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This issue brief was originally published on Student Pugwash USA’s Elections 2012 page (click on the link and go to Issues > Health >Mental Health).

The State of Mental Health in the US and Globally

Mental illness is a term which covers a large number of disorders which can broadly be categorised into five groups: anxiety disorders (e.g. phobias, obsessive-compulsive disorders); mood disorders (e.g. bipolar disorder, depression); schizophrenia; dementias (e.g. Alzheimer’s, Parkinson’s); and eating disorders (e.g. anorexia nervosa, bulimia) [1]. Mental health is as important to wellbeing as physical health – mental illness kills and disables and it causes huge amounts of suffering to individuals and the society at large as well as having enormous economic impact. Furthermore, people with mental illness are also more likely to have poor physical health than those without [2].

 
It is difficult to exaggerate the magnitude of the problem of mental illness. In the United States, it is estimated that more than a quarter of adults suffer from a diagnosable mental disorder every year. Depression alone is the leading cause of disability among people 15-44 years old, with more than 21 million cases of major depressive disorder (MDD) annually [3] and more than 30 billion US dollars lost each year due to lost productive time [4]. There were 37,000 suicides in the United States in 2009 [5], making it the tenth leading cause of death (this rises to the top three in those aged between 15 and 44). Moreover, the number of suicides in the armed forces far outnumbers the number of soldiers killed in action [6].

 
Globally, the picture is even worse. Mental illness directly affects hundreds of millions of people every year; kills about 1 million people; is responsible for 13% of global disability adjusted life years, a measure of disease burden taking into account ill-health, disability or early death; and is estimated to cost upwards of US$2.5 trillion [7-9]. A large number of countries lack a mental health strategy and in many places suicide and attempted suicide are still illegal. However, it should be noted that some disorders, such as schizophrenia, have better outcomes—i.e. higher recovery rates and lower impairment and disability from symptoms— in resource-poor settings such as sub-Saharan Africa [10] so improvements in mental health treatment and prevention are likely to come from all corners of the globe.

 

 

Stigma
There is still a great deal of stigma around having a mental illness, both from society towards people with mental illness, leading to prejudice and discrimination in employment and opportunities; and stigma that those with mental illness turn towards themselves, leading to low self-esteem and failure to pursue opportunities [11]. Many people’s view of mental illness is shaped by media, where the topic predominantly appears in the context of violent crime. Mental Health America (formerly the National Mental Health Association) identifies a number of different prominent misconceptions about mental illness including: that children don’t suffer from mental illness; that those with psychiatric problems are dangerous, need to be locked away and can never be normal; and that those with mental illness aren’t suited for important or responsible positions [1]. Needless to say all of these ‘facts’ are wrong. By greater education of the general population and greater integration and openness of people with mental illness in society, the lives of people suffering with mental health disorders can be greatly improved.

 

 

Mental Health Policy in the United States
Approximately two-thirds of those who have a diagnosable mental illness in the United States do not receive treatment [12]. Historically, the provision of mental health and substance abuse services has largely been by individual states, rather than the federal government, meaning that mental health services can differ greatly in both type and level of care across the country [13]. Perhaps unsurprisingly, poorer and more rural areas tend to have the lowest levels of mental health professionals per capita [14]. Furthermore, the high levels of fragmentation in health services in the United States means that mental health and physical health services are not well integrated. Those who do receive mental health treatment often do not get adequate treatment for comorbid physical conditions, and mental health disorders are often not diagnosed and treated within primary care. There are also large disparities among racial groups. Ethnic minorities have less access to mental health services than white people and when they do receive care it is more likely to be poor in quality [15].

 
Major reforms of mental health services in the United States over the last century or so have focused on de-institutionalisation and community-centred care, but have been federally led. This has established a commendable emphasis on community care for the mentally ill, with patients no longer suffering the poor conditions, overcrowding and isolation of past psychiatric institutions. However, these policies have also brought other problems to the fore, with many people with poor mental health having difficulty in accessing these community services as well as housing, resulting in homelessness and/or inadequate treatment [16].

 
One of the great difficulties in mental health policy has been attempting to gain parity of mental health and physical health problems. For years, health plans routinely set stricter treatment limits and imposed higher out-of-pocket costs on mental health care than care for any other illness. In 1996, Congress passed The Mental Health Parity Act, which established the principle that mental health benefits should be “on par” with medical and surgical benefits. However, though the use of disparate annual or lifetime dollar limits between mental health coverage and coverage of other illnesses was banned, insurance plans still routinely set arbitrary caps on how many mental health treatment sessions or days of hospital care they would cover regardless of medical need. In 2008, this was supplemented by the Mental Health Parity and Addiction Equity Act (MHPA) which prohibits group health plans from imposing treatment limitations and financial requirements on mental health benefits that are stricter than for medical and surgical benefits.

