World Mental Health Day falls today on the theme, ‘Mental Health in an Unequal World’
Consultant Psychiatrist and Senior Lecturer from Kotelawala Defence Univeristy, Dr. Neil Fernando throws light on the widening treatment gap in mental health, calling for a four-pronged strategy to enable wider community access to mental health services.
by Randima Attygalle
Mekala (name changed) made history as the first young person from her village in Sevanagala to enter Medical College. All was going well for the budding doctor until she was diagnosed with Schizophrenia in her fourth year. A chronic brain disorder, Schizophrenia affects the way a person thinks, acts, expresses emotions, perceives reality and relates to others.
It took nine years for Mekala to recover and when she made an appeal to the authorities to let her complete her medical studies, she was turned down on the basis that her grace period to complete her course had expired. With her hopes shattered, Mekala had a relapse.
“Despite experts in mental health making a case for the young medical student to allow her to complete her studies, making an exception to the existing rules, the authorities rejected the case, which was very sad,” recollected Consultant Psychiatrist, Dr. Neil Fernando who was among the specialists that treated Mekala.
While that was the sad plight of a medical student here, the story of the American mathematician, John Forbes Nash Jr. was the opposite. He spent years at psychiatric hospitals being treated for Schizophrenia. When his condition improved, he was allowed to return to the Princeton University to teach. Not only was Nash welcomed by his colleagues but he also won the Nobel Prize in Economic Sciences in 1994. He opened his acceptance speech with the forthright comment, “I’m a Schizophrenia patient.” Nash’s struggles with his illness and his recovery inspired Sylvia Nasar’s biography A Beautiful Mind and later a film by the same name starring Russell Crowe as Nash.
World Mental Health Day was observed for the first time on October 10, 1992. It was started as an annual activity of the World Federation for Mental Health by the then Deputy Secretary General Richard Hunter. Hunter began his career in the mental health field during World War II when as a conscientious objector he joined the Civilian Public Service programme. Hunter, a law graduate, while serving a hospital for the mentally ill patients, was disheartened by the lack of awareness of mental health which drove him to advocate for it.
This year’s theme for World Mental Health Day- ‘Mental Health in an Unequal World’ highlights that access to mental health services remains unequal. This is compounded in a world which is becoming increasingly polarized, points out Dr. Fernando. “The gap between the haves and have-nots is widening each day and the inequality is more prominent when it comes to mental health. Lack of investment in mental health disproportionate to the overall health budget contributes to the mental health treatment gap.”
People with mental disorders experience disproportionately higher rates of disability and mortality proving that ‘there is no health without mental health.’ According to WHO, persons with major depression and schizophrenia have a 40% to 60% greater chance of dying prematurely than the general population, owing to physical health problems that are often left unattended (such as cancers, cardiovascular diseases, diabetes and HIV infection) and suicide. Suicide is the second most common cause of death among young people worldwide. Yet, health systems have not yet adequately responded to the burden of mental disorders.
As a result, the gap between the need for treatment and its provision is large all over the world, notes the WHO’s Mental Health Action Plan 2013-2030. ‘Between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low-income and middle-income countries; the corresponding range for high-income countries is also high: between 35% and 50%. A further compounding problem is the poor quality of care for those receiving treatment.’
One in every four persons develops a mental illness says Dr. Neil Fernando. “Yet the annual investment in mental health is less than US$ 2 per person. In low income countries, it is less than US$ 0.25. In 2019, WHO pointed out that for every dollar spent on mental health, there is a return of four dollars from improved health and productivity.” Although it is accepted that large hospitals are not the best of places for people with mental disorders, 67% of financial resources are allocated to mental hospitals,” notes the psychiatrist who goes onto add that mental hospitals often restrain people unnecessarily resulting in abuse, poor health outcomes and human rights violations.
The tragic story of P.P. James who was confined to the asylum in Angoda for 50 years is one of the worst violations of human rights resulting in restricted hospitalization. Arrested on a charge of killing his father late one night in 1958, James was ruled mentally ill by a judge and was committed to the asylum for the criminally insane and was forgotten for 50 years, never having stood trial. Worst, the father he was charged for having killed was actually alive and died only 23 years after James’ arrest for ‘his murder’. A half a century after his arrest, his case was dismissed and James was finally free. “Although James had recovered decades ago and the courts were informed, there was no response as his file had been lost,” recollects Dr. Fernando who was serving in the hospital’s criminal ward at that time.
