|
|
 |
 |
 |
| Friday, 3 May 2002 |
 |
|
 |
Features | |
| News Business Features Editorial Security Politics World Letters Sports Obituaries
|
How sane are we? The question arises following a global study done on mental health by the World Health Organisation last year, where it has been revealed that every one out of four people in the world are suffering from some mental illness.
Yet most of them do not seek treatment from a professional even though facilities are available in most of the countries for such help. The report released recently a copy of which has been sent to us states, that a total of 480 million people of all ages suffer from some mental disability at present. This works out to about 25 per cent of the total world population or one in every four of the population. Yet "Lack of urgency, mis-information and competing demands are blinding policy makers from taking stock of this situation where mental disorders figure amongst the leading causes of disease and disability in the world. The report goes on Around 450 million people in the world are affected with some kind of mental disorder today. Depressive disorders are already the fourth leading cause of global disease burden. They are expected to rank second by 2020 behind ischemic heart disease, but ahead of all other diseases. In spite of this reality, how do policy makers in the world treat this problem? Hardly anything according to the study. No explicit policy Around 40 per cent of the countries do not have an explicit mental health policy, around 33 per cent no mental health programme let alone a policy around 33 per cent no specific drug or alcohol policy, two of the issues that are closely intertwined with mental disorders. Calling upon the governments to wake up to this problem the report suggests the following policy changes for consideration. Developing policy It is the government's responsibility to develop policy, and to set down norms and standards that protect public health. This includes defining the respective roles of the public and private sectors in financing and provision of services. It also includes identifying policy instruments and organisational arrangements required in the public and private sectors to meet mental health objectives.This leadership is poorly developed in many countries where mental health is concerned. Consider the following: No explicit policy * Policy: Around 40 per cent of countries do not have an explicit mental health policy; around 33 per cent have no mental health programme let alone a policy; around 33 per cent have no specific drug or alcohol policy, two issues that are closely intertwined with mental disorders. No specific mental health budget * Budget: 33 per cent of countries do not report a specific mental health budget within their overall public health budgets; 33 per cent of countries allocate less than 1 per cent of their public health budgets to mental health; most of the rest allocate less than 5 per cent to mental health. Financing mental health - Mental illnesses are often chronic, requiring long-term support and care. Most people cannot afford to pay the full cost for treatments that could last several years. Governments need to ensure that services are affordable over long periods of time and that people are protected from catastrophic financial risk. Core principles The report says governments need to keep in mind some core principles when designing a good financing system. Governments should minimise out-of-pocket payments in favour of prepayment methods that cover mental disorders. In general, the healthy should subsidize the sick; and the well off subsidize the poor. Prepayment policies could be ensured through general taxation, mandatory social insurance or voluntary private insurance. Subsidies In countries with few prepayment policies, difficulties in raising tax revenues or extending social insurance, reducing the out-of-pocket burden would require substantial subsidies from governments, non-governmental organisations or external donors. Covering vulnerable groups - Policies should highlight vulnerable groups with special mental health needs including children, the elderly, abused women, refugees or displaced person especially in countries experiencing civil wars or internal conflicts. Risk cover Policies should also cover people at particular risk from suicide, such as those with depressions, schizophrenia or alcohol dependence. One million people commit suicide every year, while 10 to 20 million attempt suicide. Mental health policies should also include an alcohol and illicit drugs policy, as many mental health disorders are associated with both the occurrence and perpetuation of substance abuse. Promoting human rights - The stigma and discrimination associated with mental disorders leads to the systemic violation of human rights on a daily basis all over the world. People with mental disorders are often unnecessarily admitted to and treated in psychiatric institutions against their will. Many live in inhumane conditions for years because no service or support is provided for their treatment and rehabilitation in the community. People suffering from mental disorders are exposed to stigma and discrimination in all aspects of their lives. They are often denied their political, civil, economic, cultural and social rights such as the right to vote, adequate housing, employment and education. National legislation, consistent with international human rights obligations, is essential to protect people with mental disorder. Providing