Healthy bodies, healthy minds [full issue]

healthy bodies, healthy minds WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • DECEMBER 1977 • USA $ 1 THE MADAME OF THE WORLD HEALTH OROARIZATION • DECEMBER 1ST • USA $1 Cover: Healthy bodies, healthy minds. Detail from Children's Games by Pieter Brueghel ( 1525-1569), with the permis- sion of the Kunsthistorisches Museum, Vienna. Right: Children playing in Mali. In a rapidly changing world, how can we ensure that the health body is matched by the healthy mind? (Photo WHO/P. Pittet) Contents Mental health by T.A. Lambo 2 Children in the sun by T.A. Baasher 6 Mosaic of cultures by M. H. Beaubrun 10 mental health A CHALLE\GING NEW ROLE WITHI\ WHO Racism, apartheid and mental health by A. Jablensky 17 by Dr T. A. Lambo Reaching the unreached by R.S. Murthy 22 Compete or complement? by N. Sartorius . 28 News Page 34 World Health Index 1976- 1977 35 World Health appears in Arabic, English, French, German, Italian, Persian, Portu- guese, Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. he rational materialism of post- Renaissance Europe and its North American colonies over- valued objectivity and scientific rationality and dismissed "mental" health to the realm of subjectivity. What was omitted, in the course of Western thought, from this development of ideas was the real subject—man, in the total, unfathomable inwardness of his being; man, as a being with a passion for happi- ness, including that of the erotic crises of his life. Biases of many kinds exist. Therefore it takes considerable bravery to write on Mental Health and speak out, not only with the authority of a scholar, but with an extraordinarily probing affection for the subject. Self-critical cognition should warn us not only against simple errors of fact but against the subtler errors of bias, of hidden assumptions and omissions, or answers already made likely by the for- mulations of our questions or else tacitly excluded at the outset by our search. Long before Laplace (1796) formulated the physical theory of the Universe ("Ex- position du Systeme du Monde ...")- the famous "Kant-Laplace theory"— science had accepted the ideal of strict objectivity and claimed that its results were strictly detached, impersonal. Even the World Health Organization found it could no longer stage a conve- nient "escape from truth" and finally gave carte blanche to mental health by creating a Division and by posing new challenges to it, thereby recognizing the logical and inevitable role of mental health in promoting total human well- being. If man is the focus and the central point of development, then our health strategies should be directed towards the enhancement of his potentialities, meeting his critical needs and helping us to rede- fine and set new indicators of health. The role of mental health in such a task cannot be over-estimated. By marshalling "purely scientific and intellectual reasons" and a "host of prac- tical reasons" for this new support of a mental health programme, the new divi- sion has presented its view of future directions for the promotion of mental health as part and parcel of total health strategy within Member States. It has developed a fairly comprehensive and eclectic approach to the problem of men- tal health, recognizing the fact that the effectiveness of any strategy will depend on the physical, psychological, economic and socio-cultural characteristics of the region under consideration. This Organization, within the past few years, has taken some unprecedented and revolutionary steps. In the past, WHO's mission was threatened equally by the risk of two failures, in spite of its measur- able contributions and achievements to its credit : the failure of courage and the failure of imagination. We can be des- troyed either by the paralysis of fear or by the failure to think of anything new— to think of anything better than the few poor routines of action that we already know and are becoming irrelevant and incongruous to new needs of nations. The challenges that the Organization is facing must dare it to act and know to act. The lives of individuals and nations depend on our capacity to dare and on our capacity to know, especially at a time when an old pattern of action has failed to cope with new but inescapable prob- lems. The struggle for needed new knowledge, for openness and resource- fulness, for new possibilities, cuts across the great traditional Divisions and Units of this Organization, divisions which still persist in old ways of looking at current health problems. It was this struggle to rebel and break down the barrier that stimulated the infant Mental Health Division in April 1975 to take on the task of "converting" the Sixth General Pro- gramme of Work into a pragmatic Medium Term .Programme. What are the effects of this formidable exercise? First of all, one would like to deal with the "fall-out" effects. Medium term programming, as conducted by the Mental Health Division, proved to be an aid to insight, that is, to the perception, identification and recognition of pre- viously unrecognized and/or poorly defined mechanisms or patterns of things, events, or relations. It redis- covered "new styles" of organization and strategic simplification or relations between previously highly structured hierarchies, such as WHO headquarters, the Regions and the countries. Heuristically, certain theoretical as- sumptions were made as search devices for new observations, experiments and "discoveries". The heuristic effectiveness of such assumptions is the greater, the more fruitful and rewarding it proves to be, that is, the more likely it is to lead to new discoveries, including possibly the creation of new designs and ways of dealing with certain well-defined prob- lems. What has been clearly shown is the urgent need for the re-ordering, not only of certain fixed ideas, but also of the hierarchical structures and nearly simul- taneous re-ordering of several interde- pendent structures and relations at sever- al levels of organization—headquarters, regions, countries (within each structure and between them). 3 Perhaps the most significant re-dis- covery of this exercise is the need for wholeness in our new concept of health. It would seem, in addition, to have fur- nished a model in which future observa- tions and consequences of health actions at the country level can be predicted. This includes both a model of the prob- lem area and of its wider social, econom- ic and political context. It is gradually being revealed that our "facts" and fan- tasies about countries, our social inven- tories and indicators, our formidable data programmes and cybernetic way of thinking need not be the mere piling up of sterile information, nor need they be monuments of worship of whatever facts and practices exist. They can help us discover the new dynamics of human, social, and political reality in health, so that we can develop from them dynamics of possible revolution and social change towards human self-determination and the power of any Member State to under- stand what it is a part of and be able to determine its own fate. This is a new challenge to the concept of health, to the concept of international development co- operation in health, and it certainly is an extension of its new obligation. For this monumental task you need a multidisci- plinary tool. Multidisciplinarity is in current fash- ion but, within our programme struc- tures organized by vertical mono-disci- plines, despite much valiant talk and aspiration, much of current importance accorded to it is lip service. Health policy of the future should be regarded as the penetration of new knowledge through- out the whole fabric of human activity and not merely in the sense of the West- ern (traditional) heresy which has res- tricted the concept of health for decades to physical well-being. The new ap- proach must lay great stress on the need for a multidisciplinary attack on the problems of individuals and societies which are themselves compounded of political, economic, social, psychological and technological elements. The multi- variant components of the health proble- matique can hardly be formulated, let alone solved, by the politician in isola- "If a man will begin with certainties, he shall end in doubts; but if he will be content to begin with doubts, he shall end in certainties": Fran- cis Bacon ( 1561-1626). ( Photo League of Red Cross Societies! L. Solmssen) mental health tion, by the virologist, the clinician, the economist, the psychiatrist, or the sociol- ogist. WHO's mental health programme has attempted to construct a new, more relevant and more living picture of human needs. The new mental health programme subtly reproaches the physi- cal way of thinking for its failure to understand wholeness in the process of life. What is being clearly demonstrated by the new programme is the irreversible interdependence of all disciplines. It is a justifiable feeling of many scientists today that the narrow way of thinking has, in their sense, grasped only a part of the reality, perhaps even the less essential part. In this process of re-ordering our values and priorities in health matters, we have real need of whatever wisdom any discipline or group of disciplines can contribute. Measured against the current challenges in health, our knowledge and skills are in desperately short supply. The world is better supplied with irate citizens and with zealous partisans of competing varieties of ignorance than it is with true professional competence of a global nature in the total affairs of man. We can and must realize the cognitive and scientific power which is potentially ours in the wider study of man and his total environment. Rarely, if ever in its history, has mankind needed it as much as now. It would be presumptuous and of great intellectual arrogance to think that men- tal health alone can solve all the ills of society as well as the crippling psychopa- thologies of the individual. Alan Greeg (1948), in his characteristic visionary way, stated : "Beyond and above anyone, Henry Sigerist made us aware of the fact that medicine is the study and applica- tion of biology in a matrix that is at once historical, social, political, economic, and cultural. The practice of medicine is a part of sociology, and a product of sociological factors. We were not aware of that—nor of the vistas unrolling in such comprehensive view". A poet and priest of unrivalled schol- arship was once shattered by the ex- ponential progress of vertically struc- tured disciplines, even by Copernican achievements. It was in the year 1612, just before Kepler's final triumph, that this great genius of science of man, John Donne, spoke of the new trends of science in despair: "Tis all in pieces, all coherence gone ...". To recover this coherence in disciplines that deal with the total health of man, WHO's "harmon- ics" will have to expand beyond the range of its own sight, and John Donne's complaint, deploring the loss of man's central position as a symbol of his uni- que responsibilities, may prove vain in face of these new truths—truths which may be brought out by mental health as a worthy and logical partner of other disciplines of medicine. Mental health in its bid to establish a scientific platform and credibility must, however, continue to develop rigorous scientific instruments and technics, methodologies, truly measurable indices and hypotheses testable by standards ac- ceptable to science as whole. Here, men- tal health needs to do more work without necessarily bowing to, or expressing a touching faith in, the omnipotence of technology—whether "appropriate" or not. More than any other discipline, mental health emphasizes that know- ledge must flow in both directions, from practice to research as freely as from research to practice. Today, WHO's research activities in the field of mental health cover a wide range of subjects which command priorities, from fundamental research on cognitive and affective growth of the child, to major research activities in biological psychiatry; from epidemiological and operational research to the psychological repercussions of Apartheid and related psychosocial factors; from intensive study of the natural history of certain psychiatric and neurological disorders to highly sophisticated drug research, and so forth. In its efforts to establish scien- tific credibility it must continually remind itself of its obligation to "subjec- tive" life events. The surrender of man's thinking to rationalism and of his artifice to technics have consequences which console man with the feeling that he is progressing, but make him neglect or deny the fundamental forces of his in- ner life. The apprehension of our environmen- tal insecurity, and the searching analysis of its causes are very closely related to the existential motive which provoked a Danish philosopher, Soren Kierkegaard, to vivid and voluminous contradiction. This remarkable man, to whom all exis- tentialists acknowledge their indebted- ness, led a life that was almost as un- eventful as that of Oblomov, with an inward history that was even richer in emotional drama, and of a phenomenal intellectual activity. Never did a more troubled soul, or a more lucid and swift intelligence, seek enlightenment from the learned only to reject it as valueless. I have said this to make it clear that science and technology by themselves are powerless to achieve the transition into some sort of satisfactory equilibrium state or balance, unless their develop- ment goes pari passu with re-education and great changes not only in the organ- ization of society but also in the medical profession. This, then, is another chal- lenge for mental health in its new and extended role. Here then, according to the late Au- brey Lewis, that British scholar and psy- chiatrist of distinction, is a great domain of mental health