The absence of mental health legislation in the country to suit the present day needs is also cited by the senior consultant as a drawback in realizing mental health from a human rights perspective. The proposed Mental Health Act has remained only a ‘draft’ for decades, he says.
Stigma and discrimination, very often within families of patients (even after recovery) compounds the unequal access to mental health care and impedes the quality of their lives. Problems of knowledge, attitude and behaviour contribute to stigma. Many people even after recovery are abandoned by their families and are often deprived of their rightful inheritance.
In our setting, the stigma is even extended to the very locality where the hospital for the mentally ill stands- commonly referred to as pissan kotuwa in derogatory terms. When posted to Angoda as a young psychiatrist in 1984, Dr. Fernando took the bus from Kandy to Fort and from there to Angoda. “As the bus approached Angoda, the conductor was shouting Pissan kotuwa bahinna- pissan kotuwa bahinna and nobody got down from the bus. At the next bus halt half the passengers got off the bus and opted to walk back,” he recollects. The hesitancy of residents from the area to be identified with a hospital, drove authorities to rename the areas as ‘Mulleriyawa New Town.’ Angoda Mental Hospital was renamed ‘National Institute of Mental Health.’
Migration of qualified psychiatric specialists to other countries is another challenge points out Dr. Fernando. Sri Lanka’s failure to deliver mental health care services to a larger population is attributed to four broad reasons by Dr. Fernando:
1. The centralized services limited to large hospitals
“We need to decentralize mental health care and take it to primary health care or to the village level and integrate it to normal health care services.”
2. Services are all hospital-based
“The majority of people who need mental health services do not come to hospitals, hence the treatment gap is further widened,” remarks the senior consultant who calls for a ‘complementary community-based’ system. “Like in the case of maternal health, we can develop a system where patients are seen at home. We already have psychiatric nurses and this cadre can be further strengthened.”
3. The treatment is largely disease-based
“Instead of looking only at the disease, we should have a patient-friendly service which looks at a person holistically addressing his/her other needs as well.”
4. Services are delivered on one-to-one basis
“When we know that one in four people will be affected by a mental health problem during his/her lifetime, one-to-one delivery will not be adequate,” says Dr. Fernando who says the involvement of patients as well as their care givers in mental health services is essential. The effort could make them active partners in the process, so that they too can be empowered to take ownership to the delivery of care, he says.
Why Small Farms will be the backbone of food security
The ecological axiom that: ‘Energy flow through a system tends to organise and simplify that system’, is abundantly clear in agriculture. As farms moved from small interdependent units, bounded by fences and hedgerows, to large cropping fields to accommodate machine management, we lose the biodiversity that once existed on that landscape and the biomass that provided the Ecosystem Services. This sacrifice was rationalised through the invocation of economic profit. The economic ‘profit’ gained by subsidies on fossil fuel and uncontrolled extraction from the Global Commons. The ‘development’ of agriculture has become a race to control the commodity market. The farmer ceased to be a feature of the farm. In a telling statement, the farmers of Sri Lanka sent the following statement to the CGIAR in 1998 :
‘We, the farmers of Sri Lanka would like to further thank the CGIAR, for taking an interest in us. We believe that we speak for all of our brothers and sisters the world over when we identify ourselves as a community who are integrally tied to the success of ensuring global food security. In fact it is our community who have contributed to the possibility of food security in every country since mankind evolved from a hunter-gather existence. We have watched for many years, as the progression of experts, scientists and development agents passed through our communities with some or another facet of the modern scientific world. We confess that at the start we were unsophisticated in matters of the outside world and welcomed this input. We followed advice and we planted as we were instructed. The result was a loss of the varieties of seeds that we carried with us through history, often spanning three or more millennia. The result was the complete dependence of high input crops that robbed us of crop independence. In addition, we farmers producers of food, respected for our ability to feed populations, were turned into the poisoners of land and living things, including fellow human beings. The result in Sri Lanka is that we suffer from social and cultural dislocation and suffer the highest pesticide- related death toll on the planet. Was this the legacy that you the agricultural scientists wanted to bring to us ? We think not. We think that you had good motives and intentions, but left things in the hands of narrowly educated, insensitive people.’
