8: Global Health and Behavioral Medicine

Global health and behavioral medicine intersect in two important ways. First, mental, neurological, and substance use (MNS) disorders affect every community in the world. We relate to MNS disorders at a local level, where they are embedded in our customs, culture, and context. MNS disorders also exert global influence, through their massive burden of disease, the human and economic costs of treated and untreated illness, and their secondary (often less visible) effects on the outcomes of other health conditions.

Second, the integration of behavioral, social, and biomedical sciences can improve health care globally. Adapting interdisciplinary lessons to tackle local problems may result in more effective, efficient, and responsive health care delivery. Similarly, understanding the interdependence of social determinants, health, and development may inform enlightened approaches to promoting health and empowering communities.

An interdisciplinary approach also has important implications for health worker training. Health workers in all settings should be trained to treat and prevent behavioral, social, and biological problems. They should be taught communication, leadership, and team membership skills. Burnout among health workers begins during training and leads to a range of dysfunctional behaviors. While learning to care for others, health workers should also be taught to care for themselves.

The intersection of global health and behavioral medicine is a complex and rapidly evolving area. With the goal of offering students a concise entry point into the relevant issues, we have organized this chapter into four sections:

1. The global treatment gap.

2. The need for new models of care.

3. The importance of context.

4. Health worker training and support.

The Problem

To appreciate the global treatment gap, we must first understand the level of need. One in four people will suffer from a mental illness in their lifetime. Major depression is the third largest contributor to the overall global disease burden and is expected to be the number one contributor by 2030. The World Health Organization (WHO) estimates that nearly 850,000 people commit suicide annually. Eighty percent of these suicides are in low- and middle-income countries. As a group, MNS disorders (including conditions such as depression, substance abuse, schizophrenia, dementia, and epilepsy) account for 14% of the overall global disease burden. According to a recent report by the World Economic Forum, the direct and indirect costs of mental illnesses totaled 2.6 trillion dollars in 2010 alone. By 2030, the cumulative costs are expected to exceed 15 trillion dollars. Underlying these staggering financial costs is a flood of measured and unmeasured human suffering.

Despite the enormous need, MNS disorders have received scant attention globally. Why is this the case? The following section presents a brief gap analysis, charting a cascade of inadequate global response from policy, to funding, to treatment.

Policy Gap

At each governance level (international, national, state/province, and local), policies influence funding priorities, timelines, and targets. It is not only health policies but also economic, trade, agricultural, educational, and environmental policies that matter. This is because health in general, and mental health in particular, is closely linked to the conditions in which people are born, grow, live, work, and age, which these policies shape. For the purposes of this gap analysis, we will focus on the prioritization of mental health in international and national health policies.

At the international level, significant strides have been made in recent years with the creation of the Mental Health Gap Action Programme (a series of evidence-based care protocols for MNS disorders), the Mental Health Atlas Project (more accurately mapping the global burden of disease for MNS disorders), and the Movement for Global Mental Health (a global advocacy group). Setbacks have also been common, with mental health too often marginalized or ignored in the international policy arena.

At the national level, many countries lack mental health policies (which services should be covered, for whom, and at what cost), plans (how these services should be implemented and evaluated), and legislation (to protect the rights of people who are mentally ill). Global disparities exist. Less than 40% of African countries have a mental health policy, compared with more than 70% of European countries. More than 70% of African countries do not have a national mental health plan, compared to more than 80% of European countries who have one. Globally less than 40% of countries have specific mental health legislation. The absence of mental health legislation (or their enforcement) encourages human rights abuses, which have been widely reported and described as a “failure of humanity.”

Funding Gap

The policy gaps described above lead to critical funding gaps. Compared to the burden of disease and economic loss they cause, the amount of health care spending targeted to MNS disorders is remarkably low. Again, global disparities exist. While high-income countries spend, on average, 5% of their health budgets on mental health, low-income countries spend around 0.5%. As a result, high-income countries spend 2.6 million dollars on psychiatric medications per 100,000 people each year, while low-income countries spend only 1700 dollars per 100,000 people each year. This funding stream is simply insufficient to build or sustain the necessary people, tools, infrastructure, or services needed to provide effective care for the one out of every four people worldwide who will suffer from MNS disorders in their lifetime.

