“Listen to your patient, he is telling you the diagnosis.” On my first day of medical school at UBC, my entire class was given a copy of “A Selection for Medical Students,” by Sir William Osler, a Canadian physician, often referred to as the “Father of Modern Medicine.” His words compelled us to take good histories and recognize that the patient is our most useful resource. As a family physician, the power and utility of this first lesson is never underestimated.
When I was a child, my family would occasionally travel to India during summer holidays to visit relatives. Every morning, I would have breakfast on the balcony where I could see the comings and goings of the various vendors and passers-by, birds in the park, street dogs, and scan what the neighbours were doing. This is probably the most consistent and recurring memory I have of those visits when the morning sun wasn’t quite as hot as it would get later in the day, when it would be unbearable to be outside. Part of this memory included my spotting our neighbour’s brother in the front courtyard of his house. I was told he had some sort of “mental problem” and never had an opportunity to interact with him, however, I would see this young man pacing the courtyard for morning exercise and he would look up at me with a blank stare, appearing to register who I was, then promptly look away and continue his pacing without ever looking back at me. During subsequent summer visits, he would do the exact same thing, and somehow it made me feel happy that he had acknowledged me in his own sort of way. He must be in his late 50’s by now, yet, I still see him whenever I go back, and we have the exact same interchange that reminds me that I am in a familiar place on the balcony in New Delhi. In his own way, he was telling me his diagnosis, “I have a chronic condition and I am okay today.” Not a complete diagnosis, but enough for a seven-year-old child.
He is fortunate to have grown up in a loving and supportive family able to provide him the appropriate medical care and security that he needs. In a developing country like India, where many communities struggle to maintain the basic social determinants of health and where national policies on mental health get stuck in parliamentary bureaucracy, his family provides him food, shelter, medication, a sense of community, love and security…. because they can. Sadly, this is not true for many families who struggle to maintain livelihoods and a sense of hope for the future. The burden of a mental illness in the family is a source of stress, conflict and stigma.
The World Health Organization (WHO) defines mental health as “as state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Without having the basic social determinants of health, anyone’s mental health can be affected. And those with mental disorders in developing countries are more vulnerable, especially if no national policy or access to care is in place to protect them.
7.4% of the global burden of disease is attributed to mental health illness, yet more than 75% of those living with mental illness in the developing world do not receive treatment. They remain largely in the shadows.
However, world leaders are taking note of the large-scale impacts of mental illness. In a recent study commissioned by the World Economic Forum WEF, it is estimated that by 2030, the costs of mental illness will near $6 trillion annually, exceeding the combined cost of diabetes, cancers and respiratory illness.
In 2013, the WHO put forth a Comprehensive Mental Health Action Plan 2013-2020 to strengthen mental health care worldwide.
This affords hope that, like the initiatives undertaken to reduce the burden of HIV, TB and Malaria, mental health has become part of the global health agenda. But, it will take time.
So much of mental illness around the world is burdened with misunderstanding and stigma. Lack of access to information systems, social supports and medical care has triggered human rights abuses and barriers to those with mental illness from integrating into a community, attending school, establishing relationships and employment. Women and children are particularly vulnerable.
The UBC School of Journalism’s International Reporting Program (IRP) aims to give ‘voice’ to some of the most under-reported global issues. I have the privilege of being a part of the IRP advisory board and suggested mental illness as their theme for this academic year. I was thrilled to be invited as a guest in their weekly class and also to travel with one of their teams to investigate mental health programs in India. As a faculty supervisor for global health education programs for medical students, I have had experience working in partnership with low-resource communities around the world to improve health outcomes. Working in multidisciplinary teams, we have seen both the resilience and innovation that arises in some of the most low-resourced communities and were it not for the vision and tenacity of local community members, they wouldn’t have hope. I work with our student teams to continually reflect on the impact of their role in global health partnerships and the importance of hearing and supporting the community narrative.
As a classroom observer of another form of global health education and participating in the field as a consultant, this opportunity highlighted for me how journalism can be a powerful agent of discovery, advocacy and philanthropy. Ten journalism graduate students and their professors researched the literature on global mental health and traveled to three countries to share the stories behind community-based initiatives to address mental illness and promote mental health. They heard from a world expert on how evidence has shown that community-based programs integrating mental health and social supports are bridging the gap in mental health care and are proving to be an ideal model. In the congested streets of Old Delhi, a mental health institution moves treatment into the community by partnering with a social work NGO. They work to integrate mental health and social support at a mobile clinic that serves the homeless and mentally ill, with addictions, often co-existing. In an Indian slum, our team met with an organization that works to identify and support those with mental illness through various programs with an overarching goal to provide basic rights to dignity and compassion. In Benin and Togo, the team visits a prayer camp where the atrocity of human rights abuse is exemplified and met with a man who has endeavoured to end this dehumanization of the mentally ill by providing an alternative. At a Syrian refugee camp in Jordan, mental illness in children, who fled the war and are coping with post-traumatic effects, is being addressed by a novel program run by a psychiatrist who is a refugee himself.
And finally, I created an opportunity to sit down with the neighbour and listen to the story of his experience caring for his mentally ill brother who walks the front courtyard every morning.
The work on this IRP project has resulted in a series of stories that shed light on the complexity and impact of mental illness. These stories explore how community programs and their visionary leaders are able to improve and uplift those living with mental illness, with very few resources.
It has been a privilege to be a part of this project and to work with an inspiring group of students and professors in the IRP program.
Dr. Videsh Kapoor is a family physician practicing in Vancouver and a Clinical Assistant Professor in the Department of Family Practice, Faculty of Medicine at the University of British Columbia. She is the Medical Undergraduate Program Global Health Theme Leader and Director of the Division of Global Health in the Department of Family Practice and Co-founder and faculty lead of the UBC Global Health Initiative.