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World Mental Health: Problems and Priorities in Low-Income Countries
BOOK REVIEWS
again stress the child's need for an unbroken relationship with at least one adult responsible for his or her daily needs and that the concept of family need not be solely based on biological or legal relationships. They urge recognizing nonadoptive but permanent relationships and suggest ~oster care with tenure for some children. The decision to intervene in family life is always a delicate balancing act. One must weigh the need to protect a child against the potential damage done to the family by investigations and the harm that results from false or unfounded allegations of abuse. The authors acknowledge that children can be harmed by the sexual advances of a parent but question the ability of the state to "provide something less detrimental." They further note the difficulty of differentiating affection from fondling and conclude that sexual abuse, alone, should not be a separate ground for intervening. I can understand how they might have written this in 1979, but given the advances in understanding, diagnosing, and treating sexual abuse in the intervening 17 years, their position is quite appalling. As is well known, perpetrators seek out younger and younger children who may not be able to speak for themselves. The perpetrator's sexual activity is often compulsive and progressive in nature. Rarely do perpetrators seek help on their own. If we don't speak for these young victims, who will? A final issue addressed in this section is the child's need for independent legal counsel in certain situations in which the child's interests may not be synonymous with those of his or her parents. Book 3, In the Best Interests of the Child, was published in 1986 (Free Press, New York) with the addition of Sonja Goldstein. This book addresses the role of the professional in child placement decisions and has excellent discussions on professional boundaries. Included are the dangers of personal prejudices and beliefs affecting recommendations and the risks of judges playing child psychiatrist and vice versa. The authors stress the need to ask "Am I qualified to find this fact or to give this opinion?" and discuss the hazards of straying beyond one's level of competence. This section is a must-read for anyone involved in child custody work. In summary, this volume can be appreciated on many levels: as history, as a demonstration of how we can work with and influence the law using our knowledge of child development and attachment theory, as a primer for child advocacy, and as a reminder that we need to be humble and do not have all the answers. The titles of these three separate books were confusing, and combining them into one book has definite merit. There is surprising continuity and consistency between the three books, and each builds upon theories presented in the previous work. The reader is urged to approach the authors' theories critically but not
J.
AM. ACAD. CHILD ADOLESC:. PSYCHIATRY. 36:5. MAY 1997
allow differences of opinion ing message.
to
detract from the underly-
Diane H. Schetky, M.D. Rockport, ME
World Mental Health: Problems and Priorities in LowIncome Countries. Edited by Robert Desjarlais, Leon Eisenberg, Byron Good, and Arthur Kleinman. New York and Oxford. England: Oxford University Press, 1995, 382 pp., $39.95 (hardcover), $24.95 (softcover). The landmark 1979 A1ma-Ata Declaration, in which the world's nations set the goal of "health for all" by the year 2000, established a new definition of health as not simply the absence of disease, but "a state of complete physical, mental, and social well-being." In this paradigm, mental health was envisioned as an essential component of primary health care. Yet, according to the authors of this report, mental health has never found its appropriate place in the agendas or budgets of ministries of health in countries beyond North America and Western Europe. Mental health issues have been neglected as well by the international agencies, nongovernmental organizations, and researchers and scholars who assist with development, evaluation, and funding of health programs. In the past 20 years, while there have been advances in health care and improvements in public health indicators in many nations and regions (e.g., increased life expectancy, decreased infant mortality, eradication of diseases such as smallpox, better access to safe water), the incidence of mental health problems has increased worldwide. The need for better services has become urgent. This volume is a plea and a "provocation" to the international community to wake up to this reality and to meet it not with despair, but with reasoned action. Supported by funds from several private foundations, it is the result of a 2-year collaboration between distinguished psychiatrists and anthropologists from Harvard Medical School and a panel of more than 100 advisors and consultants (clinicians, administrators of UNaffiliated agencies, public health officers, scholars, policy experts, ministers of health, legislators, educators) representing 19 countries and evety continent. The report begins with an assessment of the "burden" posed by mental, social, and behavioral health problems worldwide. Measured in "disability-adjusted life years," an indicator recently introduced by the World Bank, these problems constitute 8.1 % of the global burden of disease (GBD). In demographically developing economies, neuropsychological illness and intentional self-inflicted injuries together represent 15% of the GBD for adults aged 15 to 44. Worldwide, depressive disorders and anxiety disorders occasion one quarter to one third of all primaty health care
