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.
Pokušajte da zamislite dva čoveka - Raul i Raživ koji žive u istom kraju, podjednako su obrazovani i bave se sličnim poslom i oboje odlaze u hitnu pomoć žaleći se na bol u grudima. Doktor Raulu predlaže intervenciju na srcu dok Raživa šalje kući.
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.
Kako može da se objasni razlika između načina na koji su ova dva čoveka tretirana? Raživ ima psihičkih problema. Razlika između načina na koji su tretirani ljudi sa mentalnim problemima je jedan od razloga zašto oni kraće žive. Čak i u razvijenim zemljama ova razlika dostiže čak 20 godina. U nerazvijenim zemljama ova razlika je čak i 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, postoje i drugi načini kako mentalna bolest utiče na dužinu života. Jedan od njih je recimo samoubistvo. Iznenadiće vas da je samoubistvo jedan od najčešćih uzroka smrti mladih ljudi u svim zemljama sveta uključujući i one siromašne.
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 osim uticaja zdravstvenog stanja na životni vek zanima nas i sam kvalitet života. Da bismo mogli da vidimo kakav uticaj ima određeno zdravstveno stanje na životni vek i na kvalitet života, upotrebićemo takozvanu DALY meru, što znači godina kada se uzme u obzir određeni hendikep. Uz DALY, iz globalne perspektive vidimo neke zaista neverovatne stvari. Vidimo da su mentalne bolesti među vodećim uzročnicima invaliditeta širom sveta. Kod dece na primer, posle proliva i upale pluća depresija je treća bolest koja najviše ograničava. Kada uzmemo u obzir sve mentalne bolesti zajedno one čine 15% svih bolesti u svetu. Moram istaći da mentalne bolesti jako ograničavaju naše živote. Osim tereta bolesti, ako se osvrnemo na brojeve videćemo da po proceni Svetske zdravstvene organizacije na našoj planeti oko četiri do pet stotina miliona ljudi pati od mentalnih bolesti. Naravno, neki od vas su sigurno zaprepašćeni kada čuju taj broj. Ali, ako se na trenutak osvrnemo na veliki broj različitih mentalnih bolesti od autizma do intelektualnih poremećaja kod dece pa do depresije, anksioznosti, bolesti zavisnosti i psihoze kod odraslih ili demencije u starosti videćemo da zaista svako od nas ovde poznaje barem jednu osobu koja je na neki način mentalno obolela. Vidim da se slažete sa mnom.
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.
Osim velikog broja obolelih sa tačke gledišta globalnog zdravlja, bitno je shvatiti i zabrinuti se koliko je mali broj mentalno obolelih koji su na neki način zbrinuti. Istraživanja potvrđuju da različite vrste lečenja poput lekova, psihoterapija i socijalnih promena zaista pomažu. Ipak, čak i u najrazvijenijim zemljama ovde u Evropi oko 50% obolelih ne dobija nikakvu mentalnu pomoć. U zemljama u kojima ja radim taj procenat dostiže neverovatnih 90%. Zato i nije iznenađujuće da ako popričate sa osobom sa mentalnom bolešću, čućete priče o skrivenoj patnji, sramoti i diskriminaciji u skoro svakom segmentu njenog života. Možda je najtužnije od svega videti kako pate ljudi kojima su uskraćena najosnovnija ljudska prava. Primer je devojčica na slici. Nažalost, ova patnja može se uočiti i u psihijatrijskim bolnicama koje bi trebalo da ovim ljudima pomognu.
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.
Moja želja je da učinim makar malo da promenim život ovih ljudi koji pate. Najviše bih želeo da pomognem svima da shvate kako naše znanje može da promeni živote, znanje o uspešnim terapijama, i kako ga možemo upotrebiti u svakodnevnom životu. Jedan od najvećih izazova za mene je bio to što ima veoma mali broj stručnjaka za mentalne poremećaje, poput psihijatara i psihologa, pogotovo u zemljama u razvoju.
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.
Završio sam medicinu u Indiji, a nakon toga specijalizirao psihijatriju. Došlo je do negodovanja pogotovo kod moje majke koja je mislila da je za njenog bistrog sina bolje da postane neurohirurg. U svakom slučaju, ja sam nastavio sa mojim studijama i došao u Britaniju gde sam stažirao u nekim od najboljih psihijatrijskih bolnica. Radio sam u timu izuzetno talentovanih, saosećajnih, ali najvažnije veoma obučenih i specijalizovanih stručnjaka za mentalno zdravlje.
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 prakse, počeo sam da radim prvo u Zimbabveu, a potom i u Indiji i video nešto potpuno novo. U ovim zemljama broj stručnjaka bio je zaista mali. U Zimbabveu, na primer, radilo je oko desetak psihijatara od kojih je većina živela u glavnom gradu zemlje. Samo mali broj njih mogao se brinuti o devet miliona ljudi koji su živeli u manjim mestima.
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.
Ni u Indiji situacija nije bila mnogo bolja. Recimo, ako uzmem u obzir broj psihijatara u Britaniji, proporcionalno čovek bi očekivao oko 150 000 psihijatara u Indiji. Pokušajte da pogodite koliko ih je bilo. Samo oko 3 000 što je svega 2% od predviđenog.
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 odmah jasno da u Indiji i Zimbabveu neću moći primeniti iste modele kao one koje sam primenjivao tokom moje prakse, a koji se zasnivaju na skupoj zdravstvenoj nezi. Morao sam da počnem drukčije da razmišljam.
