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Global mental health: Global strengths and strategies
Asian Journal of Psychiatry 4 (2011) 165–171
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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Global mental health: Global strengths and strategies Task-shifting in a shifting health economy Melvin G. McInnis a,*, Sofia D. Merajver b a b
University of Michigan Depression Center and Department of Psychiatry, Ann Arbor, MI 48109, USA University of Michigan Department of Internal Medicine and Center for Global Health, Ann Arbor, MI 48109, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 November 2010 Received in revised form 13 June 2011 Accepted 19 June 2011
Global mental health challenges sit at the frontiers of health care worldwide. The frequency of mental health disorders is increasing, and represents a large portion of the global burden of human disease (DALYs). There are many impeding forces in delivering mental health care globally. The knowledge of what mental health and its diseased states are limits the ability to seek appropriate care. Limited training and experience among primary providers dilutes the capacity of systems for adequate care, support, and intervention. There are limited numbers of medical personnel worldwide to attend to individuals afflicted by mental health disorders. The challenges of global mental health are the capacity of the global systems to enhance knowledge and literacy surrounding mental health disorders, enhance and expand ways of identifying and treating mental health disorders effectively at an early stage in its course. Much has been written about the epidemiology of mental health disorders globally followed by discussions of the need for improvements in programs that will improve the lot of the mentally ill. Task shifting involves the engaging of human resources, generally nonprofessional, in the care of mental health disorders. Engaging traditional healers and community health workers in the identification and management of mental health disorders is a very strong potential opportunity for task shifting care in mental health. In doing so it will be necessary to study the concept of mental health literacy of traditional healers and health workers in a process of mutual alignment of purpose founded on evidence based research. ß 2011 Elsevier B.V. All rights reserved.
Keywords: Task shifting Global mental health Traditional healers Mental health literacy
1. Introduction It is now somewhat cliche´ to reiterate that ‘‘there is no health without mental health’’ as it begs the question of a definition of both health and mental health (Prince et al., 2007). An etymological tautology emerges as one attempts to boil down a concept of health that takes the argument through the concept of disease and its impact on the capacity of the individual from a personal and societal perspective. The biophysical aspects of many medical diseases have been characterized. The history of biomedical research proudly and rightly exemplifies the research trajectories of infectious diseases leading to the etiological understanding of AIDS, cardiovascular, or pulmonary diseases. Most medical disciplines outside of the psychiatric clinical sciences boast an etiological trajectory of understanding beginning with clinical observations and leading to a set of pathological findings coalesced into criteria for a specific disease. Illness in the psychiatric sense,
* Corresponding author. Tel.: +1 734 936 6018. E-mail addresses: [email protected] (M.G. McInnis), [email protected] (S.D. Merajver). 1876-2018/$ – see front matter ß 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2011.06.002
however, remains a series of disjunctive categories that serve as clinical guidelines and a hope for deeper future understanding of the underlying pathology. For much of the world ‘‘mental health’’ remains elusive.
Global Challenges Managing Mental Health: Limited Literacy and Understanding of Disorders; Few Care Providers; Sparse Global and National Priorities.
In this overview we examine mental health from a global perspective, and advance a pragmatic integrated approach with discussion of the burden of mental health disorders, mental health literacy, and the role of extant systems in global communities that includes the community traditional healers and education systems. Knowledge of health is the basis of health prevention and management. Engagement of individuals at many levels across the community for health care provides the opportunities for task shifting: transferring responsibility for tasks from higher to lesser specialized providers. This requires an
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understanding of the knowledge of the lesser specialized providers (mental health literacy) and implementation of programs to provide resources to them. In the global community there is a resource of traditional healers that the society seeks out for care and advice on health matters. Knowledge of the mental health literacy and resources for traditional healers willing to interact meaningfully with regional health care workers and authorities may become a base for task shifting some health care duties in the community. The education system is the societal and cultural base for the community to collectively enhance knowledge of health; knowledge of mental health needs to be an integral component of the educational system. In the global community, knowledge of local resources and challenges are critical. It is, of course, important that communities systematically build and expand medical and psycho-social resources, with doctors, nurses, and affiliated care providers. However, there are resources that may be under estimated in terms of their potential for mental health and include a local engaged traditional healer, open to working interactively with the community health authorities, to whom many mental health care tasks may be formally shifted. 1.1. Mental health literacy Mental health literacy is the general knowledge and beliefs about mental health disorders from an intellectual and functional perspective that aid in their recognition, management, and prevention; the concept of literacy is universally applicable across society (Jorm et al., 1997). The current intellectual understanding of mental health and mental health disorders is largely reflected in the current diagnostic categories of DSM IV (APA, 2000) and ICD-10 (WHO, 1992). It is readily acknowledged that the current categories are likely to be restructured with the anticipated emergence of a biological understanding of key etiological pathways leading to psychiatric disorders (Regier et al., 2009). The impact of the environment on the evolution of psychiatric disorders is widely appreciated. Western societies judge intellectual literacy of mental health disorders by how well the society, including care providers and consumers, know and recite the categories outlined in the DSM/ ICD criteria. The understanding of psychiatric disorders in the developing world is based on the heroic efforts lead by WHO and others that examine the prevalence of DSM/ICD-identified psychiatric syndromes in the global community (WHO, 2008a). Our estimates of the burden of mental disorders are based on the constellation of symptoms clustered to identify disorders according to a purely Western classification by local assessors that are literate on DSM/ICD coding, applied to societies in the global south. A specialty of cross-cultural psychiatry has emerged with every attempt to translate between the culture of study and the DSM systems. A number of critical observations have derived under the assumptions, believed to be valid, that psychiatric disorders are phenomenologically grossly similar wherein the form of the psychopathology is similar, while the cultural content may vary. However, health literacy is more than ‘‘intellectual literacy’’ which may be metrically defined and assessed, it is an integrated knowledge of health that provides the tools and resources for the individual to seek and receive needed services. In general it is the functional aspects of literacy that are elusive; impedance is found throughout, and ranges from intrinsic believes within the individual through the societal context of health care and services (IM, 2004). The burden of mental health disorders in the global community has been discussed at length in the literature and it is clear that global mental health and knowledge of the same (mental health
literacy) is singularly one of biggest health challenges facing mankind (Ngui et al., 2010). If one incorporates behavioral aspects of disorders in medical disciplines, maladaptive motivated behaviors of the addictions, dietary and recreational inequities created by a combination of cultural opportunities and resources, as well as personal choices influenced by the collective community economy – it should be apparent that the dimension of mental health reaches deep into a culture and its communities (Bauer et al., 2010). The burden of poor mental health and its specific disorders when these are known, affect most, if not all aspects of global health. But returning to the focus of the measured burden of mental health in the global community using standard Western measures, it is very clear that a very large proportion of health problems are mental health problems. Mental health disorders generally have an early age of onset, critically affecting the capacity of the developing young adult towards a productive career and/or achieving her/his potential in society. The result is that mental health disorders are projected to the single larges cause of DALYs (Disability adjusted Life years) by 2030 (WHO, 2008a), with unipolar depression topping the list. One of the most affected group in both higher and lower income communities alike is women of child bearing age, the frequency of major depression in this age group is highly similar in highly resourced and low-resourced regions and neuropsychiatric disorders combined account for 22% of DALYs (WHO, 2008b). Large-scale campaigns to combat or eradicate disease such as malaria or polio have had a clearly focused methodology and measurable outcomes. However, in the field of global mental health, the methodologies are by no means clear or agreed upon. The basic phenomenology of mental disease globally may be variable in ways that are yet to be delineated in detail. The approach in the global community towards caring for those afflicted with mental health disorders ranges from being woefully under-developed to non-existent, with a few exceptions typically associated with tertiary care specialized centers in or around large urban areas. The burden of mental health remains profound. Enhancing mental health literacy is an integral step towards diminishing the burden. Mental health literacy in the broadest sense should not be interpreted or used to suggest that the current categorical system of DSM or ICD represents the standard of literacy. The two systems are important standards, with a high degree of reliability, but with unknown validity. There are essentially no biologically established etiologies for mental health disorders. Therefore, the dimensions and measures of literacy include a sociological understanding of what the individuals of a given culture believe to be mental health and disorders thereof. This dimension of research has been the purview of anthropology, with modest interaction and contribution from medical, public health, and the social sciences. Literacy is not the purview of any one stratus or worker in society. At all age levels, parents, the nuclear and extended family, teachers, health care workers and aides, community leaders, persons associated or affiliated with organized religion, colleagues in the workforce, and others may be harnessed as mental health literacy ambassadors through a process known as task-shifting.