practice in which there has been an excessive proportion of guesswork and rather a lot of subjective certainty. More doubt might have been salutary, for the reason that Francis Bacon stated : "If a man will begin with certainties, he shall end in doubts; but if he will be content to begin with doubts, he shall end in certainties". The remedy lies in the hands of psychiatrists, beha- vioural scientists, economists, immunol- ogists, cardiologists, public health admi- nistrators, health managers and so forth, all working together. It will demand a considerable effort of reorientation, and indeed sacrifices, from those scientists who devote most of their time to the systematic traditional approach, and from the psychiatrists it will demand not only an ultimate understanding of the conditions of good clinical practice, but also the acceptance of a new role with which mental health has to cope. The education of our sensibility as professional health workers and medical scientists must take place. The perceptive capacity of modern scientists has lost its flexibility. We no longer know how to listen and feel and derive knowledge from other disciplines. Too much em- phasis is placed on its impact. We see technologies that are more and more improved, and people and societies that are more and more deteriorated. It is my hope and belief that, if in all that pertains to the optimal development of man, interchange of opinion and knowledge from differing standpoints and disciplines is freely and aggressively prosecuted, the mental horizon and the quality and effectiveness of our skill and of those of other workers, the practition- ers and specialists, whose circles' of activ- ities impinge on our own, will be materi- ally widened, to the enduring advantage alike of the individual and his society. ■ 5 children in the sun by Taha A. Baasher growing number of children in the Eastern Mediterranean countries are showing symptoms of psychiatric disturbance, but treatment in the isolation of an institution is not the answer Child psychiatry as known in the Euro- American culture has a short history, and in the majority of developing countries it is still today far from being established as a separate discipline. The bulk of psychiatric work in these countries has generally focussed on adult mental illness and on residential care. Yet mental health is more than just psychiatric institutions. It rests on healthy psycho-social develop- ment and the establishment of a normal inter-personal relationship within the family, at the place of work and in the community at large. Historically, two crucial factors have influenced the life of the people of the Eastern Mediterranean Region more than anything else—the Islamic religion and the oil industry. The former, the religion of the majority in the area, brought to believers a new code of beha- viour; the latter has provided some coun- tries with exceptionally rich resources for rapid socio-economic developments. The influence of both is of central importance to mental health. For example, in pre- Islamic times, children were killed because of poverty and material need. This critical issue was firmly resolved through Koranic teaching, which clearly proclaimed : "Do not kill your children ... for God supports them and you." Furthermore, the highly important place accorded to children is reflected in the statement that "wealth and children are the glamour of life". In general, the Islamic religion has been a dynamic force in fostering a healthy parent-child rela- tionship, in promoting children's social rights and in establishing sound princi- ples, especially with regard to child-rear- ing and weaning practices, and the care of the orphan and the socially destitute. In practically all the countries of the Eastern Mediterranean Region, the rate of social change has accelerated tremen- dously and an important issue is the impact of this change on the accepted cultural heritage and on community In the traditional social setting the child feels more secure and has a better sense of belong- ing. Disturbed or retarded children are not sent to institutions, as happens in the towns, but are looked after within the community. ( Photo WHO/E. Schwab) mental health. Naturally children, being the community's most vulnerable group, are bound to be more seriously affected. In general, the position of children in society varies with different socio-eco- nomic settings. In a nomadic and pre- literate agrarian society, for example, the whole family, including the child, usually forms the basic socio-economic unit of the community. Primarily within the family circle, the child gradually learns the practice of life and masters the tradi- tional ways of earning a living. The learning process is steady and sure, in contrast to speedy and competitive mod- ern life. Within this traditional social setting, the child feels more secure and has a better sense of belonging—two factors considered fundamental to emo- tional development and stability of the personality. Significantly, when psy- cho-social deviances occur, they are dealt with in approved traditional ways, com- monly by people elected by the commu- nity. Psychologically ill and mentally retarded children are looked after within the community and according to cultural practices. By contrast, in the growing urban cen- tres in the Eastern Mediterranean there is an increasing tendency to send mental- ly subnormal and disturbed children to far-off and socially isolated residential institutions. The outcome of this has been, in certain instances, detrimental to the mental well-being of the children. Better methods of care have to be devel- oped. Generally speaking, among the 115 million children below the age of 15 living in the Eastern Mediterranean Region, relatively more are going to school, more are reaching maturity ear- lier than before, and more are better fed and cared for. Nonetheless, although it is true to say that due to improved socio- economic conditions children are grow- ing faster physically, biologically and intellectually, the complexity and vigour of urban life are generally far from con- ducive to emotional development, psy- chological maturity and social adapta- tion. Children often do not verbalise their inner conflicts, and their suffering may be manifested in various beha- vioural reactions. Recognition of these psychological abnormalities and the un- derstanding of their underlying causes are the key points for proper treatment. From the point of view of correct planning, it is important to have ade- quate information regarding the basic nature and extent of mental health needs. However, until the early sixties, hardly any reference can be found to serious studies on assessment of the psychologi- cal and social needs of children in coun- tries of the Eastern Mediterranean. This may be attributed to several factors, in- cluding lack of technical knowledge about appraisal of psychological and social problems and the scarcity of quali- fied personnel to carry out organized and systematic research in this complex field. In recent years more efforts have been made in a few countries—mainly in Cyprus, Egypt, Iran, Kuwait, Sudan and the United Arab Emirates—to assess children's psychological needs. Yet still there is a dismal dearth of information in the general health system, and existing medical records are a poor indication of the extent of children's mental health problems. From the few specialized child psychiatric services that exist, mainly for teaching purposes, it can be concluded that more than one per cent of children are referred for expert consultation because of bed-wetting, psychoneurotic disorders, educational disabilities, epi- lepsy, and so on. But these findings reveal only part of the mental health problem, and have to be supplemented by field visits and community surveys. While relatively few children with major mental disorders report to avail- able psychiatric facilities, it can be con- cluded from epidemiological community surveys that approximately one child in ten shows emotional and behavioural symptoms—such as irrational fear, sleep- lessness, feeding problems, speech dif- ficulties, bed-wetting or quarrelsome- ness—which may be considered serious enough to warrant psychiatric consul- tation. However, the majority of these chil- dren in countries of the Eastern Mediter- ranean Region live with their symptoms without being attended to by any health worker. Apparently the symptoms are contained within the family setting and dealt with by whatever socio-cultural practices exist. 7 children in the sun Left: Most of the 115 million children of the Eastern Mediterranean countries are better fed and cared for than ever before. But they are more vulnerable than adults to the effects of rapid social change, and it seems that about one child in ten now shows symptoms of psychiatric disturbance. (Photo WHO/E. Schwab) Right: Children used to learn the practice of life and the traditional ways of earning a living mainly within the security of the family circle. The complexity and vigour of modern life, on the other hand, produce problems of social adaptation for many of them. (Photo WHO) Clearly the magnitude of children's mental health problems is greater than has hitherto been realized and should therefore be accorded a higher priority in future social and health programming. The efforts so far made in this direction can be summarized under general and special services. General planning to meet the needs of children is a new development in coun- tries of the Eastern Mediterranean Region. The Tunisian Triennial Plan (1962-1964), for example, gave a new impetus to the development of children's medical and psycho-social services by expanding the maternity centres, increas- ing paediatric beds, reforming the law of adoption, creating centres for aban- doned children, and establishing net- works of kindergartens for pre-school children. In Egypt, a Supreme Council for Youth was established in 1963, fol- lowed by a High Commission of Child Care in 1964. Since then, through im- proved organizational and administrative machineries, more attention has been given to family problems, population growth, social security, special care for handicapped children, training in the field of child welfare, and family coun- selling. A promising model for promoting mental health care through social ser- vices in educational systems seems to be developing in some countries, such as Kuwait and Qatar. The work of the newly-created Directorate of Social Ser- vices is geared towards giving more at- tention to pupils' psycho-social welfare, detecting children with emotional, social and behavioural problems, mobilizing community support, and strengthening cooperation between the home and the school. The work is done mainly by general social workers, and substantial support seems to be given to children with difficulties of social adjustment, emotional problems and mental subnor- mality. Though in countries of the Eastern Mediterranean Region there are no spe- cial units in the general health system as such for the mental health care of chil- dren, mental health needs are connected with a variety of services. Care of moth- ers, attention to ante-, para- and post- natal psycho-medical needs, immuniza- tion programmes, family welfare, sup- port during crises, treatment of sick chil- dren, alleviation of parental worries—all these are closely related to mental health work. The quality of care depends very much on the interest, concern and the training of general health workers, par- ticularly the paediatrician, the general duty doctor, the health visitor, the mid- wife, and the auxiliary worker, who are in close contact with children, mothers and families. Except in the few urban centres where there are professional psy- chiatric workers, mental health care for children, however limited it may be, basically depends on what the general health personnel are able and willing to provide. During the last three decades, a series of efforts have been made in some parts of the Region to provide care for special 8 groups of children, mainly juvenile delin- quents and the mentally retarded. Some countries, for example Bahrain and Sudan, have developed the care of juvenile delinquents within the penal sys- tem. Others, including Egypt and Syria, have gradually shifted responsibility for the care of this special group of children to the Ministry of Social Affairs. While it is recognized that psychological factors are significant in anti-social behaviour, it is important to organize care for such children as a collaborative effort between the different social services and direct activities so that education, vocational training and rehabilitation receive suffi- cient attention. In some countries, particularly Leba- non, the care of the mentally retarded is carried out mainly by voluntary organ- izations. In Cyprus and Iran too, ser- vices were initiated through voluntary work and later on Government support made it possible to expand the number of institutions and improve the quality of the care. Experience gained with self-help in this field has also been interesting. In a few countries (Iraq, Kuwait and Libya), formal residential services were established. However, despite keenness and effort, the care of mentally retarded children in some countries has been staggering under the burden of increas- ing numbers of children admitted into institutions, shortage of qualified per- sonnel, deficiencies in facilities, lack of community involvement and social isolation. Attempts have been made in some countries to develop special facilities for children within existing psychiatric insti- tutions or as separate out-patient clinics. In Egypt, Kuwait and Tunisia a begin- ning has been made in introducing spec- ialized mental health services for school- children. In general, the most serious con- straints