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.
Želim da zamislite ovo na trenutak. Dvojica muškaraca, Rahul i Rajiv, žive u istom susjedstvu, imaju istu obrazovnu pozadinu, slično zanimanje, i obojica se pojave u svojoj lokalnoj hitnoj žaleći se na akutnu bol u prsima. Rahulu je ponuđena srčana procedura, ali Rajiva pošalju doma.
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.
Što bi moglo objasniti razliku u iskustvu ove dvojice skoro identičnih ljudi? Rajiv pati od duševne bolesti. Razlika u kvaliteti medicinske njege koju primaju ljudi s mentalnim bolestima je jedan od razloga zašto žive kraće nego ljudi koji ne pate od duševnih bolesti. Čak i u najbogatijim državama u svijetu, razlika u životnom vijeku je 20 godina. U državama koje se razvijaju, ova razlika je još veća.
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.
Naravno, duševne bolesti mogu usto ubiti na mnogo direktnije načine. Najočitiji primjer je samoubojstvo. Možda može neke od vas ovdje iznenaditi, kao što je i mene, kad sam otkrio da je samoubojstvo na vrhu liste vodećih uzroka smrti kod mladih ljudi u svim državama svijeta, uključujući i najsiromašnije države.
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.
Ali više od učinka zdravstvenog stanja na životni vijek, također smo zabrinuti za kvalitetu proživljenog života. Sad, kako bismo mogli istražiti sve učinke zdravstvenog stanja na životni vijek kao i na kvalitetu proživljenog života, moramo uzeti mjeru nazvanu DALY, koja znači godinu života prilagođenu invalidnošću (Disability-Adjusted Life Year). Kad učinimo to, otkrivamo neke uznemiravajuće stvari o duševnoj bolesti iz globalne perspektive. Otkrivamo da su, na primjer, duševne bolesti među vodećim uzrocima invalidnosti u svijetu. Depresija, na primjer, je treći vodeći uzrok invalidnosti, uz stanja poput dijareje i upale pluća u djece. Kad stavite sve mentalne bolesti zajedno, one uključuju otprilike za 15% ukupnog tereta bolesti. Doista, mentalne bolesti su također vrlo štetne za ljudske živote, ali osim samog tereta bolesti, razmotrimo apsolutne brojeve. Svjetska zdravstvena organizacija procjenjuje da 400 do 500 milijuna ljudi koji žive na našem sitnom planetu pate od duševne bolesti. Neki od vas ovdje izgledaju iznenađeno tim brojem, ali razmotrite na trenutak nevjerojatnu razliku duševnih bolesti, od autizma i intelektualnih invalidnosti u djetinjstvu, kroz depresiju i tjeskobu, zloporabu supstanci i prihoze kod odraslih, sve do demencije u starijim godinama i siguran sam da svatko od nas ovdje danas može se sjetiti bar jedne osobe, bar jedne osobe, koja pati od mentalne bolesti u našim najintimnijim društvenim mrežama. Vidim neke koji kimaju glavama tamo.
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.
Ali osim zapanjujućih brojeva, što je uistinu bitno iz globalnog zdravstvenog pogleda, što je uistinu zabrinjavajuće iz globalnog zdravstvenog pogleda je to što velika većina tih pojedinaca koji pate ne dobije njegu za koju znamo da može promijeniti njihove živote, i zapamtite, imamo snažne dokaze da mnoge intervencije, lijekovi, psihološke intervencije i društvene intervencije mogu napraviti veliku razliku. A ipak, čak i u najbogatijim državama, na primjer ovdje u Europi, otprilike 50% ljudi koji pate, ne pruži im se takva intervencija. U državama u kojima radim, ta takozvana razlika u tretmanu približava se zapanjujućih 90%. Nije iznenađujuće onda da ako pričate s nekim tko pati od duševne bolesti, šanse da ćete čuti priče o skrivenoj patnji, sramu i diskriminaciji u skoro svakom dijelu njihovog života. Ali možda najsrceparajuće od svih su priče o zloporabi čak i najosnovnijih ljudskih prava, poput mlade žene prikazane na ovoj slici koje se događaju svaki dan, nažalost, čak i u samim institucijama koje su sagrađene za njegu za ljude s duševnim bolestima, u bolnicama za duševno bolesne.
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.