services In most countries, mental health services need to be assessed, re-evaluated and reformed to provide the best available treatment and care. The sheer lack of mental health services, the poor quality of treatment and services, and issues related to equity and access are some of the core issues that need to be addressed. The report suggests: Shifting away from large psychiatric hospitals - Experience from across the world has shown that large psychiatric hospitals and institutions do not work as effectively as it was once believed. Institutions leading to the loss of social skills, excessive restriction and regimentation, dependency, depersonalisation and reduced opportunities for rehabilitation no longer offer the best option for patients and families. Such institutions are also frequently associated with human rights violations. Short-term measures Certain short-term measures can be put in place until all patients are discharged from hospitals and institutions into the community with adequate community support. Psychiatric hospitals can be downsized, the living conditions of patients can be improved, staff can receive more training, procedures can be established to protect patients against unnecessary and involuntary admissions and treatments, and independent bodies can be created to monitor and review hospital conditions. Community mental health Developing community mental health services - The ultimate goal of any mental health service is towards community-based treatment and care, where people can be effectively treated and integrated into society. Institutions must be phased out in a planned manner with community services developed in tandem as a viable alternative. Although community mental health care is not available in 38 per cent of countries, many countries are moving towards this shift in services. Emergency admissions Community mental health services should include: provision for emergency admissions to general hospitals; outpatient care; community centres; outreach services; residential homes; respite for families and caregivers; occupational, vocational and rehabilitation support; and basic necessities such as shelter and clothing. Community services Governments have certain financial options. Initially, resources could be released for the development of community services by partially closing hospitals, and parallel funding could be established in order to continue with a certain level of institutional care even after community-based services have been established. Scarcity of funds Unfortunately, countries face problems in their attempts to create comprehensive mental health care because of the scarcity of funds. It is clear that comprehensive community care is unlikely to be a viable option without primary and secondary care services supporting the community care services. Integrating Integrating mental health services into general health care - A fundamental connections exists between mental and physical health. One cannot be addressed without the other. Depression may predict the onset of heart disease, for instance, or by adversely affecting the endocrine and immune functioning of the body increase the susceptibility of a person to a range of physical illnesses. Such intimate linkages make it essential that mental health be integrated into the general health systems. Advantages This integration, particularly at the primary health care level, has many advantages. Mental and behavioral disorders are common among patients attending primary care services and it is first level of health care that most people encounter and feel comfortable with. Treatment of the mentally ill in primary care involves less stigmatisation of patients and staff as mental and behavioral disorders are seen and managed alongside physical health problems. Primary health services could help improve early detection and treatment, particularly for people with physical ailments that are related to mental and behavioural disorders, or vice versa. For the administrator, advantages also include a shared infrastructure leading to efficiency savings, the potential to provide universal coverage of mental health care, and the use of community resources to offset the limited availability of mental health personnel. No medicines Ensuring the availability of essential psychotropic medicines - About 25% of countries do not have the three most commonly prescribed medicines used to treat schizophrenia, depression and epilepsy at the primary care level. Not only must the basic medicine be available throughout the health care system but health personnel need to be trained to prescribe these medicines at the primary and community health care levels. Many of the older brands are reaching the end of their patent protection offering developing countries access to cheaper generic brands. Developing countries can also avail of generic brands of medicines from several reputable suppliers and non-profit organizations such as ECHO (Equipment for Charitable Hospitals Overseas). Creating links between health and other sectors At the government level, collaboration between the various departments is essential so that adequate social and economic services are mobilized on behalf of people with mental disorders and their families. Labour, employment, commerce, economics, education, housing, other social welfare departments and the criminal justice system all deal with some aspect of mental health and their activities need to be informed by common goals. Choosing and providing service