in all countries are essentially the scarcity of qualified manpower and the difficulty of implementing technical knowledge in a simple and accepted way. The setting of priorities for future plan- ning and programming should be based on valid criteria with practical relevance to national needs, community concern, degree of prevalence and seriousness of childhood disorders, and the possibilities of providing effective care. An important priority in the majority of the countries is the need to develop an integrative approach, with closer coor- dination between medical, social, educa- tional, judicial and vocational services. This means reviewing existing pro- grammes, developing a more efficient organizational framework, pooling resources and providing better compre- hensive care. Future strategy should aim at better training at professional and non-professional levels, and the involve- ment of general health personnel and community workers. Through better knowledge, improved skill and a fresh outlook, it is to be hoped that more appropriate inroads will be made in the important field of children's mental health care. ■ 9 mosaic of cultures THE NEW MENTAL HEALTH OFFICER WAS AUTHORISED TO DEAL WITH PATIENTS "WANDERING AT LARGE": HE CANNOT CERTIFY ANYONE BUT MERELY CONVEYS PATIENTS TO HOSPITAL FOR EXPERT OBSERVATION by Michael H. Beaubrun he small twin-island nation of Trinidad and Tobago, with a population of just over a million, began a new Community Psychia- tric Service in June 1965. The country was divided into five sectors within each of which an attempt has been made to develop comprehensive mental health care integrated closely with general med- icine. A new feature of this programme today is the use of nurses trained in psychiatry and social work to serve as extensions of the psychiatrists and social workers into the community, especially in rural areas. They are called Mental Health Officers and they assist with the rehabilitation and re-admission, where necessary, of patients discharged from hospital. They are given authority and responsibility under a new law to bring to hospital for observation persons who show signs of being mentally ill and have no one to look after them. They also carry out preventive psychiatry, give ad- vice to relatives, help patients to find jobs, take part in community education and meet with community leaders in the villages. They make home visits and sometimes administer injections of long- acting tranquillizers to patients at home when such patients are unable or unwill- ing to come to the outpatient clinic. Our experience with this new programme may be of interest to other developing countries experimenting with new ways of delivering mental health care. The islands of Trinidad and Tobago lie at the south-eastern end of the Carib- bean archipelago near the coast of Vene- zuela. Together they form one country which became independent within the British Commonwealth in August 1962 and a republic in August 1976. The pop- ulation of 1,085,000 live on 1,981 square miles of land. The majority are of Afri- can (43 per cent) and Indian (40 per cent) origin. The Indians, mainly Hindus and some Moslems, were brought from India as indentured labour after the abolition of slavery, while some indentured labour also came from Madeira and China. Arabs and other Chinese came as immi- grant merchants and the British, French and Spanish as colonizers. The result is a mosaic of cultures and races living in a fair degree of harmony. The Indians are mainly villagers em- ployed in agriculture, though many in recent years have succeeded in the pro- fessions, in business and in the new manufacturing and assembling indus- tries. The Africans are urban dwellers and predominate in the civil service, and in the oilfields and refineries which pro- duce most of the country's wealth. Recent oil and natural gas finds and the sharp increase in world oil prices have radically altered the economy within the past few years, and have enabled Trini- dad and Tobago to build up financial reserves of US $3,000 million. The budget in 1976 was US $1,000 mil- lion. The country is, therefore, relatively prosperous among countries of the deve- loping world. Yet even with this relative prosperity there is still an unemployment rate which reaches about 16 per cent at the time of school graduation each year. There are about 500 doctors in the country of whom 24 are in the full- time practice of psychiatry and, of these, 11 are fully qualified specialists. This means a ratio of little more than one fully qualified psychiatrist per 100,000 population. Though this is better than in South-East Asia or Tropical Africa, it falls short of the recommended Caribbean target of two per 100,000. Psychiatric social workers, psycholo- gists and occupational therapists are in even shorter supply. There are nine psy- chiatric social workers, three clinical psy- chologists and five occupational therap- ists for the entire country. The figure for nurses is slightly better. There are 400 trained psychiatric nurses, and 160 trained psychiatric nursing assis- tants. It was to this resource that the Government turned first in its attempts to take psychiatry outside the walls of the Psychiatric Hospital. Beginning in 1973, a programme of in-service training in social work was begun for some ex- perienced psychiatric nurses. They were assigned to the Department of Social Work for a year's supervised experience and training. From these nurses were drawn 13 of the first 15 mental health officers to be appointed. The other two were a public health nurse and a general nurse with additional training in psychia- try and social work. The only psychiatric in-patient facilities in the country are a 1,600-bed psychiatric hospital in the cap- ital, Port of Spain, two psychiatric units in general hospitals (one of 28 beds and the other of 12 beds), and 6 observation beds in the Tobago General Hospital. Certain essential steps had to be taken before the community care programme could be launched : A census of the psychiatric hospital population was carried out to indi- cate which patients could be returned to the community; what coping skills they had ; what special settings might be required for their rehabilitation and where these settings should be located. In other words which A Mental Health Officer in Trinidad per- suades a patient to come to hospital for treat- ment. Wandering vagrants in the towns have long posed a public problem. ( Photo WHO IM. Beaubrun) 10

mosaic of cultures patients, living in which geographical areas, would need or could benefit from "half-way houses", sheltered workshops, day hospitals, geriatric homes or other special facilities for community care. The census pro- vided the information needed to plan the location, size and kind of facility that would be required. An interdisciplinary working com- mittee was set up in the Ministry of Health in January 1975 to plan and coordinate the programme and to modify the plans as experience dictat- ed. The committee was made up of senior persons in psychiatry, social work, mental nursing, public health nursing, health administration and community medicine. Lay participa- tion was also obtained through the Mental Health Association. New legislation, the Mental Health Act Number 30, was enacted by Parliament in 1975. This provided for easier admission and discharge of patients and at the same time offered better protection for their civil rights and property. It also created the new category of Mental Health Officer with responsibility and authority to deal with patients "wandering at large on a highway". Section 13 reads : "A person found wander- ing at large on a highway or in any public place and who, by reason of his appearance, conduct or conversa- tion, a Mental Health Officer has reason to believe is mentally ill and in need of care and treatment in a psy- chiatric hospital or ward may be taken into custody and conveyed to such hospital or ward for admission for observation ...". The Mental Health Officer cannot certify anyone. He merely conveys the patient to hospital for observation by trained psy- chiatrists, but the person so conveyed may be detained for 72 hours for an examination to be made. He is also given power to call on the police for assistance if necessary, though every effort is made not to do so. The implications of this for civil rights will be discussed later. — The country was then divided into Patients in a psychiatric ward in Port of Spain. Community education by radio, press and television created an enormous in- crease in patients as people who had never before seen a psychiatrist came forward for treatment. (Photo WHO/E. Rice) five sectors of about 200,000 people each. Care was taken to follow coun- ty boundaries and to fit into existing zones of the public health service, so that the programme could be linked administratively with that service. The available psychiatric beds at the Psychiatric Hospital and the two gen- eral hospital psychiatric units were then divided and allocated to the five sectors so as to provide each with short-, intermediate- and long-stay beds to accommodate both women and men patients. This meant some internal rearrangement of the large psychiatric hospital so as to group together the patients from each geo- graphical area. The available mental health profes- sionals were then similarly divided into five teams, each led by a consul- tant psychiatrist and a psychiatric social worker. Three existing services, dealing with alcoholism, child psychiatry, and penal and forensic services, were not sectorized to start with but remained national in scope, serving the entire country. An alcoholism treatment centre built in 1961 provides in- patient and out-patient care for alco- holics. A child guidance clinic started in 1975 as a pilot project offers con- sultant services to the country as a whole but can only accept a limited number of cases for treatment. Men- tally ill prisoners from the correc- tional services or from the courts are presently detained at a maximum security ward of the Psychiatric Hos- pital, but a special psychiatric unit has been designed for a new prison which is about to be built. From the outset a policy was pursued of not developing too rigid a plan. The cultural and social diversity of Trinidad and Tobago implied that the mental health needs of different sectors would be very different. For example Sector Three with a large preponderance of Indian, rural, sugarcane and ricefield workers might have less use for a day hospital than sector Five, made up most- ly of the City of Port of Spain. It was left to the team of each sector, in consulta- tion with the people they served, to tell the Working Committee what their sec- tor seemed to need most urgently. This seemed a more practical way to proceed than by embarking on a large expensive epidemiological survey to determine needs. 13 I- mosaic of cultures The stated goals of the programme were : to provide care as near as possible to the patient's home ; to upgrade the Psychiatric Hospital and reduce its size by returning as many patients as possible to the community; to develop additional sub-specialist services where needed; to develop a system of community con- sultation in each sector; to do community education and work with community leaders to develop bet- ter attitudes and programmes for preven- tion ; to integrate mental health with general health care; to develop evaluative research and training. Within the scope of these goals, we were able to set the targets and launch the programme in mid-1975. One of the key factors for success will be the ability to attract and retain staff at all levels. The Medical School in Trinidad has started a residency programme to train psychiatrists in culturally appropriate ways while working within the communi- ty. These trainees are also doing evalua- tive studies to test the effectiveness of the service being rendered. It was important that the Sector teams should be of both sexes and should reflect the racial diversity of the popula- tion. For instance a male black Mental Health Officer would be unlikely to have the same success as a female Indian Officer if the patient were a Hindu wom- an in a rural community. The tactfulness and experience of the Mental Health Officers has been an important factor in their success in dealing with relatives and patients alike. Changes in the tempo of life with rapid industrialisation have made greater demands for work efficiency and some individuals have not been able to adjust to this. Those with personality disorders and chronic mild neurotics, unnoticed hitherto in the more leisurely pace of life, have now become misfits, and turn up for help at the psychiatric clinics. The use of marijuana and the misuse of sedatives and minor tranquillizers by urban youth seems linked to the underemployment problem. The duties of the Mental Health Officer include administering injections of long-acting tranquillizers to out-patients in their homes. (Photo WHO/M. Beaubrun) Alcoholism is a big problem, particu- larly among the Indians who represent 75 per cent of the 450 patients treated annually at the Alcoholism Treatment Centre. There are more than 80 groups of Alcoholics Anonymous in the country with a membership somewhere between 2,000 and 3,000. The preponderance of Indians is so great that the movement has become culturally Indian in style. Socio-cultural factors contribute to the high incidence of alcoholism among In- dians. Differences between their tradi- tional attitudes and customs with regard to alcohol and those of the prevailing Trinidad lifestyle cause ambivalence and guilt about drinking. In addition there is inconsistency in the ways in which the Indian child is socialized into the use of alcohol. Frequent suicidal attempts by young East Indian girls are another conse- quence of the cultural and generation