years on, we're still nowhere near that goal.
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10:48 - 10:51Still, today, armed with that knowledge
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10:51 - 10:53that ordinary people in the community
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10:53 - 10:56can be trained and, with sufficient supervision and support,
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10:56 - 11:00can deliver a range of health care interventions effectively,
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11:00 - 11:04perhaps that promise is within reach now.
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11:04 - 11:07Indeed, to implement the slogan of Health for All,
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11:07 - 11:09we will need to involve all
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11:09 - 11:11in that particular journey,
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11:11 - 11:14and in the case of mental health, in particular we would
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11:14 - 11:17need to involve people who are affected by mental illness
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11:17 - 11:18and their caregivers.
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11:18 - 11:21It is for this reason that, some years ago,
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11:21 - 11:22the Movement for Global Mental Health was founded
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11:22 - 11:26as a sort of a virtual platform upon which professionals
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11:26 - 11:29like myself and people affected by mental illness
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11:29 - 11:32could stand together, shoulder-to-shoulder,
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11:32 - 11:34and advocate for the rights of people with mental illness
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11:34 - 11:38to receive the care that we know can transform their lives,
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11:38 - 11:41and to live a life with dignity.
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11:41 - 11:44And in closing, when you have a moment of peace or quiet
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11:44 - 11:47in these very busy few days or perhaps afterwards,
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11:47 - 11:50spare a thought for that person you thought about
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11:50 - 11:52who has a mental illness, or persons that you thought about
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11:52 - 11:54who have mental illness,
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11:54 - 11:58and dare to care for them. Thank you. (Applause)
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11:58 - 12:02(Applause)
- Title:
- Mental health for all by involving all
- Speaker:
- Vikram Patel
- Description:
-
Nearly 450 million people are affected by mental illness worldwide. In wealthy nations, just half receive appropriate care, but in developing countries, close to 90 percent go untreated because psychiatrists are in such short supply. Vikram Patel outlines a highly promising approach -- training members of communities to give mental health interventions, empowering ordinary people to care for others.
- Video Language:
- English
- Team:
- closed TED
- Project:
- TEDTalks
- Duration:
- 12:22
Thu-Huong Ha edited English subtitles for Mental health for all by involving all | ||
Miguel Cisneros-Franco edited English subtitles for Mental health for all by involving all | ||
Daniele Berti edited English subtitles for Mental health for all by involving all | ||
Daniele Berti edited English subtitles for Mental health for all by involving all | ||
Thu-Huong Ha approved English subtitles for Mental health for all by involving all | ||
Thu-Huong Ha edited English subtitles for Mental health for all by involving all | ||
Morton Bast accepted English subtitles for Mental health for all by involving all | ||
Morton Bast edited English subtitles for Mental health for all by involving all |