Increased funding for mental health is needed at national and international levels. Whereas a multilateral, international funding mechanism exists for the prevention and treatment of HIV/AIDS, tuberculosis, and malaria, no such mechanism exists for noncommunicable diseases, including MNS disorders. The Grand Challenges in Global Mental Health, a joint-initiative between the US National Institute of Mental Health, Global Alliance for Chronic Disease, and other institutions seeking to fund mental health research, represents a step in the right direction.

Treatment Gap

Policy and funding gaps bear significant responsibility for the massive global treatment gap. Approximately 85% of people with MNS disorders worldwide do not receive appropriate care. Major deficits and global disparities exist in the workforce, essential medicines, and services necessary to provide effective mental health care.

There are insufficient numbers of mental health workers at all levels. These disparities are particularly pronounced in poorer countries. For example, Africa has 0.05 psychiatrists, 0.04 psychologists, and 0.61 mental health nurses per 100,000 people. Staffing levels in the United States and Europe are two to three orders of magnitude higher. New models of mental health care may be able to make better use of (and perhaps expand) the limited mental health workforce, as we discuss later. Nevertheless, the severe shortage of providers, resulting from the withering policy and funding environment, represents a major barrier to delivering safe, effective, community-centered mental health care to all who need it. Figure 8-1 shows the uneven distribution of mental health professionals globally per 100,000 population.

Similar absolute and relative disparities exist in essential medicines for MNS disorders. For example, the antipsychotic section of the WHO Essential Medicines List (EML) has not been modified since 1977. The antipsychotics currently included in the EML (chlorpromazine, fluphenazine, and haloperidol) are significantly more toxic than newer, equally efficacious agents such as risperidone. Worse still, even the outdated medicines included in the EML are often unavailable in low- and middle-income countries. A survey conducted by the WHO in 40 developing nations found that the mean availability of antidepressant medicines was 45.1% in private sector pharmacies and 27.8% in public sector pharmacies. Similar results were found for antiepileptic medicines. Though a full discussion is beyond the scope of this chapter, it bears mentioning that international policies (and the complex factors that determine them) directly shape instruments such as the EML, which profoundly influence the scope of available care in poorer countries. Millions of people live with unnecessary disability, resulting in massive economic loss and, in some cases, conflict and humanitarian crises.

In summary, one in four people suffer from MNS disorders in their lifetime; 85% of these are unable to access appropriate care; and trillions of dollars are lost as a result each year. The causes are complex but knowable. Gaps at the policy level result in insufficient funding which translates into the extreme global shortage of mental health care.

The Problem

In most of the world, mental health care consists of episodic treatments delivered by psychiatrists in specialized, often locked, facilities. This prevailing model is problematic for four reasons. First, it is too expensive. Teams of mid-level providers and community health workers can be deployed in less time and for a fraction of the cost of training and supporting a single psychiatrist. Second, it fails to achieve sufficient coverage. Even if we assume areas near specialized facilities have access to optimal mental health care (a debatable point), such concentration of resources leaves many areas too far away to maintain longitudinal care. This exacerbates the third problem, which is the overemphasis on treatment at the expense of prevention. The root causes of mental ill health are social as well as biological. If we focus only on the terrible cases that present to the psychiatric hospital, we will miss the forest for the trees. Finally, such treatment models promote stigma and fear surrounding the treatment of mental disorders. This is a particularly sensitive issue in countries where there has been a history of colonialism or violations of human rights by government authorities.

Best Practice

How should mental health services be delivered? This remains an area of significant controversy and, at present, insufficient research. Nevertheless, five elements of best practice emerge from the current literature:

1. Collaborative care.

2. Packages of care.

3. Integration into primary care.

4. Quality improvement.

5. Direct action on the social determinants of health.

The following sections briefly describe each of these best practice elements. For students interested in reading further, we suggest several key references at the end of the chapter.