Ta nepravda je ono što je zapravo vodilo moju misiju da pokušam učiniti nešto da promijenim živote ljudi koji pate od duševnih bolesti i posebno kritična akcija na koju sam se usredotočio je premostiti jaz između znanja koje imamo koje može promijeniti živote, znanja učinkovitog tretmana i kako zapravo koristimo to znanje u svakodnevnom svijetu. I jako bitan izazov s kojim sam se morao suočiti je veliki nedostatak profesionalaca koji se bave duševnim bolestima, poput psihijatara i psihologa, pogotovo u svijetu koji se razvija.
Now I trained in medicine in India, and after that 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.
Obučen sam za medicinu u Indiji i nakon toga sam odabrao psihijatriju kao svoju specijalizaciju, na zaprepaštenje moje majke i svih svojih članova obitelji koji su nekako mislili da bi neurokirurgija bio puno ugledniji izbor za njihovog briljantnog sina. U svakom slučaju, nastavio sam, borio sam se s psihijatrijom i našao se trenirajući u Britaniji u nekima od najboljih bolnica u ovoj državi. Bio sam vrlo privilegiran. Radio sam u timu nevjerojatno talentiranih, suosjećajnih, ali najvažnije, vrhunski obučenih, specijaliziranih profesionalaca za duševne bolesti.
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.
Ubrzo nakon moje obuke, našao sam se radeći prvo u Zimbabveu i onda u Indiji te sam se suočio s potpuno novom stvanošću. To je bila stvarnost svijeta u kojem nije bilo skoro uopće profesionalaca za duševne bolesti. U Zimbabveu, na primjer, bilo je otprilike 12 psihijatara, od kojih je većina živjela i radila u gradu Harare, ostavljajući samo par njih da se bave potrebama njege duševnog zdravlja 9 milijuna ljudi koji žive na selu.
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.
U Indiji sam saznao da situacija nije puno bolja. Kako bih vam dao perspektivu, kad bih trebao prevesti proporcije psihijarata u populaciji koju možete vidjeti u Britaniji na Indiju, netko bi očekivao otprilike 150.000 psihijatara u Indiji. U stvarnosti, pogađajte. Stvaran broj je oko 3.000, oko 2% tog broja.
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.
Postalo mi je ubrzo jasno da neću moći pratiti vrstu modela duševne zdravstvene njege u kojoj sam obučen, koja se jako oslanjala na specijalizirane, skupe profesionalce za duševno zdravlje koji bi pružali njegu duševno bolesnima u državama poput Indije ili Zimbabvea. Morao sam razmišljati van kutije o nekom drugom modelu njege.
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.
Tad sam naletio na ove knjige i u tim knjigama otkrio ideju izmjenjivanja zadataka u globalnom zdravstvu. Ideja je zapravo vrlo jednostavna. Ideja je, kad imate manjak specijaliziranih profesionalaca za zdravlje, koristite bilo kog tko je slobodan u zajednici, obučite ga da pruža raznolike zdravstvene intervencije, i u ovim knjigama sam pročitao inspirirajuće primjere, na primjer kako obični ljudi koji su obučeni porađati djecu, dijagnosticirati i liječiti ranu upalu pluća, uz velik učinak. I shvatio sam da ako možete obučiti obične ljude da pružaju tako složene zdravstvene intervencije, onda bi možda mogli također napraviti isto s njegom za duševne bolesti.
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.
Danas mi je veliko zadovoljstvo izvijestiti vas da su bili mnogi eksperimenti u izmijeni zadataka u njezi za duševno bolesne u zemljama u razvoju u zadnjem desetljeću i želim podijeliti s vama nalaze tri određena takva eksperimenta, sva tri su se usredotočila na depresiju, najčešću od svih duševnih bolesti. U ruralnoj Ugandi, Paul Bolton i njegovi kolege koristeći stanovnike sela, demonstrirali su da mogu pružati međusobnu psihoterapiju za depresiju i koristeći dizajn nasumične kontrole, pokazali da 90% ljudi koji su primili takve intervencije su se oporavili uspoređeno s otprilike 40% u sličnim selima. Slično, koristeći ispitivanje nasumične kontrole u ruralnom Pakistanu, Atif Rahman i njegovi kolege pokazali su da žene koje povremeno pomažu u zdravstvenom radu, koje su društvene zdravstvene radnice za majke u pakistanskom zdravstvenom sustavu, mogu pružiti terapiju za kognitivno ponašanje za majke koje su bile depresivne, opet pokazujući dramatičnu razliku u brzini oporavka. Otprilike 75% majki se oporavilo uspoređujući s 45% u sličnim selima. . I u mom vlastitom testiranju u Goi, u Indiji, opet smo pokazali da savjetnici laici uzeti iz lokalnih zajednica mogu biti obučeni da pruže psihološku intervenciju za depresiju, tjeskobu, dovodeći do 70% većih razina oporavka uspoređujući s 50% u sličnim primanim zdravstvenim centrima.