gap. Exposed to Western ideas, they want the freedom to choose a husband and a career, and they rebel against the traditional and religious demands for strict obedience to their parents. A sui- cide attempt sometimes resolves the im- passe, saving face for everyone. In Sector Four Dr Marceau reports that of 314 sui- cide attempts seen by her in one year 77 per cent were by women, and of these 78 per cent were of East Indian origin, mainly between 15 and 24 years of age. Since the country attained indepen- dence in 1962, great importance has been placed on education, and the Child Guidance Clinic, opened in 1975, will need considerable expansion as there is a great need for guidance services in schools. A problem which had been causing some public concern for years was the presence of wandering Vagrants in urban areas, getting in the way of traffic and otherwise making themselves a nuisance. Not all of these were mentally ill but there was public clamour that the social and psychiatric services do something about them. This was the major selling point for the new Mental Health Act. The powers given to the Mental Health Officers to bring "mentally ill persons" to hospital under Section 13 provided some public debate about the possible threat to civil liberties. Fears were ex- pressed that such powers might be abused and might result in the detention of anyone the officers disliked or whose political views the Government did not like. In fact, no such abuses have occurred. The Act provides stiff penalties for any such abuse of power and there are ade- quate opportunities for appeal and redress. Yet such objections are not irrel- evant. In some countries there have been allegations of misuse of psychiatry for political purposes and, despite the good record for civil liberties enjoyed by Trini- dad and Tobago, it was necessary to build in these safeguards. In some West- ern countries, a spurious concern for the civil rights of the mentally ill has some- times endangered their right to be treat- ed, and sometimes their very lives and the lives of others. Section 13 of the Trinidad Act allows us to act with humanity in the patient's interest. It en- able us to offer him treatment before he kills himself or someone else. In an emergency, cumbersome procedures for certification may spell disaster. It has been our experience that where no doc- tor has been available to sign an urgency order, the powers given to the Mental Health Officer have been invaluable. After two years of operation the pro- gramme is still in its teething phase. It would be misleading to say that all iden- tified targets have been met. Many con- straints have held up the programme's implementation. Sometimes uneven development has created imbalances and new problems. For example, early com- munity education by radio, press and television and the opening of new clinics created an enormous increase in patient load as people who had never before seen a psychiatrist came forward for treat- ment. Some clinics recorded attendances of more than 100 patients on a single morning. Temporary drug shortages and problems of patient transport resulted and at first the number of hospitalized patients rose despite more discharges. This, coupled with delays in the building programme, put some strain on the large Psychiatric Hospital but numbers have since fallen again. Some sectors have been more successful than others in keeping patients out of hospital, and more success has been achieved where the psychiatrist has been willing to dele- gate more responsibility to the Mental Health Officer. More mental health officers are needed and the facilities to decentralize the Psychiatric Hospital must be built. But at this stage we can say that the programme is reaching all parts of Trini- dad and Tobago and with time should attain the goals set for it. ■ 15 by Assen Jablensky As the Universal Declaration of Human Rights prepares to mark its 30th anniversary, World Health looks at mental health care in South Africa "It is not possible to enslave men without logically making them inferior through and through", wrote the Black French psychiatrist and social thinker Frantz Fanon. Racism, he continued, is "the emotional, affective, sometimes in- tellectual expression of this inferi- orization". Dominant groups and classes have cultivated racism in its different varieties in order to rationalize and perpetuate social injustice, economic exploitation, and cultural oppression. The peculiar utility of racism for those who have a vested interest in its spread and mainten- ance lies in the fact that, once accepted by its converts, it simplifies enormously for them the realities of the world : hard and fast lines seem to be drawn which divide people on the basis of superficial attributes like skin colour, and social inequality can then be seen as the corre- late of a "natural" order. It is unthinkable that racism would be without implications for mental health. Healthy mental functioning and person- ality development depend on the pres- ence and continuity of such essential experiences as the individual's sense of security and worth, freedom for personal growth and identification with a commu- nity of equals. Racism undercuts at the roots of healthy mental life by depriving its victims of these experiences and by conditioning them into accepting the myth that the cause of their inferior status in society lies irrevocably within themselves. Apartheid, the cornerstone of social order in the Republic of South Africa over the past 30 years, is a system of political and social control based on the institutionalization of racial discrimina- tion which maintains the economic, political and cultural dominance of a White minority (17.4 per cent of the total population of over 21 million according to the 1970 census) at the expense of the Black majority (83.6 per cent, including over 15 million Africans, over two mil- lion Coloureds and over half a million Asians). For the individual, the simple fact of his or her racial categorization, as defined on an official identity card, deter- Sanatorium for Indian mental patients in Natal. As in every health sector in South Africa, the mental health services are segregated by race. mines every aspect of life from cradle to grave. What are the effects of this system on the mental and psycho-social develop- ment of the people coerced to live under it? The suicide rates in Durban increased sharply within a year in 1948 (from 8.8 to 18.1 per 100,000 for Africans, from 15.8 to 36.3 for Coloureds, from 20.5 to 23.6 for Asians, and from 17.5 to 19.2 for Whites) when the protagonists of apart- heid came to power and started imple- menting their plan of a "racial reclassifi- cation" of the population. One of the immediate consequences of the Prohibi- tion of Mixed Marriages Act of 1949 was that 3,890 people were convicted and many families and unions were broken up. Yet intermixing of the races has been the rule rather than the exception in South Africa since the first Europeans settled in the Cape area in the seven- teenth century. The absurdity of racial categorization can be illustrated by the fact that in 1936, i.e. before the apartheid era, it was estimated that there were at least 733,000 persons of "mixed descent" among the country's 1.9 million Whites. The educational system, one of the institutions with most powerful impact on the individual and on society as a whole, has been among the primary targets of the apartheid policies, and the so-called Bantu Education Act has forced inferior educational standards upon Africans since 1953. Its purpose, in the words of the architect of apartheid, Prime Minister Verwoerd, was to eradi- cate "the vain hope that was created among the natives that they could occu- py posts within the European communi- ty". One of the characteristics of "Ban- tu Education" is the extremely high drop-out rate among African schoolchil- dren. Only 4.5 per cent of them reach high school, compared to 34.4 per cent of the White children. The proportion of Black children qualifying for "stan- dard 10" which is a prerequisite for higher education is 0.1 per cent (4.2 per cent for White children). The educational deprivation and the laws imposing a ceiling on the occupa- tional skills and opportunities of Black Africans perpetuate an economic system in which three-quarters of the population receive less than one-quarter of the net national income. The wages and salaries of Blacks are a fraction (on the average 17 racism, apartheid and mental health Which photograph reflects the true picture? Left: Mentally ill Blacks exercising in "a Rehabilitation Institution in the Bantu Home- lands." Right: Conditions in such "sanatoria" were described two years ago by a prominent South African journalist as "a version of the Dicken- sian workhouse". None of these institutions —with a total of over 10,000 patients—has a full-time medical officer. one-fourteenth) of the income of Whites. The lack of reward for achievement, according to a socio-psychological study in South Africa, stifles creativity and leads to frustration and lack of aspira- tions. Nothing summarizes better the economic functions of apartheid than the policy statement by Dr Verwoerd : "There is no place for the Bantu in the European community above the level of certain forms of labour." The dependence of the entire economy on the exploitation of cheap Black labour is closely linked to the policy of forcing the "surplus" African population into so-called "homelands". Over three million people have been evicted and forced into the "homelands", with the resultant splitting of families (since many African men have to live as migrant workers in White-controlled areas). Thus the family unit which is the basic cell of every society and one of the essential factors in personality development, is disrupted on a mass scale by apartheid. Blacks are required to carry at all times and produce on demand by any White person a reference book with monthly police authorization of their movements. Over half a million Africans are convicted under this law each year. A recent proclamation of the State Presi- dent, providing for the setting up of special "rehabilitation" camps for such pass offenders with the purpose of "im- proving their physical, mental and moral condition" went so far that the protest it aroused impeded its implementation. These are only a few examples which show that the majority of the population is exposed to an anomalous, hostile and highly stressful environment. Other psy- chosocial indicators illustrate some of its effects. More than 7,000 Africans die as a result of violent crime every year, and in 1969-1970 the average daily prison population per 100,000 was 476 for Africans and 80 for Whites. Suicide curves for Black Africans (who in the past had the lowest suicide rates in the country) have remained high since 1948. A recent survey in Durban established that in 1971 they reached 17.5 per 100,000 (compared to 17.3 for Asians, 17.1 for Whites and 9.2 for Coloureds). The different motivation of Black suicide can be inferred from the fact that while among Whites suicide occurs mainly in advanced age, the majority of Africans committing suicide are young adults. Can organized health care, and espe- cially mental health care, prevent or all- eviate at least part of the mental health problems occurring in a racist society? There is no doubt that an appreciable segment of the health workers in South 18 Africa do not condone the racist policies. But as in every sector of health in South Africa, the mental health services are segregated by race and the Government maintains a policy of differential respon- sibility of the State towards mental health care for the different racial groups. Several facts will suffice to out- line this policy in its essence. There is not a single Black psychiatrist in South Africa. Since communication with the patient and an understanding of his culture are essential to the practice of psychiatry, especially in a multi-ethnic society like South Africa, this fact seriously affects the quality of mental health care available to Blacks. There is no legal ban on an African postgrad- uate student becoming a psychiatrist. There is, however, a legal ban on any African doctor supervising White per- sonnel, a ban on a Black physician being paid the same salary as a White physi- cian, and a ban on Africans enrolling in a medical school of their choice. The only medical school open to Africans, at the University of Natal, produced only 16 African doctors in 1972 (African med- ical students constitute 4.4 per cent of all medical students in South Africa). The total number of African physicians trained in South Africa between 1946 and 1971 was only 252 (0.65 African physician per one million Africans com- pared to 98 White physicians per one million Whites). The humiliating limita- tions under which a Black specialist doc- tor has to work explain why so few, if any, of the small number of African physicians aspire to a specialist grade. As regards the availability of hospital beds for mental patients, in 1975-76 the total number of psychiatric beds pro- vided by the Department of Health was 26,298. There were, segregated by race, as follows: 10,596 for Whites, 3,133 for Coloureds, 480 for Asians and 12,089 for Africans. The ratio of beds to population is 2.55 per 1,000 White, and 0.76 per 1,000 Coloureds, Asians and Africans. Therefore, the vast majority of the South African population has 3.36 times fewer psychiatric beds than are provided for the White minority. This has resulted in a chronic overcrowding of the hospitals for Black patients and limits severely their capacity to provide treatment ac- cording to needs. Thus there were recent- ly 3,396 Black in-patients in excess of the capacity of the mental hospitals for non- Whites, while at the same time there were 830 vacant beds in the psychiatric hospi- tals for Whites. These figures, like all those quoted in this article, derive from material published in the Republic of South Africa. 19

