Comment

A global scope for global healthincluding mental health

Unprecedented opportunities to promote excellence and equity in health-care delivery for the worlds most underserved populations are upon us. Successful programmes to reduce the transmission of and mortality from infectious diseases have invigorated discourse about the human right to health, and have resulted in viable platforms for comprehensive health programmes that provide care to millions of people facing both poverty and chronic disease.1 Indeed, the past decade has seen the introduction of the rst such platforms designed to treat incurable disorders, from AIDS to diabetes. Rapid scientic advances and health-system improvements that help us to understand and redress the biosocial roots of poor health and to develop diagnostics, therapeutics, and the technology and infrastructure to disseminate and implement them, promise to extend benets to care delivery in the realm of non-communicable diseases. However, delivery of mental health services in lowresource settings lags unacceptably and unjustly far behind that of other services. Neuropsychiatric disorders comprise a substantial share of disease-related burden and disabilityapproaching 14%, with depression the leading global cause of disabilitybut receive a disproportionately low resource allocation: the average across countries is under 4% of overall health-care budgets.2,3 Resources for mental health research are also scarce and knowledge gaps persist.4 Alongside a shortfall in trained mental health professionals, these decits are the backdrop to a disconcerting treatment gap for neuropsychiatric disorders in low-income countries, with over 75% of patients untreated.5,6 Even these dismal metrics do not fully convey the unconscionable neglect, social discrimination, and frequent abuse endured by the mentally ill,7 a situation aptly described as a failure of humanity.8 Although uncontested, neither inventories of need,9 nor the pragmatic refrain of no health without mental health by Prince and colleagues,2 which opened The Lancets 2007 Series on global mental health, have gained sucient purchase. How the message could be amplied further to transform a narrative of global neglect is dicult to imagine. Additional structural (largely economic) and cultural obstacles beset eorts to provide more eective and accessible care for mental disorders in low-resource settings.9 However, barriers that prevent patients from seeking help and impede care for mental disorders eg, functional impairment, social stigma, and low health literacy in patients and caregivershave been encountered and overcome for other disorders, as the success of the movement to confront HIV/AIDS shows. Notably, this triumph for global health equity was achieved when prevention was integrated with high-quality care through the creation of new nancing mechanisms.10,11 Although much remains to be done, the successful implementation of programmes in poorer parts of the world should act as a model for care delivery in other health-care domains, including mental health, as the coalition Movement for Global Mental Health has declared.12 Strategies to close the mental health resource gap in low-income regions are in sight, a research agenda is being set, and new protocols are ready for implementation.13,14 In 2010, WHO released its muchanticipated mental health Gap Action Programme Intervention Guide to support the implementation of treatment for mental, neurological, and substance-use disorders in primary-care health settings.15 Thoughtfully conceived basic treatment packages for common mental health disorders could improve delivery of key services at low expenditure in countries of low and middle income.1618 Straightforward treatment algorithms and innovative task-shifting mechanismswell established for other conditionsrender aordable and eective mental health care within reach, and with it potentially vast collateral health and social benets.19 However, an argument based solely on costeectiveness is unwise if it promotes only one narrow sector of the health agenda at the expense of others. Investments are needed that build on, rather than compete with, the newly created platforms to prevent and treat other chronic illnesses. The broad health benets of programmes focused on HIV/AIDS prevention and care show that good mental health care would not dilute primary health care, but could strengthen it.10,11 A unied call for integrated and comprehensive models of health-care delivery, inclusive of non-communicable diseases and mental disorders, would be compelling. The UN General Assembly High-level Meeting on Non-communicable diseases in September was only the second Special Session convened about a health-

Published Online October 17, 2011 DOI:10.1016/S01406736(11)60941-0 See Online/Series DOI:10.1016/S01406736(11)60754-X, DOI:10.1016/S01406736(11)60827-1, DOI:10.1016/S01406736(11)61094-5, DOI:10.1016/S01406736(11)60891-X, DOI:10.1016/S01406736(11)61093-3, and DOI:10.1016/S01406736(11)61458-X