 

 
Mental Health & The Patient Protection and Affordable Care Act
The passage of the Patient Protection and Affordable Care Act (ACA; also known as Obamacare) in 2010 is expected to lead to large improvements in mental health in the United States. Americans with mental health problems are more likely to be uninsured [17] than those without such conditions. Through its provisions expanding insurance coverage and Medicaid, it is thought that the ACA will lead to an extra 3.7 million Americans with severe mental illness gaining access to care when full implementation occurs in 2019 [18]. This number does not include those with mild to moderate mental health problems. Further numbers should also be covered through the prohibition of denial of insurance based on pre-existing conditions. In terms of the parity mentioned previously, the ACA extends the MHPA’s prohibition of discriminatory limits on mental health and substance use services [19].

 
The emphasis within the ACA upon integration should also help reduce problems faced by those with mental illness because of fragmentation of health systems. Those eligible for Medicaid with multiple chronic conditions, including mental health conditions, will be able to have a “health home” option, where all healthcare professionals involved in an individual’s care (e.g. primary care practitioner, psychiatrist, cardiologist etc.) can share information and coordinate treatment [20]. Another benefit included in the ACA is the supported employment programs, which help those with the most severe mental health issues to pursue competitive employment by providing them with support for an unlimited period of time including coaching on self-presentation, forming relationships with colleagues, and identifying and resolving problems at work [21]. This evidence-based strategy [22, 23] allows people to be productive, have a valuable role in their communities, and pay taxes.

 
However, the ACA still leaves a number of problems for Americans living with mental illness. Even after its full implementation, a large number of people will not be able to gain access to mental health services. This includes people whose employer-sponsored plans don’t offer behavioural health benefits and those people, such as undocumented immigrants, who aren’t eligible for the expansion in coverage [24].

 

 

Mental Health in Political Discourse
Unfortunately, mental health issues do not feature strongly in political discourse. As of 29th July 2012, I cannot find any mention from either of the main presidential candidates on the issue of mental health in the last few years. Perhaps if enough of their constituents can persuade them that this is an issue they feel strongly about, this is something that can change.

Works Cited

1. Mental Health America: Stigma: Building Awareness and Understanding [http://www.mentalhealthamerica.net/go/action/stigma-watch]

2. Felker B, Yazel JJ, Short D: Mortality and Medical Comorbidity Among Psychiatric Patients: A Review. Psychiatric Services 1996, 47(12):1356-1363.

3. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. (vol 62, pg 617, 2005). Archives of General Psychiatry 2005, 62(7):709-709.

4. Mark TL, Shern DL, Bagalman JE, Cao Z: Ranking America’s Mental Health: An Analysis of Depression Across the States. Mental Health America 2007.

5. CDC: Ten Leading Causes of Death and Injury [http://www.cdc.gov/injury/wisqars/LeadingCauses.html]

6. BBC News: US Military Suicide Rate Hits One Per Day [http://www.bbc.co.uk/news/world-us-canada-18371377]

7. Bloom DE, Cafiero ET, Jane-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A et al: The Global Economic Burden of Noncommunicable Diseases. World Economic Forum 2011.

8. Department of Mental Health and Substance Dependence: Investing in Mental Health. World Health Organisation 2003.

9. WHO Suicide Prevention [http://www.who.int/mental_health/prevention/en/]

10. Rosen A: What Developed Countries can Learn from Developing Countries in Challenging Psychiatric Stigma. Australasian Psychiatry 2003, 11(1):S89-S95.

11. Corrigan PW, Watson AC: Understanding the Impact of Stigma on People with Mental Illness. World Psychiatry 2002, 1(1):16-20.

12. Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE, Wang P, Wells KB, Zaslavsky AM: Prevalence and Treatment of Mental Disorders, 1990-2003. New England Journal Of Medicine 2005, 352(24):2515-2523.

13. President’s New Freedom Commission on Mental Health: Achieving the Promise: Transforming Mental Health Care in America. 2003.

14. Ellis AR, Konrad TR, Thomas KC, Morissey JP: County-Level Estimates of Mental Health Professional Supply in the United States. Psychiatric Services 2009, 60(10):1315-1322.

15. Office of the Surgeon General, Center for Mental Health Services, National Institute of Mental Health: Mental Health: Culture, Race and Ethnicity; A Supplement to Mental Health: A Report of the Surgeon General. 2001.

16. Kovner AR, Knickman JR: Health Care Delivery in the United States. New York: Springer Publishing Company; 2011.

17. Strine TW, Zack M, Dhingra S, Druss B, Simoes E: Uninsurance Among Nonelderly Adults With and Without Frequent Mental and Physical Distress in the United States. Psychiatric Services 2011, 62(10):1131-1137.