racism, apartheid and mental health The current policy of admission to psychiatric facilities almost eliminates any active participation in the treatment process on the part of the Black patient with a mental health problem. In view of the extreme shortage of beds, and the unavailability of community mental health care, by far the greatest number of admissions of Black patients are in- voluntary. The state hospitals for Africans are overwhelmed with severely disturbed patients admitted on court orders, usual- ly after committing an offence. Such patients can be transferred to a custodial institution as a measure of long-term disposal, merely to allow for new patients sent by the courts to be taken in. This contrasts sharply with the pattern of ad- mission of White patients, most of whom are admitted on a voluntary basis. Access to psychiatric treatment for those Africans who may seek it volun- tarily is also limited by the differential tariff of treatment fees that exists for Whites and non-Whites. Although the 1973 Mental Health Act does not men- tion race in any of its articles, the Gener- al Regulations governing its application require non-White patients to pay higher fees relative to their income than White patients. Taking as an example the rela- tively high monthly salaries of transport workers (320 Rands for Whites and 54 Rands for Blacks in 1973), one can show that the cost of one month of psychiatric treatment will amount to 60 per cent of the salary of the African worker and to less than 20 per cent of the salary of the White worker (1 Rand = US$ 1.15). Community services for the care for the mentally ill show the same gross disparity in provisions for Whites and non-Whites. Despite the efforts of a few city councils and mental health profes- sionals to redress such disparity on a local level, the facilities for supportive and preventive community care for non- Whites never exceed, in either range or number, one half of those for Whites. For example, educational and training facili- ties for mentally retarded African chil- dren simply do not exist. In Greater Stress is a factor common to human societies all over the world. All the evidence points to the fact that a racist pattern of mental health care provision cannot alleviate the stresses inflicted on millions in a racist society. ( Photo J. Mohr c ) Johannesburg (which includes Soweto), 64 per cent of all community health and social service facilities are located in White areas. One of the most telling examples of racial discrimination in the mental health field is the way the apartheid regime has dealt with the catastrophic overcrowding of the mental hospitals for Africans. Faced with an ever increasing number of chronically ill African mental patients, the Government has since 1964 contract- ed the services of a private profit-making company to accommodate in custodial institutions over 10,000 certified African patients against an annual subsidy from the health budget. This subsidy, accord- ing to official budget figures published by the Government, was over 5 million Rand for the year 1975-76. The pri- vate company makes an agreed rate of profit from it, by economising on staffing, having lower food bills and us- ing unpaid patient labour to convert abandoned mining compounds into so- called sanatoria for Black mental patients. Two years ago the conditions in these "sanatoria" were described by a prominent South African journalist as a "version of the Dickensian workhouse". All African mental patients in these "sanatoria" are involuntary admissions transferred for long-term custody from state hospitals. The number of dis- charges each year is only 12 per cent of the number of admissions. None of these institutions, with a total of over 10,000 patients, has a full-time medical officer. Supervision of treatment is car- ried out through weekly visits by staff from the nearest state hospital. The viability of the system depends entirely on the personnel, consisting of African nursing assistants hired at low rates of pay and trained by the company. The same company runs a number of small nursing homes and private treat- ment centres for a total of 716 White patients. The subsidy which the Govern- ment is paying per White patient is 5.13 Rand, compared to 1.44 Rand per African patient. The levels of service available to Whites and to Africans can be further illustrated by the contrasting examples of two institutions. The H. Moross Centre in Johannesburg (ad- ministered by the Transvaal Province Government) has 150 beds for White patients only and staff including 6 psy- chiatrists, 10 clinical assistants (physi- cians), 12 clinical psychologists, 8 occu- pational therapists, 4 social workers and an unspecified number of nurses. The Randfontein Sanatorium for Africans (run by the private company) accommo- dates 3,200 patients and has two part- time psychiatrists and one part-time gen- eral physician, 21 nurses and 164 nursing assistants. The Government subsidy is paid on a per capita basis and the profits of the company increase if more patients are committed. Transferring more Africans to private institutions also suits the in- terest of the Government, since the long- term maintenance of an African patient in a private "sanatorium" is cheaper. The efficiency of this conveyor-belt for the processing of African mental patients has occasioned self-congratulatory state- ments by some of its designers who have even proposed this as a "model" for the mental health services of other African countries. The existence of private institutions for the care of the mentally ill is not necessarily a violation of human rights. The existence of two different systems of care, one of high and the other of inferior standards, for the different racial groups, as well as the laws which allow private business to make profits on racial dis- crimination against many thousands of patients in the wealthiest country of Afri- ca, are a grave violation of human rights. The network of profit-making private institutions for Black mental patients has already provoked a wave of protests both within and outside South Africa. The Government responded with repression, passing in Parliament an amendment to the 1973 Mental Health Act which makes it a punishable offence (up to one year's imprisonment and a fine of 1,000 Rand) to publish uncensored information about the mental health ser- vices in the Republic and even to take photographs of psychiatric institutions or patients. Recent reports in the South African press indicate that as a result of continu- ing pressure at home and abroad the Government is considering phasing out the "sanatoria" and making budgetary provisions for the construction of new State hospitals for Black mental patients. This however would be no more than a cosmetic operation on the face of apart- heid. A racist pattern of mental health care provision cannot alleviate the stresses inflicted on millions in a racist society. ■ 21 reaching the unreached by R. Srinivasa Murthy n the last two decades there has been a major shift in the organization of health services all over the world. There have been efforts to "depro- fessionalize" many health activities, to decentralize services and to place in- creasing emphasis on providing services for "priority problems" for everyone. This shift can be viewed as a "public health" or "community" approach as compared with the earlier emphasis on individual health care. In this context, the present article attempts to highlight possible ways of providing mental health care in peripheral health centres of deve- loping countries, and in particular of India. Traditionally, mental disorders have been considered as a problem of the affluent countries. The organization of services is thought to be too complex and expensive for developing countries. Thus it is not surprising that there is, at present, very little recognition of men- tal health needs within general health services. The reasons behind this relative neglect of mental health needs are not difficult to understand. Firstly, until about a decade ago there was very little reliable epidemiological data relating to the distribution and prevalence of mental disorders in the population. Secondly, in the past the major effort in planning the services was directed towards establish- ing mental hospitals and clinics. These mental hospitals were more often custo- dial than therapeutic. Thirdly, there has been a severe shortage of trained profes- sionals, and few of those available have been working in urban centres. Fourthly, the general public often view mental disorders from religious, superstitious and magical standpoints. This has lim- ited the effective utilization of even the available services. Fifthly, there have been no meaningful models for the pro- vision of services suited to rural socie- ties; the research efforts of the profes- sionals have only recently been directed towards this field. Lastly, the supply of psychotropic drugs is limited and very few welfare agencies exist to undertake rehabilitative work. It is not unusual to hear health plan- ners, administrators and medical profes- sionals make comments like "Is it a problem?", "Can anything be done?" or "Don't we have more important health problems?". These doubts are especially relevant in developing countries where the funds available for health services are limited and there is a more obvious need to control communicable diseases, improve nutrition and provide immuni- zation. Above: Even today, acutely ill patients in some countries are managed by being res- trained in chains rather than by drugs and hospitalization. ( Photo WHO/R. S. Murthy) Right: Too much emphasis in the past was placed on large central mental hospitals, more often custodial than therapeutic. (Photo WHO/E. Schwab) At this point a brief consideration of the magnitude and the public health im- portance of mental health will illustrate the need as well as the scope for organiz- ing services. Epidemiological studies from different parts of India during the last decade have shown that different forms of mental disorders are prevalent in all cultures and communities. The prevalence of different forms of psy- choses is about one per cent, and if mental retardation and epilepsy are in- cluded it is about two per cent. This figure represents the severely ill, requir- ing care. What about their "community ef- fect"? It is estimated that about one-fifth of all the disability in a community is due to mental disorders, and these cause a still greater degree of social disruption. For example, the frequency of marriage- related problems in schizophrenia were shown in a Chandigarh study to be about ten times that for the comparable general population. A significant number of students with schizophrenia do not com- plete their studies. The effect on the family members is another aspect of the problem; nearly half of them resented a schizophrenic living in the family. The effects of psychotic depression in terms of individual suffering, loss of produc- tion and the risk of suicide illustrate the importance of treating acute psychoses. But mental health care is not just the care of psychotics. Health services are burdened in their routine work with a significant proportion of patients with emotional disorders. Studies carried out at a big referral hospital at Vellore, South India, and in the peripheral health centres of the Raipur Rani Block, in North India, have shown that nearly 30 per cent of general out-patients have mainly emotional problems. These cases are most often mis-diagnosed, leading to costly and time-consuming investiga- tions and treatments. This mal-utiliza- tion of the limited health services can be avoided if primary physicians and health workers are trained in mental health care. 22 S. , • „.? U y; ty4. # • Alt • . 