Targeted Task Shifting in Global Mental Health: Primary Health Care Givers; Community Health Care Worker; Traditional Healers; Educators and Schools; Extended Families; Individuals.
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1.2. Global mental health research The research to date has focused to a large degree on the crosssectional epidemiological study of the prevalence of disorders among the nations of the world (Kessler and Ustun, 2008). There are, of course, certain differences of prevalence among the countries of study, but it is the similarities that are more striking. The most common diagnoses are mood and anxiety disorders (the interquartile range of lifetime prevalence for both disorders worldwide being 10–16%); the estimated frequency in less developed countries being generally lower. The time delay in seeking treatment is greater in the lower resourced nations. The strict prevalence of any diagnosable DSM disorder (excluding all NOS diagnoses) in the study of Phillips et al. (2009) in China was in the range of 13% that was similar to a US based analysis (Regier et al., 1988). The need for further surveys has been challenged (Weich and Araya, 2004) with the acknowledgment that the survey research to date has confirmed that psychiatric disorders exist worldwide and that it would be of great relevance to the global community to develop functional programs that will be of tangible assistance to the communities: the imperative is to focus research on the development and assessment of programs and outcomes given the global burden of psychiatric disease (Table 1). The progress of the recent epidemiological research notwithstanding, it is timely for a significant shift in the focus of global mental health research. There has been only a minimal amount of outcomes research in translational mental health medicine in the global community. Even in the Western world true translational research in mental health has been sparse. While there was substantial promise and hope (perhaps with some hype as well) for a reductionist understanding of the etiology of the major mental health disorders, it is now apparent that while significant inroads have been made with the identification of genetic variants predisposing to psychiatric disorder, each of these variants contributes only a minute amount of the risk to the disorder (Schulze, 2010). The reductionist short cut to etiology will not materialize within the current methodological approaches. Innovative strategies are needed that leverage previous work and infrastructure while integrating clinical and research methods that simultaneously improve the quality of life for those burdened by disease while advancing an academic understanding of the disorders. An integrated clinical translational research paradigm that utilizes a longitudinal method of study of patients within a society and culture, using innovative clinical approaches enhanced by new technology-based assessments and interventions is one
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proposed strategy. This approach allows for the monitoring over time of individuals with a specific disorder, initially ascertained through the more or less standard criteria of DSMIV or ICD-10. The monitoring of episodes and symptom fluctuations, the course of disease, the optimal methods of managing the disorder in the communities (engaging community providers and task shifting the responsibility for care to the community and individual) are essential data needed by policymakers to impact public mental health and policies. Finally, such an approach affords the opportunity to monitor the level of understanding of the disorder – the level of literacy in the individual, their family members and the community at large. 1.3. Integrated global translational clinical research The premise of translational research is the relative immediacy of relevance to the target population that is involved and participant in the research endeavor. This involves an integrated approach that combines effort at the clinical and service delivery front lines with statistical, social, anthropological, and biological analysis of change and sustain favorable outcomes. Global health translational research implies major adaptations from the usual single discipline frameworks to an integrated trans-disciplinary approach. It is personal in the sense that it assesses and strives to improve the outcome of each patient and one clinic at a time, and global in the sense of eliciting programmatic or policy changes that are measurable socially, intellectually, economically, and culturally. The efforts of the WHO and others that measure frequency of mental health world wide have provided strong impetus and basis of data on which to develop additional resources for global mental health translational research (Kessler and Ustun, 2008). There is an enormous burden of mental health in the global community that, if not attended to, may seriously compromise the capacity of whole communities for economic development and cause undue personal suffering among the populations most depleted of resources. This, in turn, creates an environment auspicious for human rights violations, which further deepen the health inequities, and so on in a downward spiral. To break out of this self-feeding negative trajectory, we propose a starting point for global health translational research: the concept and realization of global mental health literacy. The study, assessment, and development of programs for improvements in mental health literacy across all human communities should become the unifying focus for global mental health. It is the authors’ perspective that the concept of stigma be removed from this discussion. ‘‘Fighting Stigma’’ campaigns often
Table 1 Burden of Disease by cause and region, 2004. PAHO
AFRO
EURO
SERO
EMRO
WPRO
Total
Neuropsychiatric conditions
129,585 (22%)
117,067 (20%)
165,444 (28%)
34,643 (6%)
58,559 (10%)
75,354 (13%)
580,653
Unipolar depressive disorders Bipolar disorder Schizophrenia Epilepsy Alcohol use disorders Alzheimer and other dementias Parkinson disease Multiple sclerosis Drug use disorders Post-traumatic stress disorder Obsessive-compulsive disorder Panic disorder Insomnia (primary) Migraine
39,238 7339 8771 5996 19,373 6838 796 805 6736 1607 4124 3551 2674 5399
33,683 10,610 11,101 10,728 5079 5601 985 783 3785 2433 5230 4784 2700 2322
51,677 10,069 10,978 3853 25,895 10,987 1991 1714 7129 2845 4942 5241 3393 8988
12,971 2339 3083 1319 2855 1811 1465 223 945 622 656 1175 658 1227
19,535 4596 5590 2183 1205 2542 590 469 4755 1134 2339 2192 817 1537
24,351 5623 7273 2985 8306 5050 769 571 2418 1507 1423 2858 1267 2693
181,455 40,576 46,796 27,064 62,713 32,829 6597 4566 25,767 10,149 18,714 19,801 11,510 22,166
Data adapted from the Burden of Global Disease data posted at: http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html. WHO Health Regions: PAH0 (Pan American Health Org.), AFRO (African Regional Org), EURO (European Regional Org.), SERO (South East Asia Regional Org.), EMRO (Eastern Mediterranean Regional Org.), WPRO (Western Pacific Regional Org.).