18. Garfield RL, Zuvekas SH, Lave JR, Donohue JM: The Impact of National Health Care Reform on Adults With Severe Mental Disorders. The American Journal of Psychiatry 2011, 168(5):486-494.

19.  Mental Health America: Mental Health America Hails Ruling on ACA as a Tremendous Victory [http://www.mentalhealthamerica.net/go/news/mental-health-america-hails-ruling-on-aca-as-a-tremendous-victory]

20.  SAMHSA: What is a Health Home [http://blog.samhsa.gov/2010/12/04/what-is-a-health-home/]

21. Mechanic D: Seizing Opportunities Under the Affordable Care Act for Transforming The Mental and Behavioral Health System. Health Affairs 2012, 31(2):376-382.

22. Drake RE, Becker DR: Why Not Implement Supported Employment? Psychiatric Services 2011, 62(11):1251.

23. Bond GR, Drake RE, Becker DR: An Update on Randomized Controlled Trials of Evidence-Based Supported Employment. Psychiatric Rehabilitation Journal 2008, 31(4):280-290.

24. Barry CL, Huskamp HA: Moving Beyond Parity – Mental Health and Addiction Care Under the ACA. New England Journal Of Medicine 2011, 365:973-975.

This article was originally published on Global Health Interest Forum

As always, first come the statistics. Suicide is thought to kill about a million people a year and by 2020 this is expected to increase to more than 1.5 million with 85% of suicides occurring in low- and middle-income countries. Between 10 and 20 times as many people attempt suicide as succeed and with 5 to 6 people affected by an individual’s suicidal behaviour, somewhere in the order of 100 million people are directly affected by suicidal behaviour each year. On top of this, and what these numbers cannot tell, is the enormous suffering of those who wish to end their life and of those who lose their loved ones and/or caregivers to suicide or suicidal behaviours.

From all this, we can safely say that suicide is an enormous public health issue. But is suicide itself a global health issue? There are many definitions of ‘global health’ floating around, so I should define what I mean by it here. By ‘global health’, I mean those health issues which can best be dealt with internationally, with cooperation across governments and international organisations directing or supporting international and within-country schemes. Methods of suicide, rates of suicide and cultural attitudes to suicide all differ greatly across the world. Even in a country as small as the United Kingdom, the suicide rates are very variable. In Scotland, for example, suicide rates among those under 18 years old are as high as 5.2 per 100,000 whereas in England and Wales the figure is just 1.4 per 100,000. To address this as a ‘global health’ issue, it is important to have a flexible set of aims and priorities and not a restrictive one-size-fits-all strategy which, in reality, fits no-one.

In 1993 the World Health Organization (WHO) proposed the following five broad priorities to pursue:  (i) control of gun possession; (ii) detoxification of domestic gas and car emissions; (iii) control of availability of toxic substances; (iv) toning down news reports about suicide; (v) early recognition and treatment of psychiatric disorders. The inclusion of changes to news reports as a key priority in the WHO strategy is probably an overstatement. While there has been evidence to suggest that responsible news reporting can prevent some suicides, it is thought that there is contribution of the media in only 1-2% of suicides. I believe that, nearly 20 years later, we should rethink and renew our priorities. I am not an expert in this field and I do not pretend to know better than Global Mental Health experts what to do. Nevertheless, I have below drawn up a brief list of priorities to generate discussion over what we can do globally to reduce suicide.

1. Encourage treatment of suicide as a health matter, not a criminal matter.

I have deliberately placed this as the first priority because of its huge impact upon the others. Suicide and attempted suicide are still illegal in a large number of countries, including many African countries and Islamic countries. This is often driven by religious, social and cultural beliefs and norms. The social response to suicidal behaviours in some areas can be very severe:

“In Uganda, some reports indicate that suicide victims do not receive a decent burial; their families and the survivors of suicide attempts are shunned; and those who are employed do not have their terminal benefits paid to the surviving family members.”

Obviously moves to destigmatise suicide would require a big change in the culture of these countries, but decriminalisation and medicalisation of suicide and attempted suicide could certainly help propel this forward. It is difficult to see any great downsides to legalisation. If the worry is that acceptance of suicide as legal might increase suicide rates, this does not seem to be borne out by the evidence. Indeed South America, where suicide is not illegal, is thought to have some of the lowest suicide rates in the world. It is also worth remembering that it has only been 50 years since suicide was decriminalised in England and recent decades have seen successful suicide prevention strategies there. This BBC article describes some tales of what happened to attempted suicides before decriminalisation.