1. Collaborative Care

Collaborative care is team-based care facilitated by smart systems. Complex care pathways are boiled down to discrete tasks that may be shared across different members of the team. These team members may include community health workers, health coaches, social workers, psychologists, nurse care managers, nurse practitioners, physician assistants, primary care physicians, and/or psychiatrists. In the most enlightened models, patients, families, and communities are viewed as active team members with specific and outcome-relevant expertise and knowledge.

Protocols provide decision support (i.e., what to do when, when to ask for help, and when to refer), thereby enabling each team member safely and efficiently to perform tasks that might otherwise be outside their usual scope of practice. Smart tools further support this work. These tools range from paper-based population registries (e.g., lists of patients and active issues that facilitate coordination of care) to smartphone-based decision support and data entry applications.

A strong body of evidence indicates that collaborative care models are as or more effective than other ways of delivering mental health care. In addition to demonstrable efficacy, team-based care has the advantages of lower cost, increased coverage, and better resilience in cases of staff turnover.

2. Packages of Care

The term “packages of care” refers to evidence-based bundles of interventions for specific MNS disorders. In settings where the need is great and resources are limited (the case for MNS disorders in most of the world), difficult decisions need to be taken regarding what treatments should be provided. A series of papers published in PLoS Medicine reviewed the evidence and proposed such packages of care. Table 8-1 is excerpted from one of these papers. It summarizes two evidence-based packages of care for depression, appropriate for low- and high-resourced settings.

3. Integration into Primary Care

There are three compelling reasons for integrating mental health services into primary care. First, such integration locates services closer to people’s homes, thereby improving access and reducing costs associated with seeking specialist care in distant locations. Second, it minimizes stigma and discrimination while reducing the risk of human rights violations that may occur in psychiatric hospitals. And third, it generates good health outcomes at reasonable costs. Notably, such integration is not without its pitfalls. Collaborative planning, effective task-sharing among multidisciplinary team members, and adaptation to local context are important adjuncts to care integration. In its 2008 report, Integrating Mental Health Care into Primary Care: A Global Perspective, the WHO reviewed the evidence for integration of mental health services into primary care and presented ten best practice case studies from countries around the world. The Case Illustration 3 and Table 8-2 (summary of key messages) are excerpted from the WHO report.

4. Quality Improvement

Quality improvement is the disciplined use of performance data to improve processes, systems, and outcomes. Various approaches exist. All share a focus on clearly defined goals, methods to link actions to outcomes, and steps to translate new lessons into better processes and systems. As distinct from research, which emphasizes methodological rigor at the expense of real world relevance, quality improvement takes a more pragmatic approach. Like the instrumentation of a plane, it provides continuous feedback on airspeed and altitude, enabling safe landings under difficult conditions. In multiple areas of health care, quality improvement has saved many lives at reasonable cost.

The application of quality improvement to mental health care, however, is in its infancy. The Institute for Healthcare Improvement’s Breakthrough Series for Depression demonstrated early success in the implementation and maintenance of quality improvement for depression treatment in the US primary care settings. Partners In Health and the Millennium Villages Project have begun to embed performance feedback systems into their community-based mental health programs in Haiti and Nigeria. Though the principles are sound, the evidence connecting quality improvement practices to measureable health outcomes is still forthcoming.

This should not deter the disciplined use of performance data to drive better outcomes in mental health care. Rather, we would suggest all health professional students (and indeed, all health professionals) learn the fundamentals of quality improvement and seek to apply the core principles in their daily practice. One note of caution: quality improvement processes, like all tools, are only as useful as the context and skill with which they are applied. Of particular relevance to global health and behavioral medicine, health students and professionals should marry the discipline of performance improvement to a nuanced understanding of local context (see The Importance of Context section).

5. Direct Action on the Social Determinants of Health

Mental, neurological, and substance use disorders and social determinants (i.e., the conditions in which people are born, grow, live, work, and age) are closely linked. On the one hand, the incidence of MNS disorders goes up with every step down in the social gradient. The poorest populations in every society have the highest rates of depression and alcoholism, for example. On the other hand, MNS disorders and social determinants actually drive one another in a vicious cycle, as summarized in Figure 8-2.