713
BOOK REVIEWS
visits. While the economic coli represemed by these numbers is enormous, the human colI, in terms of misery, suffering, the loss of "what is moS[ at stake in being human," is incalculable. The primary reason memal illnesses are on the rise is the so-called "demographic transition" in the developing world: more children are living imo adulthood. the period of risk for the major psychiacric disorders. Becween 1985 and 2000, the number of persons with schizophrenia worldwide will have increased by 45%, with three quarters of these individuals living in less-developed coumries. In addition, some portion of the increased incidence seems co be a consequence of modernization and economic growth. athough the pathways are complex and indirect. Finally, the global economic slowdown of the 1980s and 1990s brought unprecedemed poverry co nearly one quarter of the world's people. Poverry. along with its actendam ills such as environmemal degradation. hunger and malnucrition. and poor living conditions. has repeatedly been shown CO increase the risk of psychological morbidiry. Neglecc of memal health needs has been a consequence of several false or outmoded perceptions: first, that the magnitude of these problems was less significam than we now appreciate it co be, because craditional public health assessmems focused on mortaliry rather than morbidiry or dysfunction; second, that psychiacric conditions are noc "real" illnesses; and third, that few or no effeccive treatmems exist or that they are prohibitively expensive in comexts of constrained resources. The authors affirm that developmems in psychiacric theory, praccice, and research have led to clearer nosologies and more sophisticated illness models (such as the understanding that all memal illness is biosocial), mulcimodal treatmems of proven efficacy, and demonstration projects which have functioned cost-effectively in low-income regions. In the volume's cemral chapters. the authors examine a series of issues that challenge memal well-being (suicide, substance abuse, violence, dislocation. and healch behaviors) and the memal health status and needs of three groups at highest risk: children and youth. women. and the elderly. Each chapter comains a review of the epidemiology of the phenomenon or the issues affecting the given population. a discussion of social, political, and cultural aspects, and descriptions of imervemions that have been cried successfully and unsuccessfully. Data are drawn from diverse sources ranging from randomized concrolled studies in sciemific journals to unpublished governmem and agency reports co newspaper articles from third world capitals co theoretical and conceptual papers. and a wide range of epistemological perspectives (ethnography. epidemiology. economic analysis. etc.) are represented. The deliberately broad focus of the report-the emire global landscape-results in a degree of generalization and
vagueness that is balanced by the inclusion of many oneco cwo-page "case studies," set off in boxes, which enliven and humanize the volume. The chapter on children and youth. for example, comains extremely vivid and poignam case studies describing a program of humane group care for orphans in Eritrea, the life and death of a street child in Guatemala. the scope and impact of child prostitution and child labor worldwide, and the psychosocial causes and consequences of epilepsy and memal retardation, disorders that are three co five times more frequem in low-income coumries. In the final chapters, the authors draw on their previous findings co propose an "agenda for action" and a blueprim for "essemial" research. They recommend addressing all memal health problems in three major ways: by upgrading the quality and sustainability of community-based mental healch services imegrated into primary care, by expanding public health interventions (capitalizing on the knowledge that up to half of all mental and neuropsychiatric disorders are amenable co primary prevention), and by formulating social policies that lead co improved mental health status ("healthy policies") such as policies that encourage employmem, reduce poverty, and empower women. They outline the steps needed co strengthen the capacity for rigorous, ethical research in low-income countries, and they cite domains that merit priority funding, including the development of culturally informed databases and research on mental health services, on violence, on women's mental health, and on the evaluation of preventive approaches. The debate that this volume hopes co provoke is likely co focus less on specific recommendations than on the ability and appropriateness of Western academicians, even with an international advisory board behind them. co speak for the needs and priorities of diverse societies. Nevertheless, even this type of discussion will meet the authors' primary goal, which is to end the silence in which institutional inactention to mental health issues has come to seem ucterly mundane. Although its primary audience should be international healch planners, ministers of health, and policymakers. the volume will make stimulating reading for a wide audience including psychiatrists, ocher mental health clinicians, researchers, and trainees who wish to learn more about the place of their field and the experience of patients like theirs worldwide. The book is compact. densely written, and carefully researched, with an extensive bibliography and well-executed index. The information is consistent and the tone and style uniform. despite the large number of contributors.
714
J.