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do not work in the anticipated manner, a recent study showed no significant effect on the overall mental health knowledge schedule (MAKS) (Evans-Lacko et al., 2010). Focusing on literacy re-focuses the discussion on improving knowledge and learning, which in itself is culturally and geographically specific. Strategies for systematic programs of assessing and enhancing mental health literacy should target students throughout the formal education system, medical care workers, the traditional healers of a society, families, and of course the overall population. We postulate that an integrated global translational research program in mental health with a unifying theme of mental health literacy has the capacity to change a society dramatically over a generation. For example, assessment of views of students regarding mental health followed by specific educational programs with subsequent assessment of the effectiveness of the intervention will, over time, effect a change in the perspective of the society as more students emerge into leadership roles in the communities. Such programs need to be integrated into the educational system at all levels, beginning in the early years and continuing through university based education systems. Access to information is critical; assimilation and integration of this information into the individual cultures is hypothesized to have the potential to catalyze large improvements in diagnosis and expedient treatments, and integration of individuals suffering from mental illness into the societies with enhanced literacy about mental illness, to lead better lives. 1.4. Traditional healers and mental health In the global health community there are profound examples of apparent internal contradictions that are component to the culture and tradition of societies that have centuries of complexities in beliefs and structure. Nowhere do these contradictions manifest as strongly as in the mental health field. The emergence of mental illness within a family with traditional cultural beliefs characteristically brings shame and often serves to isolate the individual and family. Mental illness may be considered to be brought about by evil spirits or other forces, internal or external, in a combination of the personal and supernatural (the sufferer may be considered a witch or a warlock for example). Many global communities subscribe heavily to the practices of native or transplanted traditional healers who purport to harness the supernatural or other non-conventional scientific forces in a healing manner. Further, there are often few other resources, beyond the traditional healers, for those affected to seek out for help in times of need. There is tremendous variation in the traditional healers’ abilities, believes, and motivations. Many are driven by ritualistic demonic beliefs, their own financial gain, and use inhumane methods. Thankfully, there are traditional healers who are extraordinarly, kind, and integrate cultural traditions and support to the individual and family with outcomes that surpass all expectations. The study of traditional healers is complex and the focus of a recent book (Incayawar et al., 2009). Thus, while there may be an appearance of contradiction, the unifying confliction is the cultural belief system, that appears to the Western observer to focus on the supernatural. A large percentage of the world population receives its care from traditional healers, it is virtually impossible to determine both the number of traditional healers worldwide as well as how many patient visits occur. An understanding of the conflicts and contradictions, themselves fraught with ambiguity, may be best addressed by the comparative study of health and mental health literacy in global societies and by striving towards meaningful alignment of the current scientific approach to mental health and the traditional belief systems of the culture. Extensive seminars on the DSM and ICD classification systems may be helpful for the conduct of a particular study, but are unlikely to result in profound changes of mental health literacy in any society or to influence policy.
At the practical level the traditional healer is frequently an overlooked opportunity for health care collaboration from an economic and political perspective in many communities (Incayawar et al., 2009). These individuals are often ignored (and frequently scorned) in the context of provision of medical care, for a variety of interesting reasons that include a pervasive sense of lack of importance of what they do and that their all their efforts are fringe interventions of curious cultural traditions. In sensitive situations the traditional healers are an embarrassment to national health care leaders and policy makers, such as when news erupts that reveals untoward practices with compromised ethical standards to achieve the goals of, say, expelling the evil spirits that are causing disease (most frequently mental disease). Such examples are exploited politically to discredit traditional healers in the society. However, in many societies a very large percentage of the population has extremely limited options for care of mental health problems so that those in need continue to engage the healers. In emerging blended urban and rural communities, healers are sought out and can be even revered by the migrant population. Many patients will adapt into an openminded approach and visit with the local conventional medical clinics as well as the healers, or religious authorities and will themselves integrate the advice from these diverse sources in a personal way that may be in fact contradictory (and on occasion dangerous). In a recent review of clinical visits to a local health catchment area in Quito, the number of visits to the traditional healers was steadily increasing over several a span of several years, while visits to conventional medical doctors plateaued (Fig. 1). It is clear that traditional healers will continue to be a health care resource for many communities and that given the shortage of conventional medical care providers, many societies will be unwittingly dependent on these providers for the bulk of the delivery of health care. The challenge then becomes how to constructively integrate the healers into the mainstream of health care and how to define and maximize the likelihood of good quality of care either by traditional, conventional, or task-shifted providers. 1.5. Task shifting and the traditional healer Task shifting involves the rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health. Task shifting to lower educational leveled professionals emerged from the developing global community with broad applicability, albeit with considerable controversy, in the HIV arena (Zachariah et al., 2009; Brentlinger et al., 2010) with research emerging in diabetes and hypertension (Labhardt et al., 2010) as well in the obstetrical specialties (Mullany et al., 2010). Discussions have emerged with recommendations for task shifting in the psychiatric field (Patel, 2009). However, tasking to lesser-qualified individuals has, in fact, been the default practice of medical care in a substantial part of the global community’s approach to health care. Traditional healers and other cultural leaders have provided care to their communities, the healers essentially defined by a ground up approach rather than a top down ‘‘task shifting’’ approach. Global communities ‘‘make do’’ with the resources that are available to them for all aspects of their lives, including medical health care, a complex system of health care utilizing the self and community identified healers has evolved in evolving societies and integrating structure to the systems will include utilizing all levels of available health care workers from professionals to the healers.
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Fig. 1. The consistent increase in the number of visits to the Traditional Healer clinic compared to the Medical clinic over a 4-year period in a semi-rural health catchment area (urban outskirts) from Area Guamani, Quito, Ecuador. Figure is adapted from health services statistics with permission.
The WHO functional definition of task shifting supports a broad categorization of practices into four types, as follows: Task shifting I: The extension of the scope of practice of nonphysician clinicians in order to enable them to assume some tasks previously undertaken by more senior cadres (e.g. medical doctors). Task shifting II: The extension of the scope of practice of nurses and midwives in order to enable them to assume some tasks previously undertaken by senior cadres (e.g. non-physician clinicians and medical doctors). Task shifting III: The extension of the scope of practice of community health workers, including people living with the diseases of interest, in order to enable them to assume some tasks previously undertaken by senior cadres (e.g. nurses and midwives, non-physician clinicians and medical doctors). Task shifting IV: People living with the disorders of interest, trained in self-management, assume some tasks related to their own care that would previously have been undertaken by health workers. Task shifting can also be extended to other cadres that do not traditionally have a clinical function, for example pharmacists, pharmacy technicians or technologists, laboratory technicians, administrators and records managers. The cadre that assumes the new task, not the cadre that is relieved of the task, is the defining factor for task shifting types. For example, any extension of the scope of practice of nurses and midwives is defined as task shifting type II. Task shifting to the traditional healer could be considered type III. The role of the traditional healer in health care is debated (but frequently ignored) in many countries and societies. South Africa was the first to pass specific legislation that supports and governs the practices of the traditional healer, an unusual and hopefully pioneering move towards understanding the role of the traditional healer and harnessing their impact towards positive outcomes (DH SA, 2004). In S Africa there are approximately 200,000 traditional healers who provide care for 70% of the population. The legislation mandated the establishment of an internal governing board that regulated who is a traditional healer, provides regular educational events, serves as a bargaining agency for reimbursement, and mediates referrals. This accomplishment is laudable, as concerns have been raised broadly on the feasibility of governing the traditional healers. The currency of the healer is from his/her community and there have been skepticism and concerns that a governing licensing