Given the complex range of social determinants that drive MNS disorders, traditional models of facility-based care seem ill prepared to address the root causes of disease (e.g., poverty, stigma, and local context). Rather, an approach that integrates clinical medicine with public health, community empowerment, and direct action on poverty and stigma is needed. Such an approach tends to reorient the usual workforce pyramid. Instead of the most highly trained providers at the top, it is the team members who are closest to the community that are best able to earn trust, understand the local context, and coordinate care in a patient- and community-centered way.

The Problem

Context is important for four main reasons. First, the history of global health and behavioral medicine is littered with examples of good (and sometimes not so good) intentions gone awry. A nuanced and locally informed understanding of context can reduce the likelihood of unintended harm.

Second, context influences perception and stigma. The origins and effects of mental health programs—what, when, where, how, why, and with whom they are implemented—can dramatically alter their local acceptability, their cultural meaning, and their eventual impact.

Third, the root causes of mental ill health are social as well as biological. Each situation is unique: prisons are different from war zones and urban slums, and no two slums are the same. Effective action on the social determinants must necessarily be tailored to local context. Similarly, MNS disorders present and respond differently in different settings. Diagnostic and therapeutic strategies must account for these local variations, while forging past the inaction that sometimes results from such uncertainty.

Fourth, intersecting with all of the above problems, is the issue of trust. Given the complex and sometimes troubled history of global health and behavioral medicine, strategies to build and strengthen trust between communities and care providers must be grounded in a shared understanding about what truly matters, how best to partner, and how to determine the priorities and metrics for success.

For students interested in reading further about how to consider the issue of context, we recommend Arthur Kleinman’s four social theories for global health, referenced at the end of the chapter.

Complexities in Global Health and Behavioral Medicine

Behavioral medicine is complicated by a number of historical tensions that persist to the present day. For example, diagnostic systems for MNS disorders (the International Classification of Diseases, developed by the WHO, and the Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association) are not fully supported by scientific evidence, and may to some degree reflect Euro-American concepts of illness. Additional tensions that undermine consensus on how to provide mental health services in different contexts include: spiritual (supernatural or religious) and scientific (natural or biological) approaches to understanding etiology and causation; strength- (“resilience”) and illness-based interpretations of human distress in adversity; traditional and biomedical approaches to treatment; and community- and clinic-based approaches to service delivery.

Additional layers of complexity arise from the relationship of behavioral medicine to historical precedents. Specifically, psychiatry has at times been used as an instrument of political or government control. This occurred, for example, in Nazi Germany, Communist Russia, apartheid South Africa, and in a number of developing countries during the colonial period. The legacy of these kinds of practices continues to affect the perception of mental health professionals, and compounds the already strong cultural predisposition to stigmatize MNS disorders and mental health services.

A third area of complexity is the relationship of behavioral medicine to humanitarian emergencies (both “natural” and “man-made” disasters). On the one hand, these complex emergencies have created opportunities to engage the international community in strengthening mental health services in developing countries. On the other hand, humanitarian mental health responses in low-resource settings have been characterized by difficulties in coordinating the efforts of international agencies, nongovernmental organizations (NGOs), and other groups and individuals with the priorities of governments and local communities. International humanitarian response mechanisms have often contributed to a lack of local agency in decision making. These challenges underline the importance of framing humanitarian mental health efforts within a pragmatic, do-no-harm, human rights-based approach that prioritizes the engagement of local leaders and experts across disciplines (see Box 8-2).

Assessing Local Context

Given the importance of context in designing effective, community-centered mental health services, how then do we approach the task of assessing local context? The elements of this assessment include: qualitative and quantitative assessment of needs, prioritization of needs, and identification of available resources. We will expand briefly on qualitative assessment.

The first question should be: how are MNS disorders understood, described, and addressed locally? Iterative experience and ongoing assessment may be needed to plumb the depths of this critical question. As the local context comes into view, ethnographic or similar qualitative analysis should be used to adapt and modify treatments based on international standards of best practice. The adaptation of generalizable knowledge to local context is a routine, not exotic, challenge captured by the oft-described goal of linking evidence-based practice with practice-based evidence. The purpose is to enable caregivers to use proven treatments in ways that make local sense, and to leverage local understandings and resources to be more effective.