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BasicNeeds

Comment

related issue.20 Preceding optimism was warranted, but if the collective ambition of global-health advocates, scientists, and practitioners is to promote social and economic rights and equitable access to evidencebased health services for all, we must also construe and promote global health as encompassing a global scope of health domains. We join the call for the inclusion of mental health in a comprehensive health agenda for the worlds poorest populations.21 The pragmatic and moral imperatives are self-evident: without mental health care, there is no justice. The methods are in hand, the advocates have been mobilised, and the message should be unied action. *Giuseppe Raviola, Anne E Becker, Paul Farmer
Program in Global Mental Health and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA giuseppe_raviola@hms.harvard.edu
We declare that we have no conicts of interest. 1 2 3 4 Farmer P. Challenging orthodoxies: the road ahead for health and human rights. Health Hum Rights 2008; 10: 519. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet 2007; 370: 85977. Saxena S, Thornicroft G, Knapp M, Whiteford H. Resources for mental health: scarcity, inequity, and ineciency. Lancet 2007; 370: 87889. Razzouk D, Sharan P, Gallo C, et al, for the WHO-Global Forum for Health Research Mental Health Research Mapping Project Group. Scarcity and inequity of mental health research resources in low-and-middle income countries: a global survey. Health Policy 2010; 94: 21120. Meyer AC, Dua T, Ma J, Saxena S, Birbeck G. Global disparities in the epilepsy treatment gap: a systematic review. Bull World Health Organ 2010; 88: 26066. Demyttenaere K, Bruaerts R, Posada-Villa J, et al, for the WHO World Mental Health Survey Consortium. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291: 258190.

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Burns JK. Mental health and inequity: a human rights approach to inequality, discrimination, and mental disability. Health Hum Rights 2009; 11: 1931. Kleinman A. Global mental health: a failure of humanity. Lancet 2009; 374: 60304. Desjarlais R, Eisenberg L, Good B, Kleinman A. World mental health: problems and priorities in low-income countries. Oxford, UK: Oxford University Press, 1995. Walton DA, Farmer PE, Lambert W, Landre F, Koenig SP, Mukherjee LS. Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. J Public Health Policy 2004; 25: 13758. Koenig S, Ivers LC, Pace S, et al. Successes and challenges of HIV treatment programs in Haiti: aftermath of the earthquake. HIV Ther 2010; 4: 14560. Patel V, Collins PY, Copeland J, et al. The movement for global mental health. Br J Psychiatry 2011; 198: 8890. Tomlinson M, Rudan I, Saxena S, Swartz L, Tsai AC, Patel V. Setting priorities for global mental health research. Bull World Health Organ 2009; 87: 43846. Grand Challenges in Global Mental Health. Overview and denitions. http://grandchallengesgmh.nimh.nih.gov/about.shtml#overview (accessed May 17, 2011). WHO. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP). Geneva: World Health Organization, 2010. Patel V, Simon G, Chowdhary N, Kaaya S, Araya R. Packages of care for depression in low- and middle-income countries. PLoS Med 2009; 6: e1000159. Patel V, Prince M. Global mental health: a new global health eld comes of age. JAMA 2010; 303: 197677. Chisholm D, Lund C, Saxena S. The cost of scaling up mental health care in low- and middle-income countries. Br J Psychiatry 2007; 191: 52835. Ivers LC, Jerome J-G, Cullen KA, et al. Task-shifting in HIV care: a case study of nurse-centered community-based care in rural Haiti. PLoS One 2011; 6: e19276. Lee PT, Henderson M, Patel V. A UN summit on global mental health. Lancet 2010; 376: 516. WHO. Moscow Declaration: commitment to action, way forward. April 2829, 2011. http://www.who.int/nmh/events/moscow_ncds_2011/ conference_documents/en (accessed June 27, 2011).

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www.thelancet.com Published online October 17, 2011 DOI:10.1016/S0140-6736(11)60941-0