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.
Kad bih trebao prikazati sve ove različite eksperimente u izmjeni zadataka, a naravno da je bilo još mnogo takvih primjera, i pokušao identificirati koje su ključne lekcije koje možemo naučiti da mogu dovesti do uspješnog pogona izmjene zadataka, skovao sam poseban akronim, SUNDAR. Što SUNDAR predstavlja, u hindiju, je "privlačan". Čini mi se da postoji 5 ključnih lekcija koje sam prikazao na ovom slajdu koji su kritično bitni za učinkovito izmjenjivanje zadataka. Prva je da moramo pojednostaviti poruku koju koristimo, skidajući sav žargon koji je medicina izmislila oko sebe. Trebamo otpakirati složene zdravstvene intervencije u manje dijelove koji se mogu mnogo lakše prenijeti manje obučenim pojedincima. Moramo pružati zdravstvenu njegu, ne u velikim institucijama, već blizu domova, a moramo i pružiti zdravstvenu njegu koristeći bilo kog tko je dostupan i kog se može priuštiti u našoj lokalnoj zajednici. I najbitnije, moramo preraspodijeliti tih par specijalista koji su dostupni da izvrše uloge poput povećanja kapaciteta i nadgledanja.
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.
Za mene, izmjena zadataka je ideja s istinskim globalnim značenjem jer iako se izrodilo iz manjka resursa koje možete naći u razvojnim državama, mislim da ima jako puno značaja i za bogatije države. Zašto je tako? Pa, dijelom, jer zdravstvena njega u razvijenom svijetu, troškovi zdravstvene njege u [razvijenom] svijetu, polako izmiču kontroli, i velik dio tih troškova su troškovi ljudskih resursa. Ali jednako bitno je zato što je zdravstvena njega postala tako nevjerojatno profesionalizirana da je postala jako udaljena i pomaknuta iz lokalnih zajednica. Za mene, što je zbilja sundar kod ove ideje izmjene zadataka, ipak, nije to što jednostavno čini zdravstvenu njegu pristupačnom i povoljnom već što temeljno ojačava. Ojačava obične ljude da budu učinkovitiji u brizi za zdravlje drugih u svojoj zajednici, i radeći to, postanu bolji čuvari svog vlastitog zdravlja. Doista, za mene, izmjena zadataka je krajnji primjer demokratizacije medicinskog znanja, i time, medicinske moći.
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.
Prije samo 30 godina, narodi svijeta su se okupili u Alma-Ati i stvorili ovu ikoničnu deklaraciju. Ali, mislim da svi vi možete nagađati da 12 godina što smo uključeni, nismo nigdje blizu tog cilja. I dalje, danas, naoružani tim znanjem da obični ljudi u zajednici mogu biti obučeni i, s dovoljno nadgledanja i potpore, mogu pružiti velik broj zdravstvenih intervencija učinkovito, možda je to obećanje u dosegu. Doista, kako bismo implementirali slogan Zdravlje za Sve, morat ćemo uključiti sve u tom putovanju, i u slučaju duševnog zdravlja, posebno bismo morali uključiti ljude koji pate od duševnih bolesti i njihove skrbnike.
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.
Zbog tog razloga, prije par godina, Pokret za Globalno Duševno Zdravlje je osnovan kao vrsta virtualne platforme na kojoj bi profesionalci poput mene i ljudi koji pate od duševnih bolesti mogli stajati zajedno, rame uz rame, i zagovarati prava ljudi s duševnim bolestima da prime njegu koju znamo da može promijeniti njihove živote, i da žive život dostojanstveno.
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)
I za kraj, kad imate trenutak mira ili tišine ovih vrlo zaposlenih par dana ili možda kasnije, izdvojite misao za onu osobu na koju ste mislili koja ima duševnu bolest ili osobe na koje ste mislili koje imaju duševnu bolest, i usudite se brinuti za njih. Hvala vam. (Pljesak)