Structured interview guides can facilitate such qualitative assessment. The guides can be designed to understand the nature and impact of mental and emotional conditions, as well as how people seek, or would seek, care for these conditions. Community members, local leaders, health workers, and potential community partners (such as religious leaders or traditional healers) should be asked specifically about the local acceptability of carrying out certain care and treatment functions. These functions include case finding and diagnosis, patient education and engagement, use of appropriate medications, use of specific psychosocial interventions, use of community-based support systems, systematic follow-up and outcomes monitoring, expert consultation and supervision, and referral rules.

The use of qualitative methods in health care implementation is an emerging area of best practice and can be performed with varying degrees of rigor. But as a general rule it should be repeated iteratively and include a set of participatory queries that inform the understanding of MNS disorders and the use and acceptability of mental health services. For students interested in reading further on the assessment and adaptation of mental health services to local context, we recommend the framework described by Belkin et al. for implementing and delivering community mental health care.

The need for more robust training in the social and behavioral sciences for all health professionals has been well recognized. The final section of this book, Teaching Behavioral Medicine in Medical Settings, offers a fuller discussion of the nature and potential solutions to this problem. In this section, we wish to briefly emphasize three points relevant to global health and behavioral medicine.

First, new skills are needed. These include an understanding of the global treatment gap, the need for new models of care, and the importance of context, as described above. In order for such skills to be incorporated into training systems, they will need to be aligned with locally relevant terminology, qualification schemes, and practice patterns. For US physician training, for example, this means linking skills to professional competencies, evaluating performance in licensing and certification exams, and considering the set of metrics and incentives that will continue to foster these skills when trainees enter professional practice.

Second, a new ethos may be needed. Communication, leadership, and team membership skills have all been emphasized in recent calls for medical education reform. These skills are linked to cohesive team dynamics and effective care coordination across multiple providers and health systems. Based on our experience in global health practice, we would suggest an additional ethos that may integrate this set of skills and foster the development of collaborative behaviors, namely, the ethos of “accompaniment.”

Accompaniment refers to the long-term commitment to do “whatever it takes” to improve another person’s health and dignity. In practice, accompaniment translates the belief in health as a human right into pragmatic and results-oriented service. Because it is grounded in mutual respect and long-term commitment, accompaniment often helps to bridge distrust, stigma, and other social distances. This ethos carries over into the organization of teams and systems. The commitment to equity and justice creates a culture of transparency, shared accountability, and horizontal collaboration among leaders, frontline workers, patients, families, and communities. In our experience, accompaniment often unlocks the “purpose motive” for both international and local health workers, amplifying the impact of team members who are motivated by intrinsic (i.e., core values and shared commitments) rather than extrinsic (i.e., rewards and punishment) factors.

Third, self-care is essential to prevent burnout and promote resilience (see Chapters 6 & 47). The loss of empathy during health professional training, as well as the development of dysfunctional behaviors during and after training, has been well documented. Several educational initiatives, such as the Healer’s Art curriculum created by Rachel Remen and the curricular reform at Indiana University School of Medicine, have attempted to address these issues. However, these initiatives tend to cluster earlier in the training pathway, whereas burnout and dysfunctional behaviors continue to accumulate at the graduate medical education and professional levels. In particular, the complexity of practicing behavioral medicine in a global context (including the tendency of those who do “whatever it takes” to subsume personal needs) requires health workers with a high degree of resilience and self-awareness. New programs and professional norms will be needed to safeguard hope and empathy throughout training, and prepare health workers to harness the power of shared values and commitments in themselves and others in their professional practice.

This chapter has considered the rationale for integrating the study of global health and behavioral medicine, the magnitude and causes of the global treatment gap for MNS disorders, five elements of best practice for new models of mental health care, the importance of local context and how to assess it, and the need for new skills, an ethos of accompaniment, and better self-care in health worker training.

We have aimed for breadth, envisioning a concise introduction for a primarily US or European medical student audience. The depth of coverage has necessarily been limited. We hope readers will find the chapter useful, and that at least several students will be stimulated to read further and perhaps contribute to global health and behavioral medicine in their professional careers.