I want you to imagine this for a moment. Two men, Rahul and Rajiv, living in the same neighborhood, from the same educational background, similar occupation, and they both turn up at their local accident emergency complaining of acute chest pain. Rahul is offered a cardiac procedure, but Rajiv is sent home.
Quero que se imaxinen isto Dous homes, Tahul e Rajiv, os dous viven no mesmo barrio, teñen a mesma formación e traballos semellantes e os dous se achegan ao servizo de urxencias queixándose dunha dor aguda no peito. A Rahul fanlle probas do corazón pero a Rajiv non: mándanno a casa.
What might explain the difference in the experience of these two nearly identical men? Rajiv suffers from a mental illness. The difference in the quality of medical care received by people with mental illness is one of the reasons why they live shorter lives than people without mental illness. Even in the best-resourced countries in the world, this life expectancy gap is as much as 20 years. In the developing countries of the world, this gap is even larger.
Cal é a explicación do trato distinto en dúas persoas practicamente iguais? Rajiv sofre unha enfermidade mental. A diferenza na calidade dos coidados médicos recebidos por persoas con enfermidade mental é unha das razóns polas que viven menos tempo que as persoas sen enfermidade mental Mesmo nos paises que dispoñen de máis recursos no mundo, a diferenza na espectativa de vida supera os 20 anos. Nos paises en vías de desenvolvemento a diferenza aínda é maior
But of course, mental illnesses can kill in more direct ways as well. The most obvious example is suicide. It might surprise some of you here, as it did me, when I discovered that suicide is at the top of the list of the leading causes of death in young people in all countries in the world, including the poorest countries of the world.
Pero ademais, as enfermidades mentais poden matar de forma máis directa. O exemplo máis obvio é o suicidio Pode que lles sorprenda, como me pasou a min, cando descubrín que o suicidio é unha das principais causas de morte entre a xente nova en todo o mundo incluíndo os paises máis pobres do planeta
But beyond the impact of a health condition on life expectancy, we're also concerned about the quality of life lived. Now, in order for us to examine the overall impact of a health condition both on life expectancy as well as on the quality of life lived, we need to use a metric called the DALY, which stands for a Disability-Adjusted Life Year. Now when we do that, we discover some startling things about mental illness from a global perspective. We discover that, for example, mental illnesses are amongst the leading causes of disability around the world. Depression, for example, is the third-leading cause of disability, alongside conditions such as diarrhea and pneumonia in children. When you put all the mental illnesses together, they account for roughly 15 percent of the total global burden of disease. Indeed, mental illnesses are also very damaging to people's lives, but beyond just the burden of disease, let us consider the absolute numbers. The World Health Organization estimates that there are nearly four to five hundred million people living on our tiny planet who are affected by a mental illness. Now some of you here look a bit astonished by that number, but consider for a moment the incredible diversity of mental illnesses, from autism and intellectual disability in childhood, through to depression and anxiety, substance misuse and psychosis in adulthood, all the way through to dementia in old age, and I'm pretty sure that each and every one us present here today can think of at least one person, at least one person, who's affected by mental illness in our most intimate social networks. I see some nodding heads there.