Audrey Rubin, M.D. Acting Assistant Professor of Psychiatry and Behavioral Sciences University of Washington. Seattle
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:5, MAY 1997
again stress the child's need for an unbroken relationship with at least one adult responsible for his or her daily needs and that the concept of family need not be solely based on biological or legal relationships. They urge recognizing nonadoptive but permanent relationships and suggest ~oster care with tenure for some children. The decision to intervene in family life is always a delicate balancing act. One must weigh the need to protect a child against the potential damage done to the family by investigations and the harm that results from false or unfounded allegations of abuse. The authors acknowledge that children can be harmed by the sexual advances of a parent but question the ability of the state to "provide something less detrimental." They further note the difficulty of differentiating affection from fondling and conclude that sexual abuse, alone, should not be a separate ground for intervening. I can understand how they might have written this in 1979, but given the advances in understanding, diagnosing, and treating sexual abuse in the intervening 17 years, their position is quite appalling. As is well known, perpetrators seek out younger and younger children who may not be able to speak for themselves. The perpetrator's sexual activity is often compulsive and progressive in nature. Rarely do perpetrators seek help on their own. If we don't speak for these young victims, who will? A final issue addressed in this section is the child's need for independent legal counsel in certain situations in which the child's interests may not be synonymous with those of his or her parents. Book 3, In the Best Interests of the Child, was published in 1986 (Free Press, New York) with the addition of Sonja Goldstein. This book addresses the role of the professional in child placement decisions and has excellent discussions on professional boundaries. Included are the dangers of personal prejudices and beliefs affecting recommendations and the risks of judges playing child psychiatrist and vice versa. The authors stress the need to ask "Am I qualified to find this fact or to give this opinion?" and discuss the hazards of straying beyond one's level of competence. This section is a must-read for anyone involved in child custody work. In summary, this volume can be appreciated on many levels: as history, as a demonstration of how we can work with and influence the law using our knowledge of child development and attachment theory, as a primer for child advocacy, and as a reminder that we need to be humble and do not have all the answers. The titles of these three separate books were confusing, and combining them into one book has definite merit. There is surprising continuity and consistency between the three books, and each builds upon theories presented in the previous work. The reader is urged to approach the authors' theories critically but not
J.
AM. ACAD. CHILD ADOLESC:. PSYCHIATRY. 36:5. MAY 1997
allow differences of opinion ing message.
to
detract from the underly-
Diane H. Schetky, M.D. Rockport, ME
World Mental Health: Problems and Priorities in LowIncome Countries. Edited by Robert Desjarlais, Leon Eisenberg, Byron Good, and Arthur Kleinman. New York and Oxford. England: Oxford University Press, 1995, 382 pp., $39.95 (hardcover), $24.95 (softcover). The landmark 1979 A1ma-Ata Declaration, in which the world's nations set the goal of "health for all" by the year 2000, established a new definition of health as not simply the absence of disease, but "a state of complete physical, mental, and social well-being." In this paradigm, mental health was envisioned as an essential component of primary health care. Yet, according to the authors of this report, mental health has never found its appropriate place in the agendas or budgets of ministries of health in countries beyond North America and Western Europe. Mental health issues have been neglected as well by the international agencies, nongovernmental organizations, and researchers and scholars who assist with development, evaluation, and funding of health programs. In the past 20 years, while there have been advances in health care and improvements in public health indicators in many nations and regions (e.g., increased life expectancy, decreased infant mortality, eradication of diseases such as smallpox, better access to safe water), the incidence of mental health problems has increased worldwide. The need for better services has become urgent. This volume is a plea and a "provocation" to the international community to wake up to this reality and to meet it not with despair, but with reasoned action. Supported by funds from several private foundations, it is the result of a 2-year collaboration between distinguished psychiatrists and anthropologists from Harvard Medical School and a panel of more than 100 advisors and consultants (clinicians, administrators of UNaffiliated agencies, public health officers, scholars, policy experts, ministers of health, legislators, educators) representing 19 countries and evety continent. The report begins with an assessment of the "burden" posed by mental, social, and behavioral health problems worldwide. Measured in "disability-adjusted life years," an indicator recently introduced by the World Bank, these problems constitute 8.1 % of the global burden of disease (GBD). In demographically developing economies, neuropsychological illness and intentional self-inflicted injuries together represent 15% of the GBD for adults aged 15 to 44. Worldwide, depressive disorders and anxiety disorders occasion one quarter to one third of all primaty health care