The diverse farm had to yield to production monoculture, which was made possible through the burning of fossil fuels. Ironically the burning of fossil fuels is the major reason for the current destabilised climate and threat to agriculture. One consequence of climate change is the predicted rise in global temperatures. If ambient temperatures exceed 40 degrees , which has become the reality in many places even today, food production will be compromised. All the food we eat originates with plants and plants produce using photosynthesis. Photosynthesis, or the capture of solar energy by plants, is done with chlorophyll, the thing that makes plants green and chlorophyll begins to break down after 40 degrees. Landscapes whose summer temperatures go beyond this limit will have smaller and smaller crops as the temperatures increase. The only solution to this oncoming crisis, is to begin introducing trees at strategic points on the landscape.
Trees and all other forms of vegetation cool the environment around them through the transpiration process, which takes place in the leaves. The water absorbed by the roots is sent up to the leaves which release it as vapor, cooling the air around it. Measurements on trees done by research institutions worldwide, indicate that an average large tree produces the cooling equivalent of eight room sized air conditioners running for 10 hours, a cooling yield 0f 1,250,000 Bthu per day. Plantations of trees have been recoded to have daytime temperatures at least 3 degrees below the ambient. This is an important aspect of Ecosystem Services that needs to be considered for adaptive agriculture.
Small farms which produce food with low external energy and maintain high biomass and biodiversity, are the models of food production that can face the climate compromised future before us. Capital, resource and energy expensive agricultural systems could fail in a high temperature future and threaten global food security, we need options. One would be to encourage a consumption and distribution system that facilitates small farmers to enter the market. Another would be to realise the value of the ecosystem services of a farm and develop systems to measure and reward. We are all aware of the future before us. Now is not the time to stand blinking like a deer facing the headlights.
But placing trees in and around cropping areas becomes a problem in large cropping fields designed to accommodate machine management. The management of such trees and hedgerows requires needs that cannot be provided without human management. Agricultural landscapes will need management that will be adaptive to the changing climate. An example would be; small interdependent units bounded by fences and that increase biodiversity and the biomass while providing Ecosystem Services.
Investment in food security, should take climate change seriously. All new agricultural projects should address the heat thresholds of the planned crops. The Sri Lankan country statement at COP 21 stated that :
“We are aware that the optimum operating temperature of chlorophyll is at 37 deg C. In a warming world where temperatures will soar well above that, food production will be severely impacted.”
And that :
“We are aware that the critical Ecosystem services such as; production of Oxygen, sequestering of Carbon, water cycling and ambient cooling is carried out by the photosynthetic component of biomass. This is being lost at an exponential rate, due to the fact that these Ecosystem Services have not been valued, nor economically recognised.”
These statements cry out for the recognition of the role that small farms will have to play in the future. In a temperature compromised future, small farms with high standing biomass, through their cooler temperatures will continue to produce food in heat stressed periods. If such Ecosystem Services can be given a value, it will strengthen the economy of small farms and ensure local, sustainable food production into the future.
Small farms which produce food with low external energy and maintain high biomass and biodiversity, are the models of food production that can face the climate compromised future before us. Capital, resource and energy expensive agricultural systems could fail in a high temperature future and threaten global food security, we need options. One would be to encourage a consumption and distribution system that facilitates small farmers to enter the market. Another would be to realize the value of the ecosystem services of a farm and develop systems to measure and reward. We are all aware of the future before us. Now is not the time to stand blinking like a deer in sheadlights.
Encouraging signs, indeed!
Local entertainers can now breathe a sigh of relief…as the showbiz scene is showing signs of improving
Yes, it’s good to see Manilal Perera, the legendary singer, and Derek Wikramanayake, teaming up, as a duo, to oblige music lovers…during this pandemic era.
They will be seen in action, every Friday, at the Irish Pub, and on Sundays at the Cinnamon Grand Lobby.
The Irish Pub scene will be from 7.00 pm onwards, while at the Cinnamon Grand Lobby, action will also be from 7.00 pm onwards.
On November 1st, they are scheduled to do the roof top (25th floor) of the Movenpik hotel, in Colpetty, and, thereafter, at the same venue, every Saturday evening.
Constructive dialogue beyond international community
by Jehan Perera
Even as the country appears to be getting embroiled in more and more conflict, internally, where dialogue has broken down or not taken place at all, there has been the appearance of success, internationally. President Gotabaya Rajapaksa will be leading a delegation this week to Scotland to attend the UN Climate Change Conference (COP26). Both the President, at the UN General Assembly in New York, and Foreign Minister Prof G L Peiris, at the UN Human Rights Council, in Geneva seem to have made positive impacts on their audiences and, especially amongst the diplomatic community, with speeches that gave importance to national reconciliation, based on dialogue and international norms.