0,A 1 -, yr, 1 reaching the unreached In addition to the above traditional problems, there are others. Some exam- ples are the growing problem of drug abuse and dependence, adverse effects resulting from the break-up of the joint family system, and the ill-effects of in- dustrialization and urbanization. In a developing country like India, social upheaval is inevitable as a result of at- tempts to increase the rate of develop- ment and modernization. If adequate plans are not made, there is every likeli- hood that these problems will soon become the chief burden of the welfare services. Planning ahead and prevention are the two most important needs in this area. There are other sources of avoidable mental health problems in developing countries. A good example is the prob- lem of mental retardation. There is grow- ing evidence to show that malnutrition and anaemia in the pregnant mother, as well as poor nutrition in the first two years of life, contribute significantly to the incidence of mental retardation. Pro- fessor Sethi's study of rural families near Lucknow suggests that a majority (72 per cent) of the retarded in the community were of the mild retardation group. It was further noted that this could arise mostly from environmental factors, espe- cially from "nutritional deficiencies". Similarly the high rate of first cousin marriages (as much as 40 per cent) in some communities of South India may contribute towards certain forms of men- tal retardation. There is scope for prevent- ing the above groups of problems through public education, legislation and the provision of adequate maternal and child health services. This preventive ap- proach is also relevant for implementing such mass health activities as immuniza- tion and family planning. Against this background of needs, the available services and the awareness of mental health problems in the peripheral health centres are very meagre. There are fewer than one psychiatrist per million population, about one-third of the medi- cal colleges in India do not have depart- ments of psychiatry, and the mental health training of basic health workers is negligible. Thus even today most acutely ill individuals are managed by being res- trained in chains rather than by drugs and hospitalization. Fortunately, in the last 30 years, there has been a significant increase in trained personnel and training facilities in India. What has been lacking is a coherent national policy and a commitment to provide basic mental health services to a majority of the population in the quick- est time possible with the minimum of expenditure. This is the challenge facing mental health professionals in develop- ing countries. A wide network of health facilities exists in the rural and urban areas of India. The basic unit is the primary health centre (PHC) catering to about 100-120 villages with a population of about 100,000. There are two to three medical officers in each PHC along with other additional health staff. In-patient facilities for eight to twelve patients are available. The PHC is connected to the peripherally situated subcentres (six to ten per PHC) manned by auxiliary health staff—health supervisors, multipurpose workers and dais (nurse-midwives). Thus there are provisions for the rural popula- tion to get medical services through a network of subcentres and PHCs. In addition, the multipurpose workers visit each household periodically to collect vital statistics, provide care for minor illnesses and give health education. More than 5,300 PHCs and 33,000 subcentres distributed all over the coun- try have been unable to provide effective health care for a number of reasons, the chief of these being the lack of supplies, supervision and support. The drug bud- get of the PHC is Rs 6,000 (8.70 rupees = US$1) and that of the subcentres Rs 2,000 per year. The average per capita expenditure on drugs works out at less than one rupee per year, out of the ten rupees spent on health services. This drug scarcity imposes an important limi- tation on the effectiveness of the existing health staff to provide curative services. The problem of drugs becomes very clear if the following example is consid- ered. Out of the population catered for by the PHC about 900 epileptics requir- ing drugs can be expected. The treatment of these 900 with phenobarbitone, the cheapest drug, would cost more than the total drug budget of the PHC ! At present health workers have no sedatives or psy- chotropic drugs with them and even at 25 A happy scene of village children dancing. Nevertheless, a variety of mental disorders are prevalent in all cultures and communities. Indeed about one fifth of the disability in a community is due to mental disorders, which in turn cause a great deal of social disruption. ( Photo WHO I E. Schwab) reaching the unreached Left: Recent evidence shows that rural life itself may be beneficial in preventing chronic mental illness. Studies also show how impor- tant it is to avoid the dangers of social isola- tion which result from moving mental patients to hospitals away from their communities. ( Photo WHO E. Schwab) Right: In the grounds of an Indian psychiatric hospital. Today's emphasis is on integrating mental health care with general health ser- vices, and on placing responsibility for primary care upon those health workers who are closest to the community, leaving more complex prob- lems to be dealt with by more intensively trained staff ( Photo WHO/S. Kochar) the PHC the availability of the basic psycho-pharmacological agents is quite inadequate. Other limitations are the lack of mobility of health workers and medical officers which prevents proper supervi- sion and support. The same problem hinders the functioning of a proper refer- ral system from the subcentres to the specialized institutions. These are in- herent problems of the rural areas and are as relevant to mental health care as to general health care. Existing personnel can, however, be used to advantage by stepping up training, support and sup- plies, and this should result in quick benefits. The existence of large numbers of traditional healers and practitioners of indigenous systems of medicine is another source for providing care to the rural populations. What attempts have been made in the past to provide services? Efforts were mainly directed towards increasing the number of trained mental health profes- sionals, increasing such facilities as hos- pitals and clinics, and improving the training in psychiatry for medical gradu- ates. Any hope of having enough trained professionals and facilities is unlikely to be realized in the near future, nor is there likely to be a mass movement of doctors to rural areas. There is also a danger of social isolation in moving patients to hospitals away from their communities. Indeed recent evidence shows that rural life may be beneficial in preventing chronic mental illness. A more important reason for abandoning or lessening the emphasis on imported professional models is the lack of funds available for fresh programmes which require massive inputs in training, building and rehabili- tative services. The alternatives, for the present, ap- pear to lie in decentralization, increasing community participation and deploying available health workers and staff in the periphery. The aim should be to provide care for "priority conditions" in the shortest possible time. The choice of priorities should be based on community concern, prevalence, disability caused and amenability to treatment. Acute psy- choses, severe depression, epilepsy, chronic psychoses and mental retarda- tion can be chosen on the basis of above criteria. Next, the emphasis should be on integrating mental health care with the general health services. An essential part of this approach would be the strength- ening of medical personnel and facili- ties by increased support from the psy- chiatrists. The emphasis is not on the psychiatrist nor on the health worker as such, but rather on a change in their roles and their mode of work, so as to place responsibility for primary care upon those closest to the community, 26 leaving more complex problems to more intensively trained staff. The other advantages of using existing health staff include their easy avail- ability, their approachability and their closer identification with the community. The problems of patients travelling long distances to obtain drugs would be over- come, especially for those requiring long- term use of drugs such as anti-convul- sants. The above outline for mental health care can be expected to result in a dra- matic improvement. However, any at- tempt to extend care to a large popula- tion calls for major changes, including formulating a clear national policy, alter- ing the role of the professionals, increas- ing the training of health workers, pro- moting greater identification with the community and improving drug sup- plies. Here lies the challenge and possible road to success. It is interesting to recall that of the 15 drugs in the bag of a "barefoot doc- tor" in China, three are psychotropic drugs (phenobarbitone, chlorpromazine and diazepam). The reported successes in providing maternal and child health ser- vices through health auxiliaries in Tanza- nia, Cuba, Bangladesh, and Jamkhed, India are encouraging. The continuing WHO collaborative study "Strategies for Extending Mental Health Care" in four developing countries (Colombia (Cali), Senegal (Dakar), Sudan (Khartoum) and India (Raipur Rani)) should provide clear models and methods for applica- tion in the coming years. In all these plans, efforts should also be made to increase community involve- ment and to support those cultural prac- tices that have desirable effects. One such example in the rural areas is ritual mourning, which appears to prevent the occurrence of prolonged or abnormal grief reactions. Similarly the ready as- similation of sick individuals into the community once their acute symptoms disappear is beneficial in preventing chronic mental ill-health. To summarize, mental health care in the peripheral health centres has to deal with problems ranging from the treat- ment of the acutely ill and the manage- ment of emotional problems to improv- ing the effectiveness of health promotion and programmes of prevention. There is no justification for viewing it as a luxury. The implementation of programmes to meet these needs calls for a clear national policy, changes in the role of profes- sionals, the training of basic health workers, coordination with administra- tors and planners of social programmes, and increased efforts to provide supplies and promote public education. Here lies the road towards "reaching the un- reached". ■ 27 compete or complement? RESEARCH AND DELIVERY OF SERVICES ARE COVPLE- VENTARY AND NOT COMPETING ACTIVITIES IN ACHIEV- ING THE OBJECTIVES OF VENIAL HEALTH PROGRAVVES by Norman Sartorius s it necessary to do any more research in the field of mental health? There already exists a vast amount of knowledge that is not being applied. Psychopharmacological drugs and other methods of treatment have been developed that can help severely mentally ill people; and yet there are at least 40 million such people in the world who do not have access to appropriate treat- ment. Mental health skills and knowledge could contribute significantly to the quality and effectiveness of general health care and make it more humane. Yet health care is becoming more and more expensive and less and less accept- able because of its over-reliance on tech- nology and neglect of the human needs of those seeking help and of their fami- lies. Life-style is probably the most impor- tant determinant of health, and techni- ques exist which could help to make people participate in their own health care and behave in ways more conducive to promoting and preserving their health. Yet mortality and morbidity tables demonstrate that very little of that knowledge is applied. Behavioural and mental health sciences have also devel- oped knowledge that could help to avoid some of the more cumbersome and harmful side-effects of urbanization, uprooting, population movement, reset- tlement and a variety of other socio- economic changes taking place today; but little of this knowledge counts when decisions are made. There are a variety of obstacles to the application of knowledge that exists in the mental health field. Firstly, there are political constraints. The political deter- mination to elevate the health status of a population is an essential prerequisite for improvement of services. A multitude of factors influence this "political will", ranging from awareness of the problems (by politicians) to the intricate calcula- tion of possible political gains to be derived from improving health care. The timing of a major increase in the national health budget may be influenced by the chance of a forthcoming election. The fact that a mental patient has committed a sensational crime may trigger a decis- ion to construct a multi-million-dollar high-security prison hospital, even though there is no evidence that mental patients commit more crimes than the general population. Secondly, there are administrative shortcomings. A recent wHo survey of mental health legislation in 42 countries showed that in many countries no mental health laws exist. In practice this situa- tion may even be preferable to the exist- ence of outdated or inadequate mental health legislation, or to strict regulations which block the flexible management of services. In one Middle East country, the discovery that consumption of a particu- lar psychotropic drug was high led to a ruling that all psychotropic drugs should be stored in the central mental hospital, and issued only under strict rules like those governing the handling of mor- phine and other narcotics; the net effect was to hamper the treatment of minor mental disorders in out-patient clinics. Elsewhere, rules forbidding members of the family to visit patients may result in the patients staying longer than hitherto in hospital. Arbitrary assignment of areas or pop- ulations to be served by a health facility without regard for sociocultural and geo- graphical conditions may lead to under- utilization of services. Administrative separation between different types of human services results in uncoordinated effort and widens the gap between their agents, always at the expense of the patients. Appropriate technical means are also lacking. In part this is because of lack of resources in many countries; however, frequently resources are wasted and complex diagnostic machinery takes pre- cedence on a country's list of priorities over such important measures as the provision of anti-epileptic drugs to patients in rural areas through primary A volunteer cooperates with a medical team in the search for a better understanding of mental disorders. Such research is valuable—but costly. How can we ensure that new knowledge can be applied, with the least possible delay, to the millions of sufferers around the globe? (Photo WHO/P. Almasy) 28 p ~ . compete or complement? Left : Family on the move in South America. The behavioural sciences, if applied properly, could help to avoid some of the more harmful effects of uprooting, population movements, urbanization and the other socio-economic changes of today's world. ( Photo WHO I P. Almasy ) Right: Mental patients shave each other in a Middle East hospital. Too often administra- tive shortcomings interfere with mental health care and research; thus, rules forbidding mem- bers of the family to visit patients may result in the patient staying longer in hospital than is really necessary. (Photo WHO) health workers. Provision of resources to increase the number and size of custo- dial institutions saps available funds and blocks the introduction of