agency would not be recognized by the community and that the agency would be merely lending credibility to charlatans. The accomplishments in South Africa, through the process of arriving at this legislation, are a clear attempt to address these concerns. It is appreciated that there are many challenges at the level of implementation and that there remain difficulties in the integration of care between conventional medicine and traditional healers (Sorsdahl et al., 2009a). There are also many pitfalls in a program that integrates traditional healers into a health care system. Some healers are motivated by unfounded and blatantly backward belief systems, such as that mental health disorders are the result of demonic possession and need to be aggressively beaten or starved out of the individual. However, many of the perceived problems derive from interpretations, lack of insight and respect for the role that traditional healers play in the communities and the reluctance of both groups to cross-refer patients, resulting in critical delays in the initiation of effective medical care or the opportunity for ongoing support in the community. The traditional healer, like any member of society, has a concept of mental health based on their societal norms and the observed behaviors of individuals with whom they interact. It is important to assimilate, elaborate, and work with the unequivocal fact that traditional healers regularly treat individuals (patients) in their clinics, lean-tos, huts, and other sites. Given the profound lack of conventional clinical resources for mental health in the global community at large, it is clear that an integrated approach to mental health care that involves task shifting to the traditional healer and the existing medical care providers at the primary and specialty levels in a mutually respectful and collaborative manner will be the program most likely to succeed in the short and intermediate future (Sorsdahl et al., 2009b). The critical element is the willingness of both the traditional healers and medical providers to engage and learn from each other. 2. Traditions: healers, education, and literacy We propose that the integrative health care needs to be based on the concept of literacy adapted to the cultural constituencies of caregivers. In other words, just as many professions have ‘‘continuing education credits’’, we propose the similar concept of ‘‘continuing literacy credits’’ to mean activities to enhance the mutual literacy of practitioners across cultural frame works. The life stories of conventional doctors and nurses and other health workers in many global communities are profoundly intertwined with the discourse of the traditional healer, as it is very probable
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that in their own lives, they have been treated as children or adolescents by traditional healers or are aware of their practices by living in the society where the traditional healers practice. Traditional healers are a resource with roles governed by complex cultural beliefs. Understanding cultural knowledge bases (literacy) will provide the base for advancing the same. Programs that enhance and unify mental health literacy have a capacity to create a coherent mental health program in any global community, from birth through the lifespan and across occupations and social roles. The effectiveness of any mental health program relies on the knowledge, the intellectual literacy and flexibility of thought of the policy makers and care providers. The ability of the program to integrate seamlessly into and enrich a society depends on the successes of transmitting the literacy to the populate who would ideally be sufficiently literate in mental health matters to recognize their personal needs and seek suitable care. The outcomes and services oriented research measure the functional literacies of the population, how well they are able to integrate the knowledge of the programs into their daily living patterns, and mental health hygiene (rates of substance abuse, suicide attempts, social measures of family stability, attachments, life work commitment, etc.). Programs for global mental health literacy would ideally begin in the formal K-12 education system and extend through higher education, vocational training, and the lifespan. Where to start is an important question. One would like to start such a comprehensive program at a level where the conditions are most auspicious to rapidly maximize the number of mental health ‘‘literate’’ individuals that disperse into the community in leadership roles in all walks of life. For this reason, we propose that a particular focus would be placed initially on the college student who is already embedded in a milieu supportive of literacy based projects and efforts. The literate college graduate in the global community would take and hopefully implement intellectual and functional mental health literacy throughout their careers and in their own families and communities as mental health literacy ambassadors, perhaps a nominal or actual title accorded to those who attain certain competencies, if appropriate. Attitudes towards mental health would dramatically change over merely a generation. The next level of focus would be on health care policy makers and all providers, from physicians through community health care works and including the traditional healers. Strategies to emulate the positive features of the S African experience should be explored in other regions and countries. 2.1. Conclusions Providing health care in the global community is the greatest frontier in modern medicine and the challenge is most profound in the field of mental health. Delivering evidence based medical care to the world community is a global priority and a fundamental human equity. The fiscal and human resources for providing health care and specifically mental health care are limited as the priorities of medical care are many. The world is in need of an adaptive and integrative approach to health and health care that begins with literacy. Literacy about the norms and standards of specific cultures in terms of how illness is perceived and understood; and literacy surrounding evidence based knowledge of disease and care. Literacy begins at birth and continues through the lifespan, but with focused efforts in the education system and herein lies the opportunity to systematically enhance intellectual and functional knowledge of mental health across society. The ‘‘on-the-ground’’ provision of health care challenges many societies and acutely so in the global community wherein there are just not enough doctors, nurses, and other health care providers to go around and there likely will not be in the next 50–100 years. Can we as a human society rise to this challenge with a unifying
positive voice and philosophy? We believe we can. There is a large cadre of traditional healers who are in fact the primary care mental health and other health providers for the majority in the global communities. It would be most unwise to ignore this fact. The advice of traditional healers is sought by all strata of the global community. The identification of strategies to integrate conventional medical caregivers and traditional healers would benefit all, but most importantly the patient. Mental health care stands to benefit disproportionately more given the supportive nature of the interaction between provider and patient, but this is true for most other chronic diseases and for palliative care. There is a strong need to provide some common elements of regulations and standards among the traditional healers to ensure background of consistency of care and base knowledge of illnesses. Such task-shifting to the community where the care is already taking place can be achieved through concerted efforts involving the political and medical leadership and a mutual understanding and respect for culture and science. The task-shifting of mental health care and support services towards the traditional healers and other community health care workers and the lay community itself will offer the opportunity to research and compare the emerging levels of intellectual and functional literacy in the community, in the traditional healers and in the community health care workers. Conflict of interest statement This work was supported by the Thomas B and Nancy Upjohn Woodworth Professorship in Bipolar Disorder and Depression (MGM) and the Center for Global Health (SDM). Melvin G. McInnis has received honoraria for consultations with Merck, Astra-Zeneca, Glaxo Smith Kline, and Pfizer Pharmaceuticals. Sofia D. Merajver has no conflicts of interests. Acknowledgements We gratefully acknowledge the collaborative discussions with Dra. Chiriboga, Lic Acosta, Aimee Miller, Julie Maslowski, Jane Hassinger, Michelle Grunauer, Marina Piazza, and Carmen Carmachio. We thank the community health care staff of the clinics of Guamani for the kind hospitality on our visits to their clinics. References APA, 2000. Diagnostic and Statistical Manual of Mental Disorders, revised 4th ed. American Psychiatric Association, Washington, DC. Bauer, A.M., Fielke, K., Brayley, J., Araya, M., Alem, A., Frankel, B.L., et al., 2010. Tackling the global mental health challenge: a psychosomatic medicine/ consultation-liaison psychiatry perspective. Psychosomatics 51 (3), 185–193. Brentlinger, P.E., Assan, A., Mudender, F., Ghee, A.E., Vallejo Torres, J., Martinez Martinez, P., et al., 2010. Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians’ performance in HIV/AIDS care. Hum. Resour. Health 8, 23. Department of Health SA, 2004. Traditional Health Practitioners Act (No. 35 of 2004) Available from: http://www.doh.gov.za/docs/legislation-f.html. Evans-Lacko, S., London, J., Little, K., Henderson, C., Thornicroft, G., 2010. Evaluation of a brief anti-stigma campaign in Cambridge: do short-term campaigns work? BMC Publ. Health 10, 339. Incayawar, M., Wintrob, R., Bouchard, L., World Psychiatric Association, 2009. Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health. Wiley-Blackwell, Chichester, West Sussex, UK/Hoboken, NJ. Institute of Medicine (U.S.). Committee on Health Literacy, Academy for Educational Development, 2004. Health Literacy a Prescription to End Confusion. Academy for Educational Development, Washington, DC. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Pollitt, P., 1997. ‘‘Mental health literacy’’: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med. J. Aust. 166 (4), 182–186. Kessler, R., Ustun, T.B., 2008. The WHO World Mental Health Surveys. Cambridge University Press, New York.
M.G. McInnis, S.D. Merajver / Asian Journal of Psychiatry 4 (2011) 165–171 Labhardt, N.D., Balo, J.R., Ndam, M., Grimm, J.J., Manga, E., 2010. Task shifting to nonphysician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv. Res. 10 (1), 339. Mullany, L.C., Lee, T.J., Yone, L., Lee, C.I., Teela, K.C., Paw, P., et al., 2010. Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in Eastern Burma: the MOM project. PLoS Med. 7 (8), e1000317. Ngui, E.M., Khasakhala, L., Ndetei, D., Roberts, L.W., 2010. Mental disorders, health inequalities and ethics: a global perspective. Int. Rev. Psychiatry 22 (3), 235–244. Patel, V., 2009. The future of psychiatry in low- and middle-income countries. Psychol. Med. 39 (11), 1759–1762. Phillips, M.R., Zhang, J., Shi, Q., Song, Z., Ding, Z., Pang, S., et al., 2009. Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. Lancet 373 (9680), 2041–2053. Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M.R., et al., 2007. No health without mental health. Lancet 370 (9590), 859–877. Regier, D.A., Boyd, J.H., Burke Jr., J.D., Rae, D.S., Myers, J.K., Kramer, M., et al., 1988. One-month prevalence of mental disorders in the United States Based on five epidemiologic catchment area sites. Arch. Gen. Psychiatry 45 (11), 977–986.