Pero máis que o impacto que un problema de saúde teña na esperanza de vida a nós preocúpanos o seu efecto na calidade de vida Para analizar simultaneamente o impacto dun problema de saúde sobre a cantidade e a calidade de vida necesitamos usar un indicador chamado AVAD e que se corresponde cos Anos de Vida Axustados por Discapacidade Cando facemos isto, descubrimos cousas alarmantes sobre a saúde mental dende unha perspectiva global Descubrimos, por exemplo, ...que a enfermidade mental é unha das principais causas de invalidez no mundo A depresión, por exemplo, é a terceira causa de incapacidade no mundo xunto con enfermidades como a diarrea e a neumonía en nenos. Cando xuntas todas as enferidades mentais representan arredor do 15% de todas as enfermidades do mundo. A verdade é que se trata dunhas doenzas moi daniñas. Pero máis alá da carga de enfermidade imos considerar as cifras absolutas. A Organización Mundial da Saúde estima... que hai entre 400 e 500 millóns de persoas vivindo no noso pequeno planeta que padecen enfermidades mentais. Algúns de vostedes parecen un pouco sorprendidos por este número pero consideren por un momento a incrible variedade de doenzas mentais, dende o autismo e a deficiencia mental na infancia, ata a depresión e a ansiedade, abuso de substancias e psicose en adultos para chegar á demencia na vellez, e teño para min que todos os presentes podemos pensar polo menos nunha persoa, unha persoa afectada por unha enfermidade mental no noso círculo social máis próximo. Vexo que algúns asinten coa cabeza.
But beyond the staggering numbers, what's truly important from a global health point of view, what's truly worrying from a global health point of view, is that the vast majority of these affected individuals do not receive the care that we know can transform their lives, and remember, we do have robust evidence that a range of interventions, medicines, psychological interventions, and social interventions, can make a vast difference. And yet, even in the best-resourced countries, for example here in Europe, roughly 50 percent of affected people don't receive these interventions. In the sorts of countries I work in, that so-called treatment gap approaches an astonishing 90 percent. It isn't surprising, then, that if you should speak to anyone affected by a mental illness, the chances are that you will hear stories of hidden suffering, shame and discrimination in nearly every sector of their lives. But perhaps most heartbreaking of all are the stories of the abuse of even the most basic human rights, such as the young woman shown in this image here that are played out every day, sadly, even in the very institutions that were built to care for people with mental illnesses, the mental hospitals.
Pero alén das cifras sorprendentes o realmente importante dende o punto de vista da saúde mundial o realmente preocupante dende o punto de vista da saúde mundial e que a grande maioría deses individuos afectados non reciben os coidados que sabemos que poden cambiar as súas vidas e lembren que temos firmes evidencias de que unha chea de medidas, medicinas, intervencións psicolóxicas e sociais poden cambiar por completo a situación. Aínda así, mesmo nos países de mais recursos por exemplo, aquí, en Europa cerca dun 50% das persoas afectadas non reciben eses tratamentos No tipo de paises en que eu traballo esta ausencia de tratamento acércase ao sorprendente 90%. Por iso non é raro se tes que falar cunha persoa que padece unha enfermidade mental escoitar historias de sufrimento oculto vergoña e discriminación en case tódolos ámbitos da súa vida. Pero quizais, o máis desgarrador de todo sexan as historias de abuso mesmo dos dereitos humanos máis básicos tal e como amosa a imaxe desta nena que acontecen tódolos días, tristemente incluso nas institucións creadas para cuidar a estas persoas, os hospitais mentais.
It's this injustice that has really driven my mission to try to do a little bit to transform the lives of people affected by mental illness, and a particularly critical action that I focused on is to bridge the gulf between the knowledge we have that can transform lives, the knowledge of effective treatments, and how we actually use that knowledge in the everyday world. And an especially important challenge that I've had to face is the great shortage of mental health professionals, such as psychiatrists and psychologists, particularly in the developing world.
Esta inxusticia foi decisiva para que eu me propuxera como misión intentar transformar as vidas de persoas afectadas por enfermedad mental e me centro sobre todo en tender unha ponte entre os coñecementos que temos capaces de transformar vidas, os coñecementos sobre tratamentos efectivos, e o uso diario que facemos destes coñecementos no mundo. E un desafío especialmente importante co que me atopei é a grande escaseza de profesionais de saúde mental, psiquiatras e psicólogos,
Now I trained in medicine in India, and after that
sobre todo nos paises en vías de desenvolvemento.