more effective and less expensive models of care. Fourthly, there are professional prob- lems. Fierce competition and jealousy between professions within the health field, and between those and other pro- fessions, may often prove a more serious constraint than the simple shortage of trained professional staff. Both the patient and the adminstrators may be flooded with conflicting recommenda- tions which are made rather to proclaim the profession's competence than to ef- fect progress. Professional associations and interests frequently hinder the introduction of new health measures regardless of their value to the community, and conversely impose health measures that bolster the profession's importance although they are only of marginal value to the patient. The separation between mental health services has detrimental effects on the quality of care and on the utilization of resources and knowledge. To all this must be added economic constraints and the severe shortage of trained personnel. In developed coun- tries trends of expenditure for health care show a steep increase; and yet there is evidence that the care provided is often sub-optimal, that many of those who need help do not get it and that satisfac- tion with the services is decreasing. In poorer countries the total health budget is proportionally lower than in devel- oped countries although clearly the health problems are more pressing. Men- tal health services are usually low on the list of priorities, and even when there is readiness on the part of the decision- maker to recognize mental health as a major public health concern, the im- provement of service provision often meets with formidable difficulties. In the whole of South-East Asia there are some 700 psychiatrists for 800 million people. In Africa south of the Sahara a medium- sized aeroplane could accommodate all university-qualified mental health pro- fessionals with room to spare. The situa- tion is not much better with regard to other mental health professionals. Fully qualified behavioural scientists often take jobs that have nothing to do with their training or leave the country because there are no positions for them in the health and other human service, research or education systems. The increasing public health impor- tance of mental disorders is not reflected in the information reaching the health planner and decision-maker. While many countries record and report deaths and causes of death, little is known about the incidence and prevalence of non-fatal conditions, regardless of how severe and chronic they are, regardless of how much human suffering they cause. Even in hospital statistics mental disorders do not show up any more, since patients are 30 now treated in departments of general health services and in other medical, paramedical, social and welfare institu- tions, that is to say in facilities for which hardly any countries keep reliable statistics. Clearly many of the difficulties listed above can be removed by better coordi- nation of effort, direct and strong invol- vement of different sectors that can make a contribution to mental health care, and appropriate political and administrative decisions that will facilitate the develop- ment of an appropriate health delivery system. There are however specific aspects of constraints to care delivery which can be removed only if new knowledge becomes available. The research component of the mental health programme of the World Health Organization contains several projects aimed at obtaining such know- ledge. There is an acute need for simple and inexpensive methods by which mental health care can be provided to the patient at the level of primary health care. To develop these WHO has recently launched a study in several developing countries. Teams of research workers from Colombia, India, Senegal and Sudan chose specific areas within their country and assessed the mental health situation in those areas. A limited num- ber of neuropsychiatric conditions were selected as priorities for health care pro- vision according to the criteria of prev- alence, harmful consequences for the in- dividual and the community, and avail- ability of effective, simple methods of treatment. The "output" of this study will include methods which permit the assignment of tasks to the most appro- priate health workers; methods by which various people in the community such as traditional healers, police and teachers can be involved in effective family care and support of patients; training pro- grammes and simple manuals for health workers; guidelines on service organiza- tion and so forth. The definition by WHO of a list of 15 essential drugs for treat- ment of psychiatric conditions is also an effort to utilize scarce resources in a more effective way. The community response to a psycho- social problem and to services that are set up to deal with it are decisive for the success of health and social service in- terventions. In a study under way in Mexico, the United Kingdom and Zam- bia, the response of the community to problems related to alcohol is being investigated. The aim of this study is to develop methods which will help decision-makers to improve the pro- vision of care to those affected and their families, and to increase community participation in such programmes. Drug dependence is an example of a major psychosocial problem where most of the experience and theoretical know- ledge comes from a small number of developed countries while the greatest need for effective programmes lies in 31

compete or complement? developing countries with very different sociocultural and economic conditions. In cooperation with countries, WHO is evaluating different methods of treat- ment and organization of care to find out which will be most useful. Also, a report- ing system is being established to provide information that will make timely and appropriate action on country and inter- national level possible. To prevent dependence on psycho- tropic drugs an International Conven- tion is in force. This Convention requests \vim to make recommendations concern- ing the level of control required over the distribution of psychotropic substances in countries that have ratified the Con- vention. Research as well as compilation of information from different countries is necessary to perform this function and WHO has established a network of colla- borating centres to assist it in this task. Other studies also aim to develop spe- cific information necessary for effective interventions. In one such study, the re- sponse to psychopharmacological drugs by patients living in different climatic conditions, and who are in different states of nutrition and physical health, is being explored. At present most psy- chotropic drugs are being developed and produced in the industrialized countries and recommendations about the dosage and method of application are based on results of trials in that part of the world. Drugs are then exported and import regulations often do not require that the medicament be assessed in the importing countries. Will patients living in tropical climates have the same reaction to the drug? Will the side-effects be the same? Anecdotal evidence indicates that there are considerable differences in responses to specific psychotropic drugs, and the results of this comparative study, which is being carried out in collaborating centres in Asia, Africa, the Americas and Europe, should help to improve psycho- tropic drug treatment. Similar studies are also being under- taken to obtain knowledge about anti- convulsant drugs. These investigations will be carried out in a network of neuro- science centres collaborating in research and training on convulsive disorders, malnutrition and brain development, cerebrovascular disorders and infections and parasitic diseases of the brain. Studies likely to increase knowledge about culture-specific forms of mental disorders and about their natural history were, until recently, the almost exclusive province of anthropologically-orientated researchers, who have made invaluable contributions but have failed to provide data that could help in service develop- ment. The potential of such studies and their direct relevance to service delivery and planning can best be illustrated by the striking results of a large WHO compara- tive study in which more than 1,200 patients suffering from severe men- tal disorders were assessed. In this pro- ject, teams of well-trained research work- ers from nine different countries fol- lowed up the clinical condition and social functioning of groups of seriously mentally ill people over a period of more than five years. In the developing coun- tries the prognosis was considerably bet- Above: Millions of children in the develop- ing world are exposed to a variety of stressful factors that could result in mental disorders—yet the great majority emerge unscathed. ( Photo WHO) Left: Some three per cent of the world's population suffer from depressive disorders, but there have been few well-controlled studies of the factors that protect individ- uals from environmental stresses. What is rarely considered is whether the academic tradition of indulging in studies of the sick is likely to produce any quicker results than the study of the 97 per cent who are normal. (Photo WHOINovosti) ter than in the developed countries. Few- er patients were continuously ill in the less developed countries, fewer were socially incapacitated, fewer needed long-term treatment. The new know- ledge that a widespread mental disorder previously considered incurable can run a relatively benign course or result in full recovery can dispel unfounded fears and encourage health workers, patient and family to take active steps towards early treatment. Other implications of these findings for service provision and plan- ning are currently under study. Cross- cultural studies have now been under- taken to explore the role of different factors (such as family structure) on the outcome of mental disorder in order to define better ways of service provision. In the course of these and other studies—for example those concerned with the biological basis of mental disor- ders—an area of special emphasis is the development of a common language that will permit coordinated and collabora- tive studies and improve understanding among scientists and between them and the public health administrator. Stan- dardized methods have been developed for the assessment of the mental state of patients in different cultures for case- finding and for the implementation of biological studies. Internationally appli- cable and acceptable systems of classifi- cation and diagnosis suitable for use at different levels of health care, accompa- nied by glossaries and definitions, have already resulted from this work which is now concentrated on cooperation with countries in the development of simpler and less expensive methods to obtain relevant information about mental health problems. The results of this work will allow a more objective definition of health priorities, rational planning and evaluation of mental health pro- grammes. Research and delivery of services are complementary and not competing activ- ities in achieving the objectives of mental health programmes. Frequently obsta- cles to improvement of services are not due to lack of knowledge, and in such cases research is unlikely to change anything. Research should not be an excuse for inaction but a focussed effort to obtain knowledge necessary to im- prove service delivery. Above all, research should be a method by which countries' self-reliance in dealing with health matters is being achieved. ■ 33 000 000 000 000 0410 000 000 000 000 000 000000 000 000 0 0 0000 0411. w ool" 04141 4141 41 414141 . 4141 00 0 00 0 0 00 000 4100 000 000 000 4114110 000 000 000 000000 000 000 000 0 00 0 0 0000 000 0 00 000 000 000 000 0041 00• 000 •0 000• 000 000 000 000 000 0 00 000 000 000 000 00• Malaria risk for travellers A 51-year-old American who went on a camera "safari': to Kenya and Tanzania a year ago died of malaria within a month of his return despite intensive therapy in hospital. Details of the case now made available underline the need to inform and protect travellers intending to visit malaria-affected parts of the world. The man, who had taken no anti-malaria prophylaxis, was admitted to hospital with a history of malaise, jaundice and recurrent chills, fever and prof- use sweating. His liver was found to be enlarged, a typical symptom of malaria, and a laboratory test revealed the pre- sence of the malaria parasite, Plasmodium falciparum. Mosquitos may lurk even on tourist beaches. (Photo WHO) Despite intensive therapy his condition deteriorated. On the eighth day in hospital, following a rise in his temperature to 39°C and a fall in blood pressure, he had a cardiac arrest and died. This summer, two Spanish na- tionals, a 42-year-old house- wife and a 37-year-old electri- cian, died on their return home from tropical countries in Africa. They, too, had taken no preven- tive medication against malaria, and their blood examination re- vealed the presence of P. falci- parum. A steady rise in the number of imported cases of malaria has been recorded in Europe over the past few years. From 1304 cases in 1971, the number went up to 2402 in 1975—an 84 percent in- crease. Malaria deaths over the period totalled 151. WHO has repeatedly emphasiz- ed the need to inform all tourists on the possible malaria risk in areas they propose to visit, measures of protection against that risk, and the steps to be ta- ken should the traveller develop fever after returning home. It is WHO's view that providing advice to international travellers is a joint responsibility of the traveller's country of origin and of his country of destination. A WHO document, "Information on Malaria Risk for International Travellers", provides material on the