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Regier, D.A., Narrow, W.E., Kuhl, E.A., Kupfer, D.J., 2009. The conceptual development of DSM-V. Am. J. Psychiatry 166 (6), 645–650. Schulze, T.G., 2010. Genetic research into bipolar disorder: the need for a research framework that integrates sophisticated molecular biology and clinically informed phenotype characterization. Psychiatr. Clin. North Am. 33 (1), 67–82. Sorsdahl, K., Ipser, J.C., Stein, D.J., 2009a. Interventions for educating traditional healers about STD and HIV medicine. Cochrane Database Syst. Rev. 4, CD007190. Sorsdahl, K., Stein, D.J., Grimsrud, A., Seedat, S., Flisher, A.J., Williams, D.R., et al., 2009b. Traditional healers in the treatment of common mental disorders in South Africa. J. Nerv. Ment. Dis. 197 (6), 434–441. Weich, S., Araya, R., 2004. International and regional variation in the prevalence of common mental disorders: do we need more surveys? Br. J. Psychiatry 184, 289–290. WHO, 2008a. Global Burden of Disease. Available from: http://www.who.int/ healthinfo/global_burden_disease/estimates_country/en/index.html. WHO, 2008b. The Global Burden of Disease: 2004 Update. WHO, Geneva. WHO, 1992. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva. Zachariah, R., Ford, N., Philips, M., Lynch, S., Massaquoi, M., Janssens, V., et al., 2009. Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa. Trans. R. Soc. Trop. Med. Hyg. 103 (6), 549–558.
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Global mental health: Global strengths and strategies Task-shifting in a shifting health economy Melvin G. McInnis a,*, Sofia D. Merajver b a b
University of Michigan Depression Center and Department of Psychiatry, Ann Arbor, MI 48109, USA University of Michigan Department of Internal Medicine and Center for Global Health, Ann Arbor, MI 48109, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 November 2010 Received in revised form 13 June 2011 Accepted 19 June 2011
Global mental health challenges sit at the frontiers of health care worldwide. The frequency of mental health disorders is increasing, and represents a large portion of the global burden of human disease (DALYs). There are many impeding forces in delivering mental health care globally. The knowledge of what mental health and its diseased states are limits the ability to seek appropriate care. Limited training and experience among primary providers dilutes the capacity of systems for adequate care, support, and intervention. There are limited numbers of medical personnel worldwide to attend to individuals afflicted by mental health disorders. The challenges of global mental health are the capacity of the global systems to enhance knowledge and literacy surrounding mental health disorders, enhance and expand ways of identifying and treating mental health disorders effectively at an early stage in its course. Much has been written about the epidemiology of mental health disorders globally followed by discussions of the need for improvements in programs that will improve the lot of the mentally ill. Task shifting involves the engaging of human resources, generally nonprofessional, in the care of mental health disorders. Engaging traditional healers and community health workers in the identification and management of mental health disorders is a very strong potential opportunity for task shifting care in mental health. In doing so it will be necessary to study the concept of mental health literacy of traditional healers and health workers in a process of mutual alignment of purpose founded on evidence based research. ß 2011 Elsevier B.V. All rights reserved.
Keywords: Task shifting Global mental health Traditional healers Mental health literacy
1. Introduction It is now somewhat cliche´ to reiterate that ‘‘there is no health without mental health’’ as it begs the question of a definition of both health and mental health (Prince et al., 2007). An etymological tautology emerges as one attempts to boil down a concept of health that takes the argument through the concept of disease and its impact on the capacity of the individual from a personal and societal perspective. The biophysical aspects of many medical diseases have been characterized. The history of biomedical research proudly and rightly exemplifies the research trajectories of infectious diseases leading to the etiological understanding of AIDS, cardiovascular, or pulmonary diseases. Most medical disciplines outside of the psychiatric clinical sciences boast an etiological trajectory of understanding beginning with clinical observations and leading to a set of pathological findings coalesced into criteria for a specific disease. Illness in the psychiatric sense,
* Corresponding author. Tel.: +1 734 936 6018. E-mail addresses: [email protected] (M.G. McInnis), [email protected] (S.D. Merajver). 1876-2018/$ – see front matter ß 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2011.06.002
however, remains a series of disjunctive categories that serve as clinical guidelines and a hope for deeper future understanding of the underlying pathology. For much of the world ‘‘mental health’’ remains elusive.
Global Challenges Managing Mental Health: Limited Literacy and Understanding of Disorders; Few Care Providers; Sparse Global and National Priorities.
In this overview we examine mental health from a global perspective, and advance a pragmatic integrated approach with discussion of the burden of mental health disorders, mental health literacy, and the role of extant systems in global communities that includes the community traditional healers and education systems. Knowledge of health is the basis of health prevention and management. Engagement of individuals at many levels across the community for health care provides the opportunities for task shifting: transferring responsibility for tasks from higher to lesser specialized providers. This requires an
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understanding of the knowledge of the lesser specialized providers (mental health literacy) and implementation of programs to provide resources to them. In the global community there is a resource of traditional healers that the society seeks out for care and advice on health matters. Knowledge of the mental health literacy and resources for traditional healers willing to interact meaningfully with regional health care workers and authorities may become a base for task shifting some health care duties in the community. The education system is the societal and cultural base for the community to collectively enhance knowledge of health; knowledge of mental health needs to be an integral component of the educational system. In the global community, knowledge of local resources and challenges are critical. It is, of course, important that communities systematically build and expand medical and psycho-social resources, with doctors, nurses, and affiliated care providers. However, there are resources that may be under estimated in terms of their potential for mental health and include a local engaged traditional healer, open to working interactively with the community health authorities, to whom many mental health care tasks may be formally shifted. 1.1. Mental health literacy Mental health literacy is the general knowledge and beliefs about mental health disorders from an intellectual and functional perspective that aid in their recognition, management, and prevention; the concept of literacy is universally applicable across society (Jorm et al., 1997). The current intellectual understanding of mental health and mental health disorders is largely reflected in the current diagnostic categories of DSM IV (APA, 2000) and ICD-10 (WHO, 1992). It is readily acknowledged that the current categories are likely to be restructured with the anticipated emergence of a biological understanding of key etiological pathways leading to psychiatric disorders (Regier et al., 2009). The impact of the environment on the evolution of psychiatric disorders is widely appreciated. Western societies judge intellectual literacy of mental health disorders by how well the society, including care providers and consumers, know and recite the categories outlined in the DSM/ ICD criteria. The understanding of psychiatric disorders in the developing world is based on the heroic efforts lead by WHO and others that examine the prevalence of DSM/ICD-identified psychiatric syndromes in the global community (WHO, 2008a). Our estimates of the burden of mental disorders are based on the constellation of symptoms clustered to identify disorders according to a purely Western classification by local assessors that are literate on DSM/ICD coding, applied to societies in the global south. A specialty of cross-cultural psychiatry has emerged with every attempt to translate between the culture of study and the DSM systems. A number of critical observations have derived under the assumptions, believed to be valid, that psychiatric disorders are phenomenologically grossly similar wherein the form of the psychopathology is similar, while the cultural content may vary. However, health literacy is more than ‘‘intellectual literacy’’ which may be metrically defined and assessed, it is an integrated knowledge of health that provides the tools and resources for the individual to seek and receive needed services. In general it is the functional aspects of literacy that are elusive; impedance is found throughout, and ranges from intrinsic believes within the individual through the societal context of health care and services (IM, 2004). The burden of mental health disorders in the global community has been discussed at length in the literature and it is clear that global mental health and knowledge of the same (mental health
literacy) is singularly one of biggest health challenges facing mankind (Ngui et al., 2010). If one incorporates behavioral aspects of disorders in medical disciplines, maladaptive motivated behaviors of the addictions, dietary and recreational inequities created by a combination of cultural opportunities and resources, as well as personal choices influenced by the collective community economy – it should be apparent that the dimension of mental health reaches deep into a culture and its communities (Bauer et al., 2010). The burden of poor mental health and its specific disorders when these are known, affect most, if not all aspects of global health. But returning to the focus of the measured burden of mental health in the global community using standard Western measures, it is very clear that a very large proportion of health problems are mental health problems. Mental health disorders generally have an early age of onset, critically affecting the capacity of the developing young adult towards a productive career and/or achieving her/his potential in society. The result is that mental health disorders are projected to the single larges cause of DALYs (Disability adjusted Life years) by 2030 (WHO, 2008a), with unipolar depression topping the list. One of the most affected group in both higher and lower income communities alike is women of child bearing age, the frequency of major depression in this age group is highly similar in highly resourced and low-resourced regions and neuropsychiatric disorders combined account for 22% of DALYs (WHO, 2008b). Large-scale campaigns to combat or eradicate disease such as malaria or polio have had a clearly focused methodology and measurable outcomes. However, in the field of global mental health, the methodologies are by no means clear or agreed upon. The basic phenomenology of mental disease globally may be variable in ways that are yet to be delineated in detail. The approach in the global community towards caring for those afflicted with mental health disorders ranges from being woefully under-developed to non-existent, with a few exceptions typically associated with tertiary care specialized centers in or around large urban areas. The burden of mental health remains profound. Enhancing mental health literacy is an integral step towards diminishing the burden. Mental health literacy in the broadest sense should not be interpreted or used to suggest that the current categorical system of DSM or ICD represents the standard of literacy. The two systems are important standards, with a high degree of reliability, but with unknown validity. There are essentially no biologically established etiologies for mental health disorders. Therefore, the dimensions and measures of literacy include a sociological understanding of what the individuals of a given culture believe to be mental health and disorders thereof. This dimension of research has been the purview of anthropology, with modest interaction and contribution from medical, public health, and the social sciences. Literacy is not the purview of any one stratus or worker in society. At all age levels, parents, the nuclear and extended family, teachers, health care workers and aides, community leaders, persons associated or affiliated with organized religion, colleagues in the workforce, and others may be harnessed as mental health literacy ambassadors through a process known as task-shifting.