In a recent interview to the media Prof Peiris affirmed the value of dialogue in rebuilding international relations that have soured. He said, “The core message is that we believe in engagement at all times. There may be areas of disagreement from time to time. That is natural in bilateral relations, but our effort should always be to ascertain the areas of consensus and agreement. There are always areas where we could collaborate to the mutual advantage of both countries. And even if there are reservations with regard to particular methods, there are still abundant opportunities that are available for the enhancement of trade relations for investment opportunities, tourism, all of this. And I think this is succeeding because we are establishing a rapport and there is reciprocity. Countries are reaching out to us.”
Prof Peiris also said that upon his return from London, the President would engage in talks locally with opposition parties, the TNA and NGOs. He spoke positively about this dialogue, saying “The NGOs can certainly make a contribution. We like to benefit from their ideas. We will speak to opposition political parties. President Gotabaya Rajapaksa is going to meet the Tamil National Alliance on his return from COP26, which we will attend at the invitation of the British Prime Minister. So be it the NGO community or the foreign diaspora or the parliamentary opposition in Sri Lanka. We want to engage with all of them and that is very much the way forward”
The concept of a whole-of-government approach is indicative of a more cohesive approach to governance by government ministries, the public administration and state apparatus in general to deal with problems. It suggests that the government should not be acting in one way with the international community and another way with the national community when it seeks to resolve problems. It is consistency that builds trust and the international community will trust the government to the extent that the national community trusts it. Dialogue may slow down decision making at a time when the country is facing major problems and is in a hurry to overcome them. However, the failure to engage in dialogue can cause further delays due to misunderstanding and a refusal to cooperate by those who are being sidelined.
There are signs of fragmentation within the government as a result of failure to dialogue within it. A senior minister, Susil Premajayantha, has been openly critical of the ongoing constitutional reform process. He has compared it to the past process undertaken by the previous government in which there was consultations at multiple levels. There is a need to change the present constitutional framework which is overly centralised and unsuitable to a multi ethnic, multi religious and plural society. More than four decades have passed since the present constitution was enacted. But the two major attempts that were made in the period 1997-2000 and again in 2016-2019 failed.
President Rajapaksa, who has confidence in his ability to stick to his goals despite all obstacles, has announced that a new constitution will be in place next year. The President is well situated to obtain success in his endeavours but he needs to be take the rest of his government along with him. Apart from being determined to achieve his goals, the President has won the trust of most people, and continues to have it, though it is getting eroded by the multiple problems that are facing the country and not seeing a resolution. The teachers’ strike, which is affecting hundreds of thousands of schoolchildren, is now in its fourth month, with no sign of resolution. The crisis over the halting of the import of chemical fertiliser is undermining the position of farmers and consumers at the present time.
An immediate cause for the complaints against the government is the lack of dialogue and consultation on all the burning issues that confront the country. This problem is accentuated by the appointment of persons with military experience to decision-making positions. The ethos of the military is to take decisions fast and to issue orders which have to be carried out by subordinates. The President’s early assertion that his spoken words should be taken as written circulars reflects this ethos. However, democratic governance is about getting the views of the people who are not subordinates but equals. When Minister Premajayantha lamented that he did not know about the direction of constitutional change, he was not alone as neither does the general public or academicians which is evidenced by the complete absence of discussion on the subject in the mass media.
The past two attempts at constitutional reform focused on the resolution of the ethnic conflict and assuaging the discontent of the ethnic and religious minorities. The constitutional change of 1997-2000 was for the purpose of providing a political solution that could end the war. The constitutional change of 2016-19 was to ensure that a war should not happen again. Constitutional reform is important to people as they believe that it will impact on how they are governed, their place within society and their equality as citizens. The ethnic and religious minorities will tend to prefer decentralised government as it will give them more power in those parts of the country in which they are predominant. On the other hand, that very fact can cause apprehension in the minds of the ethnic and religious majority that their place in the country will be undermined.
Unless the general public is brought aboard on the issue of constitutional change, it is unlikely they will support it. We all need to know what the main purpose of the proposed constitutional reform is. If the confidence of the different ethnic and religious communities is not obtained, the political support for constitutional change will also not be forthcoming as politicians tend to stand for causes that win them votes. Minister Premajayantha has usefully lit an early warning light when he said that politicians are not like lamp posts to agree to anything that the government puts before them. Even though the government has a 2/3 majority, this cannot be taken for granted. There needs to be buy in for constitutional reform from elected politicians and the general public, both from the majority community and minorities, if President Rajapaksa is to succeed where previous leaders failed.
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