Mind the World Health Gap

Four of the top ten causes of disability in women are psychiatric conditions, according to the World Health Organization's Mental Health Global Action Plan. These conditions include clinical depression, schizophrenia, bipolar disorder, and panic disorder. Yet the Obama administration's Global Health Initiative (GHI) turns a blind eye to the enormous burden that mental health places on all populations.

The GHI commits an unprecedented $63 billion to improving health care in select countries around the world. America stands to reap many humanitarian and diplomatic fruits from reducing global health disparities through the GHI. Yet, as the Obama administration now gets set to announce the recipient countries, the absence of mental health goals stands out as a glaringly self-defeating omission in its plan.

The GHI focuses on the health of women and children with the thoughtful premise that they lie at their center of communities. In so doing, the GHI explicitly grows out goals four, five, and six of the World Health Organization's Millennium Development Goals, released in 2000 as a vision for eliminating poverty, disease, and hunger. Mental health was neither among the eight goals nor anywhere in their fine print. This conflicts with WHO's own much less trumpeted Mental Health Global Action Plan and its related declaration that there can be "no health without mental health."

The specific conditions the GHI will address are HIV/AIDS, malaria, tuberculosis, maternal health, child health, nutrition, family planning/reproductive health, and tropical diseases such as leprosy. Although not mentioned, psychiatric conditions may as well have been due to their enormous interactions with medical ones. In general, people with psychiatric illness have more medical problems and have a worse medical course. For example, psychiatric conditions predispose people to the behaviors that place them at risk for acquiring HIV/AIDS and then impact on their ability to adhere with necessary treatment. Similar issues arise with TB. And, a case study has predicted that better treatment of maternal depression throughout Pakistan would count among its benefits a substantial reduction in the stunting of infant growth in that country.

The GHI sensibly pursues its goals by strengthening and coordinating existing programs in poor countries. This ironically might offer one explanation why mental health gets overlooked, as model international programs in mental health are scarce to non-existent.

It is estimated that 1/3 of countries lack a public budget for mental health and the poorest countries spend the proportionately smallest portion of their health care budgets on mental health care. Scholars have found that many low income countries spend as little as 10 to 20 cents per person on a "core" package of mental health services that address major mental illness. Yet, they likewise estimate that these same countries could accomplish such a comprehensive program in ten years if their annual expenditure was increased to just $2/person over that period. Although admittedly a ten fold increase, this is a tiny amount compared to the billions allocated in the GHI.

If the facts so clearly underscore the immense burden and distressing under-treatment of mental illness worldwide despite its cheap price tag, why does mental health get overlooked in the GHI? Reasons include pervasive stigma about mental illness and misplaced concerns about psychiatric "imperialism." At least as much as any other field of medicine, psychiatry remains more caught up in treating mental illness than in maintaining mental health. It also has lagged in articulating a vision for reducing global mental health disparities, perhaps unwittingly fostering a belief that mental health is really more of a luxury than a need.

There exists an unmistakable imperative for the U.S. to address global mental health or risk overlooking a fatal flaw in its global health agenda. It may not be too late to allocate funds within the GHI for this purpose. Expecting recipient programs to attend to mental health as part of their funding for the major health targets of the GHI makes sense, especially as global mental health disparities are most practically addressed by integrating it into other services. One way or the other, the United States can and should foster worldwide mental health by supporting a network of pilot mental health programs around the world that pair U.S. specialists with local resources. A "mindless" vision of world health will not suffice.