Targeted Task Shifting in Global Mental Health: Primary Health Care Givers; Community Health Care Worker; Traditional Healers; Educators and Schools; Extended Families; Individuals.
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1.2. Global mental health research The research to date has focused to a large degree on the crosssectional epidemiological study of the prevalence of disorders among the nations of the world (Kessler and Ustun, 2008). There are, of course, certain differences of prevalence among the countries of study, but it is the similarities that are more striking. The most common diagnoses are mood and anxiety disorders (the interquartile range of lifetime prevalence for both disorders worldwide being 10–16%); the estimated frequency in less developed countries being generally lower. The time delay in seeking treatment is greater in the lower resourced nations. The strict prevalence of any diagnosable DSM disorder (excluding all NOS diagnoses) in the study of Phillips et al. (2009) in China was in the range of 13% that was similar to a US based analysis (Regier et al., 1988). The need for further surveys has been challenged (Weich and Araya, 2004) with the acknowledgment that the survey research to date has confirmed that psychiatric disorders exist worldwide and that it would be of great relevance to the global community to develop functional programs that will be of tangible assistance to the communities: the imperative is to focus research on the development and assessment of programs and outcomes given the global burden of psychiatric disease (Table 1). The progress of the recent epidemiological research notwithstanding, it is timely for a significant shift in the focus of global mental health research. There has been only a minimal amount of outcomes research in translational mental health medicine in the global community. Even in the Western world true translational research in mental health has been sparse. While there was substantial promise and hope (perhaps with some hype as well) for a reductionist understanding of the etiology of the major mental health disorders, it is now apparent that while significant inroads have been made with the identification of genetic variants predisposing to psychiatric disorder, each of these variants contributes only a minute amount of the risk to the disorder (Schulze, 2010). The reductionist short cut to etiology will not materialize within the current methodological approaches. Innovative strategies are needed that leverage previous work and infrastructure while integrating clinical and research methods that simultaneously improve the quality of life for those burdened by disease while advancing an academic understanding of the disorders. An integrated clinical translational research paradigm that utilizes a longitudinal method of study of patients within a society and culture, using innovative clinical approaches enhanced by new technology-based assessments and interventions is one
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proposed strategy. This approach allows for the monitoring over time of individuals with a specific disorder, initially ascertained through the more or less standard criteria of DSMIV or ICD-10. The monitoring of episodes and symptom fluctuations, the course of disease, the optimal methods of managing the disorder in the communities (engaging community providers and task shifting the responsibility for care to the community and individual) are essential data needed by policymakers to impact public mental health and policies. Finally, such an approach affords the opportunity to monitor the level of understanding of the disorder – the level of literacy in the individual, their family members and the community at large. 1.3. Integrated global translational clinical research The premise of translational research is the relative immediacy of relevance to the target population that is involved and participant in the research endeavor. This involves an integrated approach that combines effort at the clinical and service delivery front lines with statistical, social, anthropological, and biological analysis of change and sustain favorable outcomes. Global health translational research implies major adaptations from the usual single discipline frameworks to an integrated trans-disciplinary approach. It is personal in the sense that it assesses and strives to improve the outcome of each patient and one clinic at a time, and global in the sense of eliciting programmatic or policy changes that are measurable socially, intellectually, economically, and culturally. The efforts of the WHO and others that measure frequency of mental health world wide have provided strong impetus and basis of data on which to develop additional resources for global mental health translational research (Kessler and Ustun, 2008). There is an enormous burden of mental health in the global community that, if not attended to, may seriously compromise the capacity of whole communities for economic development and cause undue personal suffering among the populations most depleted of resources. This, in turn, creates an environment auspicious for human rights violations, which further deepen the health inequities, and so on in a downward spiral. To break out of this self-feeding negative trajectory, we propose a starting point for global health translational research: the concept and realization of global mental health literacy. The study, assessment, and development of programs for improvements in mental health literacy across all human communities should become the unifying focus for global mental health. It is the authors’ perspective that the concept of stigma be removed from this discussion. ‘‘Fighting Stigma’’ campaigns often
Table 1 Burden of Disease by cause and region, 2004. PAHO
AFRO
EURO
SERO
EMRO
WPRO
Total
Neuropsychiatric conditions
129,585 (22%)
117,067 (20%)
165,444 (28%)
34,643 (6%)
58,559 (10%)
75,354 (13%)
580,653
Unipolar depressive disorders Bipolar disorder Schizophrenia Epilepsy Alcohol use disorders Alzheimer and other dementias Parkinson disease Multiple sclerosis Drug use disorders Post-traumatic stress disorder Obsessive-compulsive disorder Panic disorder Insomnia (primary) Migraine
39,238 7339 8771 5996 19,373 6838 796 805 6736 1607 4124 3551 2674 5399
33,683 10,610 11,101 10,728 5079 5601 985 783 3785 2433 5230 4784 2700 2322
51,677 10,069 10,978 3853 25,895 10,987 1991 1714 7129 2845 4942 5241 3393 8988
12,971 2339 3083 1319 2855 1811 1465 223 945 622 656 1175 658 1227
19,535 4596 5590 2183 1205 2542 590 469 4755 1134 2339 2192 817 1537
24,351 5623 7273 2985 8306 5050 769 571 2418 1507 1423 2858 1267 2693
181,455 40,576 46,796 27,064 62,713 32,829 6597 4566 25,767 10,149 18,714 19,801 11,510 22,166
Data adapted from the Burden of Global Disease data posted at: http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html. WHO Health Regions: PAH0 (Pan American Health Org.), AFRO (African Regional Org), EURO (European Regional Org.), SERO (South East Asia Regional Org.), EMRO (Eastern Mediterranean Regional Org.), WPRO (Western Pacific Regional Org.).
