Cultural and professional bias exists in most intercultural endeavors. This is particularly true in international mental health, where the views and practices of international consultants from industrialized nations often conflict with the resources, needs and treatment philosophies of developing nations (Kleinman & Cohen, 1997). The underlying beliefs of mental health professionals from developed nations cannot readily explain or accept the differences in symptomatic expression or prevalence of mental illness due to cultural, biological and psychosocial differences of life in developing countries. Thus, the advice and technical assistance given by international consultants of the World Health Organization (WHO), other international organizations, and NGOs generally mirrors practices in their native countries. This often sidetracks and/or defeats mental health initiatives, and ignores basic tenants of public health practice (Des Jarlis, Eisenberg, Good & Kleinman, 1995).
Sectorization and Sub-sectorization of Mental Health Services in Developing Countries
In the industrialize world, the sub-sector of psychiatry and mental health has grown to the point of almost becoming and independent sector, with separate funding streams, tertiary hospitals and community based resources. Hence, the public health systems of most developed nations accept this situation and generally excludes mental health from their primary care and other public health agendas. This causes public mental health programs to exist in a similar vacuum. Transporting this dual practice to developing nations, without the benefit of the vast resources of industrialized countries, actually increases the drain on already overloaded physical and mental health systems and affects services for all patients who use public care systems.
Though WHO sponsored studies have shown a dramatic decrease in morbidity rates, and in general, life expectancies have risen from 40 to 66 years over the past half century, mental illness has risen dramatically in developing countries . Longer life spans have produced increased prevalence of Alzheimer's and dementia; and increasing rates of violence, depression, substance abuse and suicide have been directly linked to increased urbanization and economic restructuring of developing countries (Ustun & Sartorius, 1995). The WHO estimates that mental illness accounts for at least 25% of all acute care visits in developing nations and that up to half of these cases are misdiagnosed by primary care clinicians (WHO, 1995).
Without appropriate resources to maintain mental health services as a separate sector, the trend toward increased utilization of all health services will continue. Psychiatric and mental hygiene services should therefore be reintegrated into the public health services sector. For clinical training and education purposes, it makes sense to continue the mental health sub-sector separation. It also makes sense for the treatment of long term, chronically mentally ill or endangered patients, who are at risk for themselves or others and who require specialized care. However, most cases that are psychogenic in etiology never present to the few psychiatric facilities that do exist and rely on the public health care systems.
To bridge the gaps that currently exist in developing public health systems, reconnection of mental hygiene to the health sector is a necessary evil. This would improve not only mental health services but strengthen the entire public health system of participating countries.
A Case in Point:
In Honduras, for example, millions of dollars have been funneled into a primary health care promoter and delivery system since 1993 (World Bank, 1993). While this has helped to build a functional health promoter and regionally based health care system, it ignored the mental health care sector entirely. As a consequence, illness and injury due to family abuse, alcoholism, and major mental illness were virtually ignored and patients were forced to rely on the few understaffed and poorly funded tertiary hospitals that exist in the country. In addition, mental health hospitals received no additional funding and are currently operating at pre 1993 budget levels. This leaves patients in substandard conditions, attended by poorly staffed and in some cases poorly trained clinical support.
Had the development loan taken mental health services into account, there would have been a net decrease in both mental health and primary health care visits in acute care facilities over the past four years, and the goals of primary health care would have been met. As it stands, both systems suffered because Mental Health was treated as a separate sector and a luxury item in a developing country.
WHO has been working with a regionally based primary care approach to mental health services in 12 western pacific nations. This combines regionally and community based health care systems with mental health to deal with a variety of mental health issues in the context of overall health care (WHO, 1993). When performed at the local level through training and education (by mental health professionals) and reinforced by an active community based health promotion and case management system, the combined effort actually reduced acute care visits and served the patients, families, and communities in a more humane manner than most care systems of developing nations.
Getting back to the basic concept of recognizing mental health (including substance abuse and addiction care systems) as a sub-sector of health and utilizing it as a primary care resource will improve conditions and models of care for all patients of developing countries. After all, the ultimate goals of mental health care are the same as those of all health care systems: To reduce distress to the greatest degree possible and increase our patient's functional adaptation to their environment to the greatest degree possible. Integrating the mental health sub-sector into overall health care initiatives helps to meet these goals in a culturally specific, cost effective manner without the typical systems bias of the industrialized world.
Kleinman, A. and Cohen, A. (1997. Psychiatry's Global Challenge. Scientific American. March, 86-89.
Des Jarlais, R., Eisenberg, L., Good. B., and Kleinman, A. (1995) World Mental Health: Problems and Priorities in Low-Income Countries. Oxford University Press.
Ustun, T.B. and Sartorius, N. (1995) Mental Illness in General Health Care: An International Study. Juhn Wiley & Sons.
World Bank (1993). Honduran Primary Health Care Development Loan. Washington DC.
World Health Organization (1993). Mental Health Care in the Western Pacific Region: Present Status, Needs, and Future Directions. International Journal of Mental Health. Vol. 22 (1), 101-116.
World Health Organization (1995) World Health Report 1995: Bridging the Gap.
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