I chose psychiatry as my specialty, much to the dismay of my mother and all my family members who kind of thought neurosurgery would be a more respectable option for their brilliant son. Any case, I went on, I soldiered on with psychiatry, and found myself training in Britain in some of the best hospitals in this country. I was very privileged. I worked in a team of incredibly talented, compassionate, but most importantly, highly trained, specialized mental health professionals.
Estudiei medicina na India, e despois elexín psiquiatría como especialidade para desgusto da miña nai e de toda a miña familia que pensaban que a neurocirurxía sería unha opción máis respectable para o seu brillante fillo. Sexa como fora eu seguín coa psiquiatría, e atopeime estudando en Inglaterra nalgún dos mellores hospitais do país. Fun un privilexiado. Traballei nun grupo moi talentoso, compasivo, pero o máis importante moi ben formado e especializado en saúde mental. Pouco despois de rematar os estudos
Soon after my training, I found myself working first in Zimbabwe and then in India, and I was confronted by an altogether new reality. This was a reality of a world in which there were almost no mental health professionals at all. In Zimbabwe, for example, there were just about a dozen psychiatrists, most of whom lived and worked in Harare city, leaving only a couple to address the mental health care needs of nine million people living in the countryside.
comecei a traballar primeiro en Zimbabue e despois na India onde atopo unha realidade totalmente nova. Foi a realidade dun mundo no que casi non había profesionais da saúde mental En Zimbabue, por exemplo, apenas había unha ducia de psiquiatras a maioría deles vivían e traballaban na cidade de Harare, quedando só un par deles ao coidado das necesidades de saúde mental dos 9 millóns de persoas que vivían no campo.
In India, I found the situation was not a lot better. To give you a perspective, if I had to translate the proportion of psychiatrists in the population that one might see in Britain to India, one might expect roughly 150,000 psychiatrists in India. In reality, take a guess. The actual number is about 3,000, about two percent of that number.
Na India non atopo unha situación moito mellor. Para que se fagan unha idea, se na India houbera a mesma proporción de psiquiatras que en Gran Bretaña debería haber 150.000 psiquiatras na India Adivinen cantos hai. Nestes momentos arredor de 3.000 case o 2% dos que debía haber.
It became quickly apparent to me that I couldn't follow the sorts of mental health care models that I had been trained in, one that relied heavily on specialized, expensive mental health professionals to provide mental health care in countries like India and Zimbabwe. I had to think out of the box about some other model of care.
En seguida me din de conta de que non podía seguir os modelos de coidados de saúde mental que estudiara baseados en profesionais caros e altamente especializados para paises como a India e Zimbabue. Tiña que pensar noutro modelo de coidados.
It was then that I came across these books, and in these books I discovered the idea of task shifting in global health. The idea is actually quite simple. The idea is, when you're short of specialized health care professionals, use whoever is available in the community, train them to provide a range of health care interventions, and in these books I read inspiring examples, for example of how ordinary people had been trained to deliver babies, diagnose and treat early pneumonia, to great effect. And it struck me that if you could train ordinary people to deliver such complex health care interventions, then perhaps they could also do the same with mental health care.
Foi así que atopei estes libros, e neles descubrín a idea da delegación de tarefas na saúde global. A idea é moi simple. A idea é, cando dispoña de poucos profesionais utilice calquera persoa dispoñible na comunidade, fórmeos para prestar uns coidados mínimos. Nos libros lin exemplos inspiradores por exemplo, como se formou a xente non preparada para atender partos ou diagnosticar e tratar pneumonía, con bos resultados. E pensei que si se lles pode preparar para facer tarefas tan complexas quizáis tamén se lles poda preparar para prestar coidados en saúde mental. Hoxe, compráceme informarlles que se ten experimentado moito
Well today, I'm very pleased to report to you that there have been many experiments in task shifting in mental health care across the developing world over the past decade, and I want to share with you the findings of three particular such experiments, all three of which focused on depression, the most common of all mental illnesses. In rural Uganda, Paul Bolton and his colleagues, using villagers, demonstrated that they could deliver interpersonal psychotherapy for depression and, using a randomized control design, showed that 90 percent of the people receiving this intervention recovered as compared to roughly 40 percent in the comparison villages. Similarly, using a randomized control trial in rural Pakistan, Atif Rahman and his colleagues showed that lady health visitors, who are community maternal health workers in Pakistan's health care system, could deliver cognitive behavior therapy for mothers who were depressed, again showing dramatic differences in the recovery rates. Roughly 75 percent of mothers recovered as compared to about 45 percent in the comparison villages. And in my own trial in Goa, in India, we again showed that lay counselors drawn from local communities could be trained to deliver psychosocial interventions for depression, anxiety, leading to 70 percent recovery rates as compared to 50 percent in the comparison primary health centers.