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do not work in the anticipated manner, a recent study showed no significant effect on the overall mental health knowledge schedule (MAKS) (Evans-Lacko et al., 2010). Focusing on literacy re-focuses the discussion on improving knowledge and learning, which in itself is culturally and geographically specific. Strategies for systematic programs of assessing and enhancing mental health literacy should target students throughout the formal education system, medical care workers, the traditional healers of a society, families, and of course the overall population. We postulate that an integrated global translational research program in mental health with a unifying theme of mental health literacy has the capacity to change a society dramatically over a generation. For example, assessment of views of students regarding mental health followed by specific educational programs with subsequent assessment of the effectiveness of the intervention will, over time, effect a change in the perspective of the society as more students emerge into leadership roles in the communities. Such programs need to be integrated into the educational system at all levels, beginning in the early years and continuing through university based education systems. Access to information is critical; assimilation and integration of this information into the individual cultures is hypothesized to have the potential to catalyze large improvements in diagnosis and expedient treatments, and integration of individuals suffering from mental illness into the societies with enhanced literacy about mental illness, to lead better lives. 1.4. Traditional healers and mental health In the global health community there are profound examples of apparent internal contradictions that are component to the culture and tradition of societies that have centuries of complexities in beliefs and structure. Nowhere do these contradictions manifest as strongly as in the mental health field. The emergence of mental illness within a family with traditional cultural beliefs characteristically brings shame and often serves to isolate the individual and family. Mental illness may be considered to be brought about by evil spirits or other forces, internal or external, in a combination of the personal and supernatural (the sufferer may be considered a witch or a warlock for example). Many global communities subscribe heavily to the practices of native or transplanted traditional healers who purport to harness the supernatural or other non-conventional scientific forces in a healing manner. Further, there are often few other resources, beyond the traditional healers, for those affected to seek out for help in times of need. There is tremendous variation in the traditional healers’ abilities, believes, and motivations. Many are driven by ritualistic demonic beliefs, their own financial gain, and use inhumane methods. Thankfully, there are traditional healers who are extraordinarly, kind, and integrate cultural traditions and support to the individual and family with outcomes that surpass all expectations. The study of traditional healers is complex and the focus of a recent book (Incayawar et al., 2009). Thus, while there may be an appearance of contradiction, the unifying confliction is the cultural belief system, that appears to the Western observer to focus on the supernatural. A large percentage of the world population receives its care from traditional healers, it is virtually impossible to determine both the number of traditional healers worldwide as well as how many patient visits occur. An understanding of the conflicts and contradictions, themselves fraught with ambiguity, may be best addressed by the comparative study of health and mental health literacy in global societies and by striving towards meaningful alignment of the current scientific approach to mental health and the traditional belief systems of the culture. Extensive seminars on the DSM and ICD classification systems may be helpful for the conduct of a particular study, but are unlikely to result in profound changes of mental health literacy in any society or to influence policy.
At the practical level the traditional healer is frequently an overlooked opportunity for health care collaboration from an economic and political perspective in many communities (Incayawar et al., 2009). These individuals are often ignored (and frequently scorned) in the context of provision of medical care, for a variety of interesting reasons that include a pervasive sense of lack of importance of what they do and that their all their efforts are fringe interventions of curious cultural traditions. In sensitive situations the traditional healers are an embarrassment to national health care leaders and policy makers, such as when news erupts that reveals untoward practices with compromised ethical standards to achieve the goals of, say, expelling the evil spirits that are causing disease (most frequently mental disease). Such examples are exploited politically to discredit traditional healers in the society. However, in many societies a very large percentage of the population has extremely limited options for care of mental health problems so that those in need continue to engage the healers. In emerging blended urban and rural communities, healers are sought out and can be even revered by the migrant population. Many patients will adapt into an openminded approach and visit with the local conventional medical clinics as well as the healers, or religious authorities and will themselves integrate the advice from these diverse sources in a personal way that may be in fact contradictory (and on occasion dangerous). In a recent review of clinical visits to a local health catchment area in Quito, the number of visits to the traditional healers was steadily increasing over several a span of several years, while visits to conventional medical doctors plateaued (Fig. 1). It is clear that traditional healers will continue to be a health care resource for many communities and that given the shortage of conventional medical care providers, many societies will be unwittingly dependent on these providers for the bulk of the delivery of health care. The challenge then becomes how to constructively integrate the healers into the mainstream of health care and how to define and maximize the likelihood of good quality of care either by traditional, conventional, or task-shifted providers. 1.5. Task shifting and the traditional healer Task shifting involves the rational redistribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health. Task shifting to lower educational leveled professionals emerged from the developing global community with broad applicability, albeit with considerable controversy, in the HIV arena (Zachariah et al., 2009; Brentlinger et al., 2010) with research emerging in diabetes and hypertension (Labhardt et al., 2010) as well in the obstetrical specialties (Mullany et al., 2010). Discussions have emerged with recommendations for task shifting in the psychiatric field (Patel, 2009). However, tasking to lesser-qualified individuals has, in fact, been the default practice of medical care in a substantial part of the global community’s approach to health care. Traditional healers and other cultural leaders have provided care to their communities, the healers essentially defined by a ground up approach rather than a top down ‘‘task shifting’’ approach. Global communities ‘‘make do’’ with the resources that are available to them for all aspects of their lives, including medical health care, a complex system of health care utilizing the self and community identified healers has evolved in evolving societies and integrating structure to the systems will include utilizing all levels of available health care workers from professionals to the healers.
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Fig. 1. The consistent increase in the number of visits to the Traditional Healer clinic compared to the Medical clinic over a 4-year period in a semi-rural health catchment area (urban outskirts) from Area Guamani, Quito, Ecuador. Figure is adapted from health services statistics with permission.
