Redefining the role of psychiatry in South Asia
Psychiatry in South Asia faces a dilemma. While a bewildering number of professional associations, crowd the annual calendar with conferences where we hear exhortations to improve mental health care in the region, the reality is far more dismal. Consider the reality of the region’s mental health resources as shown in Table 1. In summary, our 1.3 billion people make us home to over sixth of humanity, and we are still growing. Between 30 to 40% of our population is under the age of 14, making our region home to the largest number of the world’s children. Yet, the combined total of all the psychiatrists in the region barely reaches 2500 and, incredibly, we have even fewer psychiatric nurses. While our region is desperately short of psychiatric beds, the real scandal is that more than 3 out of 4 beds which are available are housed in mental hospitals, contrary to the progressive guidelines of the WHO1. Let us contrast this situation with two countries where a large proportion of the South Asian psychiatrists live: the United Kingdom with its population 20 times smaller than South Asia, and Australia with its population 65 times smaller. The total number of psychiatrists in South Asia is, amazingly, about the same as the number in Australia, and about a third of the number in the UK. The total number of psychiatric nurses in Australia outnumber South Asia 10 fold, while the UK outnumbers us 60 fold! Both countries enjoy much larger proportion of beds overall and, in particular, in general hospital settings. At the rate at which we currently produce new mental health specialists, it is unlikely that we will achieve the level of human resources enjoyed by rich countries for several generations to come. These grotesque inequities are only being worsened as the hunger for psychiatrists and psychiatric nurses in rich countries continues to attract large numbers of South Asian professionals.
I raise these inequities, which are well-known to most mental health professionals in the region, to serve as the rationale for the call that South Asian psychiatry must chart a course quite different from that of our colleagues in rich countries. There, the vast majority of psychiatrists work in well-supported health service environments including highly resourced multi-disciplinary community mental health care and social welfare systems, in well-paid public or private sector jobs, and a strong public health infrastructure to take care of population mental health needs and research. These realities pretty much leave the psychiatrist to focus on the narrow realms of clinical practice and management. In our region, however, none of the riches our colleagues enjoy can be taken for granted. If we continue to focus almost entirely on hospital or clinic based patient management psychiatry will remain, at best, only a marginal player in improving mental health care. If we truly believe that psychiatry’s role is to contribute to improvements in mental health in our region, then we will have to temper our role as primary clinicians. Instead, we need to shift our goals to empowering and building capacity in other sectors of the health system and the community at large.
This means, in practical terms, four major roles. First, as trainers for a new generation of health practitioners of diverse backgrounds including nurses, general medical graduates, medical specialists in relevant disciplines, community health workers and so on. It is imperative that the training curriculum emphasizes community and primary care perspectives. Current models of training emphasize hospital based care for severely ill patients which, ironically, are largely the domain of specialist care. The training of specialist psychiatrists must include a comprehensive coverage of the roles such as training methods, research skills, advocacy and community mental health program development. An important role is that of supervision and support to community and primary health care teams; psychiatrists may take on the responsibility of population based care, providing tertiary referral services (for e.g. for acute emergencies) and supervision. Supervision and support are critical components of effective primary mental health care programs2. It is also important to carry out research in the priority mental health research areas for the region. Instead of focusing on hospital based studies with samples of patients who are highly selected, or pharmaceutical company sponsored licencing trials, our profession must engage with answering the questions which really matter to improving mental health care in the population. A systematic research priority-setting exercise for four groups of mental disorders has recently been completed for the forthcoming Lancet Series on Global Mental Health (in press) which emphasizes health systems and epidemiological research as key priorities. The final role is that of an advocate to raise the public profile of mental illness and the rights of the mentally ill. But advocacy can go beyond this, for example, advocating to our diaspora about the potential harmful impact of unrestricted recruitment of young doctors and nurses from the region to work in already well-resourced countries.
Table 1: Mental health resources in South Asia
What is clear from these roles is that blindly aping a model of care from the UK or Australia which is built on enormous human and financial resources will not be feasible for the foreseeable future. Neither these models will be affordable or necessarily more effective than low-cost community and primary care models. Here is where the lack of comprehensive mental health resources in South Asia presents an opportunity, an opportunity to innovate new models of mental health care which reaches out to larger sections of the population, built upon principles of equity, acceptability (to the community), affordability and effectiveness. We need to challenge ourselves to step out of our clinical pigeon-holes. There is an enormous demand for and awareness about mental health care, new resources for mental health program development and research, and a tremendous opportunity to be creative and to make a difference. To achieve this ambitious goal, we must learn from one another-particular from others in the region. South Asia is home to numerous champions for the mentally ill who are constantly innovating and creating new models. There are numerous examples of such innovators, from those who are reforming the colonial-era mental hospitals to modern psychiatric care institutions, to those who are extending their clinical psychiatric practice to serve under-privileged populations, to those who are working in community based NGOs to provide rehabilitation services, to those who are advocating for the rights of persons affected by mental disorders. Some of these models have been described in a recent book on NGO innovations in India3. The South Asian mental health fraternity must share and learn from these innovations, and develop its own models of mental health care if we are to be relevant to the rapidly growing mental health agenda for the region. We must recognize that both the private and public sectors share the responsibility towards achieving our goals of mental health are for all.
There is also the enormous threat to the already scarce resources posed by the brain-drain and much has been written about this threat4. We must acknowledge that people leave our region not only for financial reasons- the ‘pull factors’, but also because the working conditions in our system are often bleak-what is sometimes referred to as the ‘push’ factors. We all recognize examples of such ‘push’ factors-poor salaries, promotions and career paths based on seniority rather than performance, unwarranted political interference in appointments, poor mentoring of younger talent by established leaders, and an unregulated private sector with considerable conflict of interest with the region’s pharmaceutical industry. We need to put our own house in order if we are to stem the brain-drain. We need to reform our mental health system, make a career in mental health in our region attractive, and counter the growing and imbalanced influence of the pharmaceutical industry.
The place of mental health in the global public health agenda, and on the agenda of the governments in our region, is rapidly rising. Consider two key indicators of this rapid rise in profile: first, the proposal of India’s Ministry of Health to scale up its District Mental Health Programme to cover all of the over 600 districts in India (from just over 100 currently); and second, the initiative by the Lancet, one of the world’s leading medical journals, to publish a six article Series devoted to global mental health (due to be launched on September 3rd, 2007). Although many psychiatrists from our region have been centrally involved with both these initiatives, the reality is that the majority are not even aware of them. There is a real danger that unless we step out of our cosy conferences and clinics and engage with public policy and stakeholders for public mental health, our profession will remain marginal and irrelevant to these initiatives-and to the future prospects of improving mental health care in our region. Let us make the most of these golden opportunities to advocate for reform in mental health care in our region-and in doing so, revise what we think our roles should be to achieve these goals.
1. World Health Organization. The World Health Report 2001: Mental health: New Understanding, New Hope.
Geneva: WHO, 2001.
2. Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative care for depression in primary care: Making sense of a complex intervention: systematic review and meta-regression. Br J Psychiatry 2006;189:484-93.
3. Patel V, Thara R. Meeting Mental Health Needs in Developing Countries: NGO Innovations in India. New Delhi: Sage (India), 2003.
4. Mullan F. The metrics of physician brain drain. N Engl J Med 2005;353:1810-8.