strategies Governments have many strategies to choose from keeping in mind principles of public good, cost effectiveness and equity. The crucial decision is how to use public funds. This is the area directly under government's control where reforms to improve mental health will be the easiest to undertake. Standards for private sector Governments can also influence and set standards for the private sector. Currently, insurance is a primary source for funding mental health care in about one-fifth of countries. The share of insurance, both public and private, is slowly increasing in many parts of the world. Access to mental health Governments need to ensure that people, especially vulnerable populations, have adequate and equal access to mental health insurance. One option is to require that both public and private insurers include certain mental health services in the basic package being offered to all clients. Countries such as Brazil and Chile have opted for this solution. Competition A lot of countries are also facing increasing pressure to introduce more competition and regulation into the mental health service provision market. The report says there is insufficient evidence on whether competition per se would make mental health services more equitable. Developing countries often lack the resources and experience to regulate contractual agreements between health care providers and their clients, and such agreements should be approached cautiously says the report. Developing human resources The lack of specialists as well as general health workers with the knowledge and skills to manage mental and behavioural disorders is an important barrier to providing treatment and care. In setting up community care and integrating mental health into the general health systems, people will be assuming new roles and responsibilities. Training is essential to provide the skills necessary to carry out these new tasks. Basic Training Basic training should be extended not only to the allied health professionals such as nurses and social workers, but to the informal health sector as well. Traditional healers, for instance, are the main source of assistance for at least 80% of the rural population in developing countries. If traditional healers are included in the circle of official care providers, they can facilitate referral and provide counselling, monitoring and follow-up care. These are some of the minimum requirements that countries need to keep in mind when drafting policies and programmes to address the mental health needs of their people. ========================= Parliamentary honour for centenarians Ronnie de Mel, MP and former Minister of Finance, has agreed to help the recently formed Centenarian Friendship Association headed by Prof. Colvin Goonaratne to seek the possibility of granting a people honour to the living centenarians through Parliament, thus making Sri Lanka the first country in the world to do so by way of 'respect for human life'. In his letter to the friendship association Mr. de Mel says: "I was deeply touched by the objects of your association which I will consider a great pleasure to help in sponsoring and developing. I will certainly take the matter of the centenarian honour by Parliament with the Speaker and other leaders in Parliament. ========================= New WHO report finds low income countries pay 70% of their TB bill A strategy that can cure up to 90% of all tuberculosis cases, and thus in the best chance for controlling the global TB epidemic, is reaching only 27% of the world's TB patients. This is one of the startling discoveries documented in the latest annual World Health Organization report on the disease entitled "WHO Report 2002: Global Tuberculosis Control" which is being released today (http//www.who.int/gtb/publications/globrep02/indes.html). Public health officials estimate that $1 billion a year will be needed to treat patients and control the TB epidemic in 22 countries that now account for 80% of the world's TB burden. Surprisingly, WHO found that the governments of these 22 low-income nations are already paying 70% of the cost of TB treatment and control. 'Clearly, even the poorest countries are deeply committed to fighting this disease, and the international community must respond just as vigorously," says J.W. Lee, WHO's Director of Stop TB. TB is a contagious disease that spreads through the air. Nearly one third of the world's population is infected with the TB bacillus and million people die of it each year. In 1993, the growing worldwide TB epidemic so alarmed public health experts that WHO, in an unprecedented step, declared TB a global emergency. WHO regularly assesses the state of the epidemic as well as progress being made against it. The current assessment, "Report 2002," is the sixth such report. The strategy developed by WHO is known as DOTS. It has been cited as one of the most cost effective strategies ever devised against a major killer. The strategy requires, among other essential things, that health workers watch TB patients take their drugs for at least the first two months of therapy. This reduces the chance of patients stopping treatment before they are cured from the disease. This can lead to drug resistance developing in the patient and that same resistance can be passed on to others. By the end of 2000, 148 of 210 countries were implementing the DOTS strategy, an increase of 21 countries since 1999. Where the DOTS approach is used in Asia, Africa and Latin-America, it has produced an average cure