713
BOOK REVIEWS
visits. While the economic coli represemed by these numbers is enormous, the human colI, in terms of misery, suffering, the loss of "what is moS[ at stake in being human," is incalculable. The primary reason memal illnesses are on the rise is the so-called "demographic transition" in the developing world: more children are living imo adulthood. the period of risk for the major psychiacric disorders. Becween 1985 and 2000, the number of persons with schizophrenia worldwide will have increased by 45%, with three quarters of these individuals living in less-developed coumries. In addition, some portion of the increased incidence seems co be a consequence of modernization and economic growth. athough the pathways are complex and indirect. Finally, the global economic slowdown of the 1980s and 1990s brought unprecedemed poverry co nearly one quarter of the world's people. Poverry. along with its actendam ills such as environmemal degradation. hunger and malnucrition. and poor living conditions. has repeatedly been shown CO increase the risk of psychological morbidiry. Neglecc of memal health needs has been a consequence of several false or outmoded perceptions: first, that the magnitude of these problems was less significam than we now appreciate it co be, because craditional public health assessmems focused on mortaliry rather than morbidiry or dysfunction; second, that psychiacric conditions are noc "real" illnesses; and third, that few or no effeccive treatmems exist or that they are prohibitively expensive in comexts of constrained resources. The authors affirm that developmems in psychiacric theory, praccice, and research have led to clearer nosologies and more sophisticated illness models (such as the understanding that all memal illness is biosocial), mulcimodal treatmems of proven efficacy, and demonstration projects which have functioned cost-effectively in low-income regions. In the volume's cemral chapters. the authors examine a series of issues that challenge memal well-being (suicide, substance abuse, violence, dislocation. and healch behaviors) and the memal health status and needs of three groups at highest risk: children and youth. women. and the elderly. Each chapter comains a review of the epidemiology of the phenomenon or the issues affecting the given population. a discussion of social, political, and cultural aspects, and descriptions of imervemions that have been cried successfully and unsuccessfully. Data are drawn from diverse sources ranging from randomized concrolled studies in sciemific journals to unpublished governmem and agency reports co newspaper articles from third world capitals co theoretical and conceptual papers. and a wide range of epistemological perspectives (ethnography. epidemiology. economic analysis. etc.) are represented. The deliberately broad focus of the report-the emire global landscape-results in a degree of generalization and
vagueness that is balanced by the inclusion of many oneco cwo-page "case studies," set off in boxes, which enliven and humanize the volume. The chapter on children and youth. for example, comains extremely vivid and poignam case studies describing a program of humane group care for orphans in Eritrea, the life and death of a street child in Guatemala. the scope and impact of child prostitution and child labor worldwide, and the psychosocial causes and consequences of epilepsy and memal retardation, disorders that are three co five times more frequem in low-income coumries. In the final chapters, the authors draw on their previous findings co propose an "agenda for action" and a blueprim for "essemial" research. They recommend addressing all memal health problems in three major ways: by upgrading the quality and sustainability of community-based mental healch services imegrated into primary care, by expanding public health interventions (capitalizing on the knowledge that up to half of all mental and neuropsychiatric disorders are amenable co primary prevention), and by formulating social policies that lead co improved mental health status ("healthy policies") such as policies that encourage employmem, reduce poverty, and empower women. They outline the steps needed co strengthen the capacity for rigorous, ethical research in low-income countries, and they cite domains that merit priority funding, including the development of culturally informed databases and research on mental health services, on violence, on women's mental health, and on the evaluation of preventive approaches. The debate that this volume hopes co provoke is likely co focus less on specific recommendations than on the ability and appropriateness of Western academicians, even with an international advisory board behind them. co speak for the needs and priorities of diverse societies. Nevertheless, even this type of discussion will meet the authors' primary goal, which is to end the silence in which institutional inactention to mental health issues has come to seem ucterly mundane. Although its primary audience should be international healch planners, ministers of health, and policymakers. the volume will make stimulating reading for a wide audience including psychiatrists, ocher mental health clinicians, researchers, and trainees who wish to learn more about the place of their field and the experience of patients like theirs worldwide. The book is compact. densely written, and carefully researched, with an extensive bibliography and well-executed index. The information is consistent and the tone and style uniform. despite the large number of contributors.
714
J.
Audrey Rubin, M.D. Acting Assistant Professor of Psychiatry and Behavioral Sciences University of Washington. Seattle
AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:5, MAY 1997