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About the Authors

Vaughan C. Turekian is the editor-in-chief of Science & Diplomacy.

Allen Moore is a senior advisor at the Stimson Center. He helped create PEPFAR while serving as the policy director to former Senate Majority Leader Bill Frist.

Mark M. Rasenick is a distinguished professor of physiology and psychiatry at the University of Illinois at Chicago. He worked on mental health policy while serving as a Robert Wood Johnson Fellow on Senator Edward Kennedy’s staff.

Editorial

Mental Health Diplomacy: Building a Global Response

When a person collapses in public, strangers rush to help. When a person manifests symptoms of mental illness in public, strangers look away or cross the street. Sadly, this all-to-common response by individuals could be a metaphor for official policy in much of the world. Most policy makers avoid engaging or investing in mental health programs, preferring to draw distinctions between mental health and somatic health. This is largely a product of stigma and ignorance about the causes of mental illness and potential treatments. It is true in America and other wealthy countries, and even more so in poorer countries.

As U.S. foreign policy makers strengthen the links between health and diplomacy, there is a need to elevate attention to the huge burden of mental illness. The World Health Organization estimates that mental illness constitutes 28 percent of the global burden of noncommunicable diseases, or 14 percent of the overall global disease burden. Around the world, an estimated 450 million people suffer from one or more mental disorders;1 900,000 people complete suicide every year;2 and nearly one-quarter of years lost because of disability are attributed to mental illness, including abuse of alcohol and drugs.3 By the end of this decade, depression is expected to be second only to ischemic heart disease as a cause of disability worldwide.4

As with so many health problems, populations in the developing world suffer a disproportionate share of mental illness. An estimated 86 percent of suicides occur in low- and middle-income countries,5 and nearly three-fourths of the global burden of neuropsychiatric disorders fall on populations from these countries.6 Mental trauma is exacerbated by war and natural disaster and related issues of hunger and loss of shelter. The incidence of psychiatric disorders typically doubles after such tragedies, again with a disproportionate impact on developing countries.7 Some of the highest-profile threat cases result from PTSD (post-traumatic stress disorder), individual dysfunction resulting from armed conflict, violence, and natural disaster. Because former combatants suffering from depression and PTSD often have access to firearms, they are highly susceptible to harming others—and themselves. Women and girls are especially vulnerable to acts of sexual violence. Sufferers of PTSD pose special risks to stability, safety, and economic security.8

In 2013, the World Health Organization adopted its first-ever Global Mental Health Action Plan. The plan lists four objectives to guide international efforts to reduce the global burden of mental illness: stronger leadership and governance for mental health programs; comprehensive, integrated mental health and social services in community settings; implementation of strategies for prevention of mental illness and promotion of available services; and strengthened information systems, evidence, and research. The plan emphasizes the potential for recovery, with special attention to education and employment opportunities along with housing and social services and other social determinants of mental health such as.

Mental illness can be even more challenging to address than other diseases, and not just because of ignorance and stigma. Guidelines for diagnosis and treatment of mental disorders are well developed, but effective treatment is especially difficult where there is a need for extensive, individualized interactions with trained personnel, often in cross-cultural settings. Where will those trained personnel come from? Western Europe has about one psychiatrist per 10,000 people, while Africa has only one for every 390,000 people. The shortages are most critical where the need is greatest. In 2010, Tanzania’s population of 44 million had just thirteen practicing psychiatrists, nine of whom were concentrated in the largest city, Dar es Salaam.

The training of community health workers for mental health is complicated by the technical requirements of effective diagnosis and treatment. Medication provides a related challenge. While a wide array of effective medications is at the disposal of mental health professionals in the developed world, most of the newer drugs are not available in poorer regions. Moreover, the safe use of these medications often requires highly specialized training and laboratory facilities to monitor changes in body chemistry.

Such daunting challenges contribute to the unwillingness of governments, health systems, nongovernmental organizations, and philanthropic organizations to devote more resources toward reducing and treating mental illness. The resulting inaction has sweeping negative consequences across social, economic, and security issues. The World Economic Forum estimated in 2011 that noncommunicable diseases will reduce global GDP by 4 percent over the ensuing twenty years. That amounts to a staggering $47 trillion, about one-third of which is attributed to losses associated with mental health.9 The United States and other countries must not look away. A truly global initiative may be beyond the current reach of governments, especially in light of the lingering effects of the global recession on national budgets. But meaningful things can still be done. Action is in America’s national interest—and it is the right thing to do.