rate of 80. The goals set for TB control are that by 2005, 70% of all active infectious TB cases will be diagnosed and 85% will be successfully treated. This requires a regular supply of drugs, equipped labs and trained health professionals. While all of this is expensive, even the poorest countries are financing the bulk of TB costs themselves. Even so, this still leaves a gap of $300 million a year; about 30 cents a year for each person in the industrialized world. This shortfall has slowed the rate of expanding diagnosing and treatment services. According to the new WHO report, at the current rate, TB targets set for 2005 will not be reached until 2013. Encouraged by the financial commitments the high burden countries are making to fight the disease, donors are starting to increase their funding for DOTS expansion, and announce these around World TB Day 24 March. China, for example, will conclude a creative agreement to expand DOTS involving the World Bank and United Kingdom's Department for International Development, joining efforts of other partners. Other major pledges of assistance are being made this week by Canadian CIDA to aid TB efforts in Indonesia, bangladesh, Nigeria, Cambodia and Democratic People's Republic of Korea among others. DOTS is the internationally recommended strategy for TB treatment and control. It has five key components. These are government commitment to sustained TB control; case detection by sputum microscopy; standardized treatment of six to eight months; a regular supply of essential TB drugs; and a standardized reporting system. - WHO Release ========================= In heart attacks where doctors admit ignorance Dr. D.P. Atukorale writes It is common knowledge that heart attacks occur in people who have certain risk factors such as tobacco use, high blood levels of LDL cholesterol (bad cholesterol), low blood levels HDL cholesterol (good cholesterol), hypertension (high blood pressure), diabetes mellitus, obesity (over-weight) and heredity (family history of heart attacks). But in 50% of heart attacks patients above risk factors are absent and we have to declare our gross ignorance with regard to the causation of heart attacks. When a heart attack patient says "Doctor, I never smoked in my life, I don't have "pressure", I don't have sugar, I don't have cholesterol and one of my close relatives had heart attacks. Please tell me what caused my heart attack?" As mentioned previously we have to admit our ignorance and tell the patient that we don't know the answer and reassure the patient and treat the patient to the best of our ability. It is in the above context that role of infections and inflammation in the causation of heart attacks has emerged. It is common knowledge that atherosclerosis (thickening and plaque formation in the inner wall of coronary arteries due to deposition of cholesterol and fatty acids thus interferering with the nutrition of the heart muscle) causes narrowing of coronary arteries in which clot formation (coronary thrombosis) occurs in the atherosclerotic artery, resulting in an attack of myocardial infarction (heart attack). For a long time scientists have noted that high blood levels of high sensitively C - reactive proteins (CRP) occur in a significant number of these heart attack patients. CRP reflects the degree of inflammation of the arterial plaque. In this context it is noteworthy that the group of drugs called statins (prescribed by physicians for patients suffering from hypercholesterolaemia) have been found to reduce the inflammation of the arterial plaque thus helping the patients suffering from severe angina (unstable angina) and myocardial infarction (heart attacks) to tide over the attack with the least number of complications. At present most cardiologists prescribe these statins to patients with infarcts on admission to C.C.U. (Coronary Care Unit) even before doing the lipid profile. Role of bacteria and viruses in the causation of coronary atherosclerosis Viruses and bacteria have been proposed to have direct and indirect roles is both atherosclerosis and the unstability of the arterial plaques. It has been postulated that injury to coronary arterial wall and the inflammatory response evoked are responsible for the development of atherosclerosis. The epidemiological data suggest that certain bugs (organisms) such as Chlamydia pneumoniae, Cytomegalovirus (CMV), Herpes Simplex Virus (HSV-1) and dental flora, each of these have been found in the atherosclerotic plaque. Elevated antibody levels to Chlamydia pneumoniae, and HSV - 1 were associated with either higher risk of myocardial infarction or coronary death in the helsinki Heart Study. A high incidence of heart attacks has also been observed in patients with higher levels of CMV antibodies. Elevated CRP levels are strong and independent predictors of established coronary artery disease. Certain retrospective data have suggested that prior use of antibiotics such as Tetracyclines and quinolones was associated with reduction in the risk of first time myocardial infarction. ========================= Fruits and vegetables - cancer preventives The article we published under above caption in our issue on April 12 was sent by Dr. Terrance Perera former Senior Advisor, WHO, and not Dr. Terrance Fernando as inadvertently carried in the article. Sorry for the error - Health Watch ========================= We invite you to send your health problems on
the above to: |
|
News | Business | Features
| Editorial | Security
Produced by Lake House |