na delegación de tarefas en saúde mental na última década nos paises en vías de desenvolvemento, e quero compartir con vostedes os resultados de tres experimentos todos eles enfocados na depresión, a enfermidade mental máis común. Na Uganda rural, Paul Bolton e os seus colaboradores demostraron que os aldeáns podían facer psicoterapia para a depresión e mediante un estudo aleatorio controlado demostró que o 90% das persoas que recibiron esta intervención se recuperaron fronte a un 40% no grupo control. Noutro estudo aleatorio controlado en áreas rurais de Pakistán, Atif Rahman e os seus colaboradores demostraron que as mulleres visitadoras que eran traballadoras de saúde maternal da comunidade pertencentes ao sistema de saúde pakistaní poideron prestar terapia cognitiva conductual a nais que sufriron depresión demostrando grandes diferencias nas tasas de recuperación. Cerca do 75% das nais se recuperaron fronte ao 45% no grupo control. E no meu propio estudo en Goal, na India, novamente mostramos como conselleiros oriundos das comunidades locais poden ser entrenados para facer intervencións psicosociais para a depresión ou a ansiedade, acadando taxas do 70% de remisión en comparación co 50% nos centros de atención primaira.
Now, if I had to draw together all these different experiments in task shifting, and there have of course been many other examples, and try and identify what are the key lessons we can learn that makes for a successful task shifting operation, I have coined this particular acronym, SUNDAR. What SUNDAR stands for, in Hindi, is "attractive." It seems to me that there are five key lessons that I've shown on this slide that are critically important for effective task shifting. The first is that we need to simplify the message that we're using, stripping away all the jargon that medicine has invented around itself. We need to unpack complex health care interventions into smaller components that can be more easily transferred to less-trained individuals. We need to deliver health care, not in large institutions, but close to people's homes, and we need to deliver health care using whoever is available and affordable in our local communities. And importantly, we need to reallocate the few specialists who are available to perform roles such as capacity-building and supervision.
Se tivese que reunir todos estes experimentos de delegación de tarefas, e hai moitos outros exemplos, e intentase identificar os aspectos clave que contribúen ao éxito na delegación de tarefas resumiríano co acrónimo SUNDAR que eu veño de acuñar. SUNDAR, en Hindi, significa "atractivo". Eu creo que hai cinco leccións clave que amoso nesta diapositiva para unha axeitada delegación de tarefas. A primeira é que necesitamos simplificar a mensaxe que utilizamos eliminando toda a xerga que rodea a medicina. Temos que dividir as intervencións complexas de coidados en unidades pequenas para poder transferirlas fácilmente ás persoas menos entrenadas. Hai que prestar os coidados non en grandes institucións, senón perto dos fogares da xente e cómpre facelo utilizando a quen estea accesible e dispoñible na comunidade. E, moi importante, temos que reubicar aos poucos especialistas que hai para desenvolver labores de formación e supervisión.