The WHO functional definition of task shifting supports a broad categorization of practices into four types, as follows: Task shifting I: The extension of the scope of practice of nonphysician clinicians in order to enable them to assume some tasks previously undertaken by more senior cadres (e.g. medical doctors). Task shifting II: The extension of the scope of practice of nurses and midwives in order to enable them to assume some tasks previously undertaken by senior cadres (e.g. non-physician clinicians and medical doctors). Task shifting III: The extension of the scope of practice of community health workers, including people living with the diseases of interest, in order to enable them to assume some tasks previously undertaken by senior cadres (e.g. nurses and midwives, non-physician clinicians and medical doctors). Task shifting IV: People living with the disorders of interest, trained in self-management, assume some tasks related to their own care that would previously have been undertaken by health workers. Task shifting can also be extended to other cadres that do not traditionally have a clinical function, for example pharmacists, pharmacy technicians or technologists, laboratory technicians, administrators and records managers. The cadre that assumes the new task, not the cadre that is relieved of the task, is the defining factor for task shifting types. For example, any extension of the scope of practice of nurses and midwives is defined as task shifting type II. Task shifting to the traditional healer could be considered type III. The role of the traditional healer in health care is debated (but frequently ignored) in many countries and societies. South Africa was the first to pass specific legislation that supports and governs the practices of the traditional healer, an unusual and hopefully pioneering move towards understanding the role of the traditional healer and harnessing their impact towards positive outcomes (DH SA, 2004). In S Africa there are approximately 200,000 traditional healers who provide care for 70% of the population. The legislation mandated the establishment of an internal governing board that regulated who is a traditional healer, provides regular educational events, serves as a bargaining agency for reimbursement, and mediates referrals. This accomplishment is laudable, as concerns have been raised broadly on the feasibility of governing the traditional healers. The currency of the healer is from his/her community and there have been skepticism and concerns that a governing licensing
agency would not be recognized by the community and that the agency would be merely lending credibility to charlatans. The accomplishments in South Africa, through the process of arriving at this legislation, are a clear attempt to address these concerns. It is appreciated that there are many challenges at the level of implementation and that there remain difficulties in the integration of care between conventional medicine and traditional healers (Sorsdahl et al., 2009a). There are also many pitfalls in a program that integrates traditional healers into a health care system. Some healers are motivated by unfounded and blatantly backward belief systems, such as that mental health disorders are the result of demonic possession and need to be aggressively beaten or starved out of the individual. However, many of the perceived problems derive from interpretations, lack of insight and respect for the role that traditional healers play in the communities and the reluctance of both groups to cross-refer patients, resulting in critical delays in the initiation of effective medical care or the opportunity for ongoing support in the community. The traditional healer, like any member of society, has a concept of mental health based on their societal norms and the observed behaviors of individuals with whom they interact. It is important to assimilate, elaborate, and work with the unequivocal fact that traditional healers regularly treat individuals (patients) in their clinics, lean-tos, huts, and other sites. Given the profound lack of conventional clinical resources for mental health in the global community at large, it is clear that an integrated approach to mental health care that involves task shifting to the traditional healer and the existing medical care providers at the primary and specialty levels in a mutually respectful and collaborative manner will be the program most likely to succeed in the short and intermediate future (Sorsdahl et al., 2009b). The critical element is the willingness of both the traditional healers and medical providers to engage and learn from each other. 2. Traditions: healers, education, and literacy We propose that the integrative health care needs to be based on the concept of literacy adapted to the cultural constituencies of caregivers. In other words, just as many professions have ‘‘continuing education credits’’, we propose the similar concept of ‘‘continuing literacy credits’’ to mean activities to enhance the mutual literacy of practitioners across cultural frame works. The life stories of conventional doctors and nurses and other health workers in many global communities are profoundly intertwined with the discourse of the traditional healer, as it is very probable
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that in their own lives, they have been treated as children or adolescents by traditional healers or are aware of their practices by living in the society where the traditional healers practice. Traditional healers are a resource with roles governed by complex cultural beliefs. Understanding cultural knowledge bases (literacy) will provide the base for advancing the same. Programs that enhance and unify mental health literacy have a capacity to create a coherent mental health program in any global community, from birth through the lifespan and across occupations and social roles. The effectiveness of any mental health program relies on the knowledge, the intellectual literacy and flexibility of thought of the policy makers and care providers. The ability of the program to integrate seamlessly into and enrich a society depends on the successes of transmitting the literacy to the populate who would ideally be sufficiently literate in mental health matters to recognize their personal needs and seek suitable care. The outcomes and services oriented research measure the functional literacies of the population, how well they are able to integrate the knowledge of the programs into their daily living patterns, and mental health hygiene (rates of substance abuse, suicide attempts, social measures of family stability, attachments, life work commitment, etc.). Programs for global mental health literacy would ideally begin in the formal K-12 education system and extend through higher education, vocational training, and the lifespan. Where to start is an important question. One would like to start such a comprehensive program at a level where the conditions are most auspicious to rapidly maximize the number of mental health ‘‘literate’’ individuals that disperse into the community in leadership roles in all walks of life. For this reason, we propose that a particular focus would be placed initially on the college student who is already embedded in a milieu supportive of literacy based projects and efforts. The literate college graduate in the global community would take and hopefully implement intellectual and functional mental health literacy throughout their careers and in their own families and communities as mental health literacy ambassadors, perhaps a nominal or actual title accorded to those who attain certain competencies, if appropriate. Attitudes towards mental health would dramatically change over merely a generation. The next level of focus would be on health care policy makers and all providers, from physicians through community health care works and including the traditional healers. Strategies to emulate the positive features of the S African experience should be explored in other regions and countries. 2.1. Conclusions Providing health care in the global community is the greatest frontier in modern medicine and the challenge is most profound in the field of mental health. Delivering evidence based medical care to the world community is a global priority and a fundamental human equity. The fiscal and human resources for providing health care and specifically mental health care are limited as the priorities of medical care are many. The world is in need of an adaptive and integrative approach to health and health care that begins with literacy. Literacy about the norms and standards of specific cultures in terms of how illness is perceived and understood; and literacy surrounding evidence based knowledge of disease and care. Literacy begins at birth and continues through the lifespan, but with focused efforts in the education system and herein lies the opportunity to systematically enhance intellectual and functional knowledge of mental health across society. The ‘‘on-the-ground’’ provision of health care challenges many societies and acutely so in the global community wherein there are just not enough doctors, nurses, and other health care providers to go around and there likely will not be in the next 50–100 years. Can we as a human society rise to this challenge with a unifying
positive voice and philosophy? We believe we can. There is a large cadre of traditional healers who are in fact the primary care mental health and other health providers for the majority in the global communities. It would be most unwise to ignore this fact. The advice of traditional healers is sought by all strata of the global community. The identification of strategies to integrate conventional medical caregivers and traditional healers would benefit all, but most importantly the patient. Mental health care stands to benefit disproportionately more given the supportive nature of the interaction between provider and patient, but this is true for most other chronic diseases and for palliative care. There is a strong need to provide some common elements of regulations and standards among the traditional healers to ensure background of consistency of care and base knowledge of illnesses. Such task-shifting to the community where the care is already taking place can be achieved through concerted efforts involving the political and medical leadership and a mutual understanding and respect for culture and science. The task-shifting of mental health care and support services towards the traditional healers and other community health care workers and the lay community itself will offer the opportunity to research and compare the emerging levels of intellectual and functional literacy in the community, in the traditional healers and in the community health care workers. Conflict of interest statement This work was supported by the Thomas B and Nancy Upjohn Woodworth Professorship in Bipolar Disorder and Depression (MGM) and the Center for Global Health (SDM). Melvin G. McInnis has received honoraria for consultations with Merck, Astra-Zeneca, Glaxo Smith Kline, and Pfizer Pharmaceuticals. Sofia D. Merajver has no conflicts of interests. Acknowledgements We gratefully acknowledge the collaborative discussions with Dra. Chiriboga, Lic Acosta, Aimee Miller, Julie Maslowski, Jane Hassinger, Michelle Grunauer, Marina Piazza, and Carmen Carmachio. We thank the community health care staff of the clinics of Guamani for the kind hospitality on our visits to their clinics. References APA, 2000. Diagnostic and Statistical Manual of Mental Disorders, revised 4th ed. American Psychiatric Association, Washington, DC. Bauer, A.M., Fielke, K., Brayley, J., Araya, M., Alem, A., Frankel, B.L., et al., 2010. Tackling the global mental health challenge: a psychosomatic medicine/ consultation-liaison psychiatry perspective. Psychosomatics 51 (3), 185–193. Brentlinger, P.E., Assan, A., Mudender, F., Ghee, A.E., Vallejo Torres, J., Martinez Martinez, P., et al., 2010. Task shifting in Mozambique: cross-sectional evaluation of non-physician clinicians’ performance in HIV/AIDS care. Hum. Resour. Health 8, 23. Department of Health SA, 2004. Traditional Health Practitioners Act (No. 35 of 2004) Available from: http://www.doh.gov.za/docs/legislation-f.html. Evans-Lacko, S., London, J., Little, K., Henderson, C., Thornicroft, G., 2010. Evaluation of a brief anti-stigma campaign in Cambridge: do short-term campaigns work? BMC Publ. Health 10, 339. Incayawar, M., Wintrob, R., Bouchard, L., World Psychiatric Association, 2009. Psychiatrists and Traditional Healers: Unwitting Partners in Global Mental Health. Wiley-Blackwell, Chichester, West Sussex, UK/Hoboken, NJ. Institute of Medicine (U.S.). Committee on Health Literacy, Academy for Educational Development, 2004. Health Literacy a Prescription to End Confusion. Academy for Educational Development, Washington, DC. Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Pollitt, P., 1997. ‘‘Mental health literacy’’: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med. J. Aust. 166 (4), 182–186. Kessler, R., Ustun, T.B., 2008. The WHO World Mental Health Surveys. Cambridge University Press, New York.
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