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.
Tada sam naišao na ove knjige u kojima sam video ideju prenosa zaduženja. Jako je jednostavna. Radi se o tome da kada nema dovoljno specijalista mogu da pomognu čak i ljudi koji nisu specijalizovani. Treba ih samo naučiti. U ovim knjigama video sam primere običnih ljudi koji su naučili kako da uspešno porađaju žene ili da primete rane znake upale pluća i da je leče. I zaista me je podstaklo na razmišljanje to da ako tako obični ljudi mogu da nauče tako komplesne intervencije, onda bi sigurno ti isti ljudi mogli da nauče kako da pomognu mentalno obolelima.
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.
Sada mogu reći da sam zaista srećan jer mogu da vas obavestim da su urađeni raznovrsni eksperimenti u kojima je ustanovljeno da u zemljama koje su u razvoju u poslednjih deset godina obični ljudi zaista mogu da nauče kako da tretiraju mentalno obolele. Podeliću sa vama tri takva eksperimenta. Sva tri se odnose na depresiju koja je najčešća mentalna bolest. U selima u Ugandi, Pol Bolton i njegove kolege uvideli su da obični seljaci mogu da pomognu depresivnim ljudima putem interpersonalne terapije. Koristeći eksperiment sa nasumičnom kontrolom, pokazali su da se 90% onih koji su primili ovakvu intervenciju oporavilo, u poređenju sa oko 40% njih koji nisu dobili nikakvu vrstu nege. Slična situacija je i u Pakistanu gde su Atif Rahman i njegove kolege pokazali da su žene zdravstvene radnice u pakistanskom zdravstvenom sistemu, mogle putem kognitivno bihejvioralne terapije da pomognu depresivnim majkama, pokazujući velike razlike u stopama oporavka. Oko 75% depresivnih majki uspelo je da se oporavi u odnosu na samo 45% u selima u kojima pomoć nije bila ponuđena. U eksperimentu koji sam nadgledao u oblasti Goa u Indiji, došli smo do zaključka da ljudi mogu da se obuče kako da pravilno ponude psiho-socijalne vrste terapija za lečenje depresije i anskioznosti, vodeći do 70% oporavka u poređenju sa 50% u centrima primarne zdravstvene zaštite.
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 morao da analiziram ove različite eksperimente, a zaista ih ima mnogo, i da pokušam da identifikujem ključne lekcije o tome šta čini ovakve programe uspešnim, smislio sam jedan akronim, SUNDAR. SUNDAR na hindu jeziku znači zgodan. Sada ću vam pokazati koje su po meni posebno bitne lekcije za uspešnu obuku ljudi u zemljama u razvoju. Prva je da pojednostavimo poruku koju želimo da podelimo sa ljudima kako bi bila bez komplikovanog medicinskog žargona. Potom da pojednostavimo zdravstvene intervencije i podelimo ih na manje delove koji mogu lako da se objasne i onima koji nisu specijalizovani. Zatim, moramo da se postaramo da je zdravstvena nega blizu ljudi, u blizini njihovih kuća i da tu negu daje ko god je u mogućnosti. Jako je bitno i to da taj mali broj specijalista koji su stručni da nadgledaju negu koja se obolelima daje bude pravilno raspoređen.
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.
Ja mislim da je ideja prenosa zaduženja od globalnog značaja, jer može biti izuzetno korisna i u razvijenim zemljama, iako je nastala podstaknuta ograničenim brojem resursa u nerazvijenim zemljama. Zašto tako mislim? Pa zato što troškovi zdravstvene nege u razvijenim zemljama izuzetno rastu i veliki deo tih troškova ide na zaposlene. Isto tako, jako je bitno reći da je zdravstvena nega postala toliko stručna da se udaljila od običnih ljudi. Zapamtite da SUNDAR ne daje samo zdravstvenu negu siromašnima već i osnažuje. Osnažuje ljude bez prethodnog iskustva da pomognu obolelima u svojoj zajednici i na taj način očuvaju i svoje zdravlje. Za mene je ona primer toga kako znanje može da se proširi na što veći broj ljudi i na taj način postane moć.
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.
Pre tridesetak godina države sveta su se okupile u gradu Alma Ata i postavile cilj da se svim ljudima sveta do 2000. godine da pravo na zdravlje. Vidite i sami da smo nakon 12 godina još uvek daleko od tog cilja. Danas smo praćeni znanjem da obični ljudi, kada ih nadgledamo i podržimo mogu naučiti da pomognu obolelima. Zato možda taj naš cilj nije toliko daleko. Da bismo ga ostvarili, moramo u to putovanje uključiti sve ljude. Što se tiče mentalnog zdravlja, morali bismo uključiti ljude koji su oboleli i ljude koji se o njima staraju.
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.
Upravo zato je pre nekoliko godina osnovan Pokret za svetsko mentalno zdravlje, kao virtuelna platforma, u kojem psihijatri poput mene zajedno sa obolelima mogu da se udruže i da se zalažu da oboleli dobiju negu koja im je potrebna da bi im se životi promenili na bolje i da bi živeli 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)
Voleo bih na kraju da vas podsetim da nađete trenutak u vašim životima da pomislite na tu dragu osobu ili osobe koji su mentalno oboleli i da pokušate da im pomognete. Hvala vam. (Aplauz) (Aplauz)