Now for me, task shifting is an idea with truly global significance, because even though it has arisen out of the situation of the lack of resources that you find in developing countries, I think it has a lot of significance for better-resourced countries as well. Why is that? Well, in part, because health care in the developed world, the health care costs in the [developed] world, are rapidly spiraling out of control, and a huge chunk of those costs are human resource costs. But equally important is because health care has become so incredibly professionalized that it's become very remote and removed from local communities. For me, what's truly sundar about the idea of task shifting, though, isn't that it simply makes health care more accessible and affordable but that it is also fundamentally empowering. It empowers ordinary people to be more effective in caring for the health of others in their community, and in doing so, to become better guardians of their own health. Indeed, for me, task shifting is the ultimate example of the democratization of medical knowledge, and therefore, medical power.
Para min, a delegación de tarefas é dunha importancia transcendental porque aínda que xurdiu do problema da falta de recursos nos paises en vías de desenvolvemento creo que tamén é importante nos países con recursos abundantes. E por qué? en parte porque os coidados de saúde nos paises desenvolvidos, os custos dos coidados de saúde nos paises desenvolvidos, estanse a ir rápidamente fóra de control, en boa medida polo custo dos recursos humáns. Pero tamén porque os coidados de saúde teñen acadado unha especialización tan alta que se teñen distanciado das comunidades locais. O concepto de SUNDAR na transferencia de tarefas non afecta só á accesibilidade e á economía senón á capacitación e o fortalecemento das comunidades. Esta formación de xente sen estudos para o coidado da saúde doutras persoas na súa comunidade, axúdalles tamén a coidarse mellor a si mesmos. A delegación de tarefas é o exemplo máis importante da democratización do coñecemento médico, do poder médico.
Just over 30 years ago, the nations of the world assembled at Alma-Ata and made this iconic declaration. Well, I think all of you can guess that 12 years on, we're still nowhere near that goal. Still, today, armed with that knowledge that ordinary people in the community can be trained and, with sufficient supervision and support, can deliver a range of health care interventions effectively, perhaps that promise is within reach now. Indeed, to implement the slogan of Health for All, we will need to involve all in that particular journey, and in the case of mental health, in particular we would need to involve people who are affected by mental illness and their caregivers.
Hai pouco máis de 30 anos, os paises do mundo reuníronse en Alma-Ata e fixeron esta simbólica declaración. (Saúde para todos no ano 2000) Creo que todos poden imaxinar que 12 anos despois aínda estamos lonxe desta meta. Hoxe, sabendo que a xente entrenada na comunidade, con suficiente supervisión e apoio pode prestar un amplo abano de coidados de forma efectiva, tal vez estemos máis cerca de acadar esta meta. De feito, para poñer en marcha a iniciativa "Saúde para Todos" necesitamos incluír a todos nesa estratexia particular e, no caso da saúde mental en particular, necesitamos incluír ás persoas que padecen unha doenza mental xunto aos seus coidadores.
It is for this reason that, some years ago, the Movement for Global Mental Health was founded as a sort of a virtual platform upon which professionals like myself and people affected by mental illness could stand together, shoulder-to-shoulder, and advocate for the rights of people with mental illness to receive the care that we know can transform their lives, and to live a life with dignity.
É por esa razón que, hai uns anos, fundouse o Movemento Global pola Saúde Mundial, un tipo de plataforma virtual na que os profesionais coma min e as persoas que padecen unha enfermidade mental poden loitar xuntos, ombro con ombro, e defender os dereitos das persoas con doenzas mentais para recibiren os coidados que sabemos que poden cambiar as súas vidas e para que poidan vivilas con dignidade.
And in closing, when you have a moment of peace or quiet in these very busy few days or perhaps afterwards, spare a thought for that person you thought about who has a mental illness, or persons that you thought about who have mental illness, and dare to care for them. Thank you. (Applause) (Applause)
E para rematar, cando teñan un momento de tranquilidade nestes días tan ocupados, ou senón despois, dediquen un momento a pensar na persoa ou persoas que recordaron que teñen unha enfermidade mental e atrévanse a coidalos. Gracias.