Important lessons can be learned from the fight against infectious diseases. After decades of neglect, these diseases began to receive significant new attention and resources in 2002 with the creation of the multilateral Global Fund to Fight AIDS, Tuberculosis, and Malaria. That was followed in 2003 by PEPFAR (the United States President’s Emergency Plan for AIDS Relief). The program’s investment of $17 billion over five years to HIV/AIDS treatment was much larger than any previous global health initiative. Today, the United States spends more than $6 billion annually on HIV/AIDS-related programming, more than half the total contributions from all donor governments. Recipient countries are also making major commitments. Over the past twelve years, tremendous advances have been made. AIDS is no longer an automatic “death sentence,” and the idea of an “AIDS-free generation” is no longer a total fantasy.

So much progress is being made against infectious diseases that noncommunicable diseases such as heart and lung disease, diabetes, and cancer are gaining attention and resources in the developing world. Still, mental health lags behind. As ignorance about mental disorders10 is being overcome in the developed countries, the needs of the developing world become clearer. The stakes are enormous. At risk are political stability, global development goals, and America’s national security interests. There may be little political appetite today for large-scale investments in global mental health, but many opportunities exist for targeted interventions in relatively controlled environments to prove concepts that could become more broadly applicable.

An enormous amount of knowledge could be gained by funding multiyear initiatives in a camp of Syrian refugees in Jordan or Turkey, a recently stabilized community in the Democratic Republic of Congo, a town or village in South Sudan if the recent ceasefire holds, and in other conflict or post-conflict situations. Regrettably, we live in an environment filled with many such “target-rich” possibilities. Several nongovernmental organizations operate small-scale mental health intervention and treatment programs in refugee camps that could become platforms on which to test potentially scalable programs.

Governments cannot, should not, and need not tackle all of these problems on their own. They need partners—mental health professionals, the pharmaceutical industry, civil society, multilateral organizations, philanthropies, and the corporate sector. A mental health initiative will require resources, and the competition for government funds is fierce. But the time has come for the United States to take the next step in allowing mental illness to join the ranks of the many other illnesses that have benefited from the power of bridging health and diplomacy to improve the people’s lives.

 

Endnotes

  1. “Mental health: strengthening our response,” World Health Organization. Updated April 2014, accessed May 29, 2014, http://www.who.int/mediacentre/factsheets/fs220/en/index.html.
  2. “10 Facts on Mental Health,” World Health Organization, accessed May 29, 2014, http://www.who.int/features/factfiles/mental_health/mental_health_facts/en/index5.html.
  3. Ibid.
  4. “Mental Health Basics,” Centers for Disease Control and Prevention, accessed May 29, 2014, http://www.cdc.gov/mentalhealth/basics.htm.
  5. “10 Facts on Mental Health,” World Health Organization.
  6. Scaling up care for mental, neurological, and substance use disorders, mhGap: Mental Health Gap Action Programme(Geneva, Switzerland: World Health Organization, 2008), http://www.who.int/mental_health/mhgap_final_english.pdf.
  7. “10 Facts on Mental Health,” World Health Organization.
  8. There has been much investigation into the role of PTSD on violence and mental health issues in the security arena. See, for example,
    Larry Abramson, “Can Counseling Complicate Your Security Clearance?” National Public Radio, September 11, 2012, http://www.npr.org/2012/09/11/160898774/question-21-a-matter-of-national-security.
    “Post Traumatic Stress Disorder,” RAND Corporation, accessed May 29, 2014, http://www.rand.org/topics/post-traumatic-stress-disorder.html.
    Greg Botelho, “Army's Robert Bales gets life, no parole for Afghan rampage -- but was it justice?” CNN, August 23, 2013, http://www.cnn.com/2013/08/23/justice/robert-bales-afghan-killings.
    “Robert Bales sentenced to life in prison for Afghanistan massacre,” The Guardian, August 23, 2013, http://www.theguardian.com/world/2013/aug/23/afghanistan-massacre-robert-bales-trial.
    Clark McCauley, Sophia Moskalenko, and Benjamin Van Son, “Characteristics of Lone-Wolf Violent Offenders: a Comparison of Assassins and School Attackers,” Perspectives on Terrorism 7, no. 1 (2013), http://www.terrorismanalysts.com/pt/index.php/pot/article/view/240/html.
    Pamela Engel, “Accused Boston Bomber Tamerlan Tsarnaev Reportedly Heard Voices And May Have Been Schizophrenic,” Business Insider, December 15, 2013, http://www.businessinsider.com/tamerlan-tsarnaev-heard-voices-and-might-have-been-schizophrenic-2013-12.
  9. World Economic Forum, “Non-communicable Diseases to Cost $47 trillion by 2030, New Study Released Today,” news release, September 18, 2011, http://www.weforum.org/news/non-communicable-diseases-cost-47-trillion-2030-new-study-released-today.
  10. WHO definition: “Mental disorders … are generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others. Examples are schizophrenia, depression, mental retardation and disorders due to drug abuse. Most of these disorders can be successfully treated.” “Mental Disorders,” World Health Organization, accessed May 29, 2014, http://www.who.int/topics/mental_disorders/en.