basis of which travel agen- cies, carriers, tourist information offices and other organizations can provide advice on the malaria risk in the areas to be visited. (The document can be obtained from the Distribution and Sales section, WHO Head- quarters, Geneva.) Besides keeping Member Go- vernments informed of the status of malaria through its weekly re- ports, WHO provides them with a comprehensive annual report on the world malaria situation, giving such particulars as preva- lence of the disease by large epidemiological areas, malaria deaths, and distribution of the strains of P. falciparum that have become resistant to anti-malarial drugs. New-style doctors for the Caribbean Countries of the Caribbean community are actively debating ways and means of creating a class of physicians trained specifically to meet local health needs, and not to sell their talents in the world market. It has been estimated that during the past 20 years the University of the West Indies produced about 1000 doctors. Of these not more than 60 percent have stayed to work in the region. The rest have migrated to countries such as Canada and the USA. To halt this trend, the first step being taken is a drastic revision of the medical curriculum. The new curriculum, expected to come into effect next year, is Doctor in training in Jamaica. (Photo WHO E. Rice) designed to produce a doctor oriented towards community medicine, and takes fully into account the major health prob- lems of the Caribbean. Among the major changes fore- seen in the curriculum by the Daily Gleaner, Jamaica, as quoted by Cajanus, bimonthly of the Caribbean Food and Nutrition Institute, are: a four- year instead of five-year pro- gramme leading to the medical degree, and a pre-registration period of two years, one of which will be devoted to exten- sive community work. Physician, heal thyself WHO is intensifying its anti- smoking campaign at its own home base. A recent circular declares that all meeting rooms at WHO's Geneva headquarters will henceforth be included in the non-smoking area of the building. Smoking is already prohibited in the main meeting room where WHO's Executive Board and other bodies meet and which is also sometimes hired out to other organizations. Successive World Health Ass- emblies have passed three re- solutions calling for measures to combat smoking. The most recent, adopted last year, re- cognizes "the indisputable scientific evidence showing that tobacco, smoking is a major cause of chronic bronchitis, em- physema and lung cancer as well as a major risk factor for myocardial infarction, certain pregnancy-related and neonatal disorders and a number of other serious health problems". The resolution also affirms that harm is caused too to non-smokers involuntarily exposed to tobacco smoke. Not a whiff of smoke is seen at WHO's 150-member World Health Assembly or at the meet- ings of its main committees. This has been so since 1970, when the Assembly resolved that "all those present at meet- ings of the Assembly and its committees be requested to re- frain from smoking in the rooms where such meetings are held". Two-thirds of the space in the WHO Headquarters cafeteria is reserved for non-smokers. Many staff members display signs on their office doors saying "Non- fumeur—Non-smoker", a hint to callers and visitors who may have the urge to smoke. Silver Award Three short films made with technical advice from WHO have won a second prize—silver medal—award at the Seventh International Festival of Red Cross and Health Films, held at Varna, Bulgaria, in June. They deal with External Bleed- ing, Immobilization of Fractures of the Lower Legs, and First Aid. The films each last for an aver- age of eight minutes and were made in colour for 16 mm pro- jection. Versions exist in French, German and Spanish as well as English, and copies may be ordered from the distributors, Hunt and Broadhurst Ltd., Oxford OX2 OHE, UK. The "First Aid" section of the Varna Film Festival is sponsored jointly by the International Labour Organisation (ILO), the League of Red Cross Societies and WHO. In the next issue A UN Conference on Tech- nical Cooperation among Developing Countries will be held during 1978 in Buenos Aires. The January issue of World Health will be devoted to this challenging concept. 34 WORLD HEALTH INDEX 1976/1977 1976 January: Health and Human Rights The right to live • Gene- tic engineering • Human guinea-pigs • Pollu- tion • Medicine and ethics • Index 1975. Feb.-March: Foresight Prevents Blindness Trachoma • River blind- ness • Worldwide cam- paign Pattern of • genes Cataract Eye accidents. April: Miscellaneous Senegal health survey • Weekly Epidemiological Record • Experiences in Mongolia, Kenya, the Philippines. May: Human Settlements Habitat and health • Athens — Mother City • Nomads • Where the streetlamps stop • Village needs. June: Biomedical Research The challenge • Bio- logical revolution • Risks and rewards • Tropical disease research • WHO's activities. July: WHO Priorities Country health pro- gramming . • Environ- mental health • Health manpower • Immuniza - tion • Leprosy • Cholera. Aug.-September: Decade for Women IWY and after • Legal reforms • Social change • Women at work. October: WHO's Six Regions Articles from Africa, the Americas, Eastern Mediterranean, Europe, South-east Asia and Western Pacific. November: Miscellaneous Nutrition in Kenya •• Scourge of Venus • What are the real needs? • Community health in India and Costa Rica. December: The Crucial Years Articles on the hopes, doubts and problems of Adolescence. VVORLD HEALTH -ft Dr MO WNWM^ WORLD HEALTH PANT .- ' 4 1977 January: Water Key to health • Hidden dangers • Progress in the Americas, Sarawak, the Mediterranean • Coi- laborating centres. Feb.-March: Immunize and JANUARY VV'ORLD FEALTH (1 )) FEBRUARY- MARCH uunam HEALTH '.'..r..7.1:-..,..',.._•-".."... 1 .! FEN, %, ■,1_,..4, I WILEAVOS MAY JANUARY WORLD HEALTH Protect your Child Six killers • Saving young lives in Mexico and Ghana • Vaccine re - search • Smallpox • Problems and prospects. April: Health training Health manpower and planning • Brain drain • New schools for old • Team work • Mongolian May: Nutrition The vicious spiral of malnutrition and how to overcome it • World food prospects • Five defi- ciency diseases. June: Rheumatism An issue to mark World Rheumatism Year • AM- Iles on many aspects of this all too common ail- ment. July: The Waste Lands Man and the Desert • On the brink of starvation • Hospital in the Turkana. Aug.-September: Health in the Americas feldsher. Mtn, t•.',1,,,, 1- r, Ot,, FEBRUARY- MARCH woRLD FEALTH ,„.., ..,...„, .„,... ,,... ,, .dits - .• 41, MAY WORLD HEALTH ,._,..,..................- '`,,-i , WORLD HEALTH RPACUN'3u .. , The Pan American Health Organization looks with pride at its 75-year history. October: Miscellaneous Did foresight prevent blindness? • Aspects of health in Papua New Guinea, India, Zambia, JULY WORLD I-EALTH ' ... .. ,. . „,. .. NOVEMBER JUNE the USA • The smokers' world. November: Traditional Medicine map HEALTH The Staff of Aescula- plus • Experiences in Malaysia, Mexico, the Philippines, Ghana • Ay- 1.wjli Curhviendaa • SvvtudHycyTs oupr roin- ft-I lir gramme. December: Healthy Bodies, '' j Healthy Minds An issue dealing with AUGUST- SEPTEMBER mental health and mental health care around the world. Authors of the month Dr T.A. LAMBO is Deputy Director- General of the World Health Organ- ization. Dr T. A. BAASHER is Regional Advi- sor on Mental Health at WHO's Regional Office for the Eastern Medi- terranean in Alexandria. Dr M. H. BEAUBRUN is Professor of Psychiatry at the University of the West Indies, Trinidad. Dr A. JABLENSKY is a Senior Medical Officer in the Division of Mental Health at WHO headquarters in Geneva . Dr R. SRINIVASA MURTHY iS a lectur- er in the Department of Psychiatry at the Postgraduate Institute of Medical Education and Research, Chandi- garh, India. Dr N. SARTORIUS is Director of the Division of Mental Health at WHO headquarters in Geneva. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$' Sw.fr.* One year 10.— 25. Two years 18.— 45. Three years 24.— 60. One year : Two years : Three years : El I enclose cheque/postal order in the amount of Name: Street: City: Country: or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland Mental health teams paying house-calls on patients are gradually replacing old-style "insane asylums". ( Plot° WHO/ E, Sthititib) THROUGH MENTAL HEALTH ACTION - r ( I Culturs in coffision—whict t eliefs sur./.'re? 3ewillered d7 reje.3ted—what suture hes ahead of Ifrn? Life s.`y.'es are :hangin7—some a dapt and some suffer - . 0-- ) she depre.:sad, can the rura; tealth centre teip? F9-10TOS WHO PROTECTING POPULATIONS AT RISK pp overty, malnutrition and infectious dis-eases provide no immunity against mental disorder. The majority of the 40 million sufferers from serious mental illness live in the developing world—and the same is true of the 200 million suffering from less severe mental disorders. Forced resettlement of whole communities; liter- ate children confronting their illiterate elders; disintegration of traditional modes of living; poverty; dehumanizing work and living condi- tions; the nightmare of urban slums—these are but a few of the psychosocia stresses and strains resulting from rapid social change and economic development. These stresses can exacerbate or provoke mental disorder, lead to alcohol and drug abuse and dependence, and contribute to other psychosocial problems such as delinquency and violence. The dilemma is made even more acute by the scarcity of human and material resources available and by the many other pressing health problems that must be dealt with. All too often those mental health services that do exist are either inadequate or not relevant to the needs of the people. Large centrally-located mental hospitals are unsuited to the widely dispersed, multilingual, rural popula- tions found in most developing countries. Mental health care remains the responsibility of mental health professionals who are few and far be- tween. For each working psychiatrist there are tens of thousands of patients with serious mental disorders in most African countries; compare this with the developed countries where there is one for every 80-150 patients. Special Focus: Vulnerable Populations. Public health leaders of the Third World have given WHO the mandate to cooperate with them in taking urgent mental health action in view of the "severi- ty of psychosocial stresses cur-ently facing many populations of the developing countries and espe- cially the high-risk populations in southern Afri- ca". Governments are determined to take action now before irreparable damage is done to the health and social productivity of individuals and communities. Countries in southern Africa are a focus of effort. Recent struggles for independence have ravaged them and they now face a period of rapid development and social change. Their health resources are extremely limited. Racist policies place severe stresses on the vast number of people who have to seek employment across national borders and on their families. Large numbers of refugees live in camps without ade- quate care and with an uncertain future. ANEW STRATEGY Simple and effective methods to deal with these mental health problems exist, and the World Health Organization has formulated a new strate- gy for mental health action in which priorities will be selected by their social relevance and their potential for rapidly alleviating psychosocial prob- lems in populations at risk. Mental health will be integrated into overall health and development efforts. The new orientation of the programme is based on the principles that mental health prob- lems are not synonymous with psychiatric disor- der; that by mental health workers we mean not only the psychiatrists; that in dealing with mental health, the expertise of many disciplines is needed; and that mental health has an essential role to play in changing health behaviour so as in turn to improve nutritional habits, combat com- municable diseases and introduce basic sanita- tion. In May 1977 the World Health Assembly en- dorsed WHO's new approach to mental health. Coordinating groups have already been estab- lished at national and regional levels to formulate policies, review the programme content, assist in its implementation and ensure that appropriate mental health technologies are available and used where they are most needed. Mental Health Resource Centres are being established in deve- loping countries to provide technical support, including training, to national health programmes. Voluntary Contributions Needed. WHO is cooperating with governments and UN agencies in implementing the new mental health strategy. However, voluntary contributions are essential to speed up the programme. If such funds were made available, the programme would enable countries to respond now to the problems they face — before it is too late. Countries' efforts could be coordinated; available resources such as training facilities shared and strengthened. Appro- priate simple and inexpensive preventive, curative and rehabilitative techniques could be developed or adapted and personnel trained in their use. Additional funds would also ensure the ex- change of information and experiences in solving problems and provide for basic equipment such as transport and supplies of needed drugs. For the programme's preparatory phase (1977- 1978), $250000 is still needed and $5 million will be required annually for its 1978-1983 phase. If we are to cope with the growing problem of mental disorders and respond to individuals' psy- chosocial needs in a world facing political upheavals, changing values and a technological revolution, the message is obvious: MENTAL HEALTH MATTERS! WORLD HEALTH ORGANIZATION Division of Mental Health Avenue Appia 1211 Geneva 27 Switzerland