2. Better reporting of suicide and suicidal behaviour.

The first thing you’ll notice about the map above is how astonishingly little data there is on suicide in Africa. In fact, there is no country-wide data on suicide for more than half of the world’s countries, most of which are resource-poor countries in Asia and Africa. The most recent WHO report (Violence and Health in the WHO African Region 2010) offers an excellent overview of the available data, but most of their data comes from South Africa, with only four countries providing country-wide data (Mauritius, Sao Tome & Principe, Seychelles and Zimbabwe). For such a large and diverse continent, this is obviously a poor representation and extrapolation is difficult. Poor reporting is likely intimately linked with the first point, with political, religious and cultural reasons given for this paucity of data. In rural parts of India, where suicide is illegal, it is estimated that underreporting of suicide may be as much as 9- or 10-fold. Getting good data is vital to developing local and regional suicide prevention strategies. Without knowing the nature of the problem, it is exceedingly difficult to find solutions.

It is also very important to have a standardised definition of what constitutes suicide. This may sound pretty obvious, but different countries have different rules for determining when a death is declared a suicide. Some countries require external evidence of intent, such as a suicide note, while others require only judgement of intent. Furthermore, globally there is even less data on attempted suicide. How much of the variation between countries is due to success rates in treating those who have attempted suicide; how much to differences in chosen methods; and how much to rates of suicidal behaviour? It is very difficult to say. Greater reporting of suicidal behaviours and unsuccessful suicide attempts could give a greater understanding of suicide prevention strategies worldwide.

3. Greater recognition of good mental health as key to good health – early recognition and treatment of psychiatric disorders.

In a recent article, I lamented the disproportionately low attention received by mental illness as a global health problem and suicide could be described as perhaps the most dramatic outcome of poor mental health. Psychiatric illness is an important factor in suicide. Evidence from so-called ‘psychological autopsy’ studies suggests that over 90% of people who commit suicide had recognisable psychiatric illness at the time of death. Furthermore, the presence of depression in those who go on to commit suicide appears to be a universal across cultures, rather than a construct of Western psychiatric practices.

The nature of necessary mental health services will vary greatly by country and region, depending on culture, resources etc. However, what is clear is that all countries are under-treating mental illness with no country thought to be treating more than a third of those who experience mental illness and that number substantially lower in more resource-poor countries.

 

4. Where feasible, control of methods of suicide

The control of methods of suicide made up three of the WHO’s five strategies for suicide prevention in 1993. I have left this priority for last because of the diversity of suicide methods around the world. The priority given to each control method will differ greatly between countries. For example gun control is a much bigger concern in the US (where it is the chosen method of 60% of male suicides and 36% of females) than in Japan (0.2% and 0.0% respectively). Similarly, there is a huge problem in many resource-poor countries with suicide by ingestion of agricultural pesticides, reaching approximately 90% of suicides in El Salvador as well as in rural areas of Malaysia; while such a problem is almost non-existent in most of the so-called “developed” countries. Further, in those parts of the world where the most common suicide methods are hanging, falling, cutting etc. the control of suicidal methods is likely to be much less plausible or effective. Nevertheless, it is clear that tighter controls on guns and toxic substances could have a large impact on global suicide numbers.

Taken together, I believe these priorities form an effective framework for both reducing suicide rates and gaining a greater understanding of suicide and suicidal behaviours worldwide. Furthermore, by learning about suicide around the world, it is likely that we can gain insight into different ways of dealing with and preventing suicidal behaviours both medically and at the community level. It is already known that approaches from resource-poor countries to some mental illnesses can be more effective than “Western” approaches, such as with schizophrenia. It is entirely possible that the same could be true of suicidal behaviours. By countries working together rather than separately, we can be more than the sum of our parts and develop more effective ways of reducing suicide. As I have said previously, I am no expert in this area, but I hope that by drawing up a list of priorities like this, we can stimulate discussion of what I believe to be an under-appreciated global health problem.

I recently read an article linked to from Twitter called “Ten reasons not to legalise same-sex marriage in Britain“. In this article, Peter Saunders, CEO of Christian Medical Fellowship gives ten points as to why we should keep a homophobic law. Now I only really need one reason to change this law: because it’s discriminatory against same-sex couples. However, I thought I should address each of his points in detail.

1. Marriage is the union of one man and one woman

Throughout history in virtually all cultures and faiths throughout the world, marriage has been held to be the union of one man and one woman. Marriage existed thousands of years before our nation began and has been recognised in our laws as the ‘voluntary union of one man and one woman to the exclusion of all others for life’ (Hyde v Hyde 1866). The UN Declaration of Human Rights (article 16) recognises that the family, headed by a man and a woman, ‘is the natural and fundamental group unit of society and is entitled to protection by society and the State’. It is not up to governments to redefine marriage – but simply to recognise it for what it is, and to promote and protect it as a unique institution.

Article 16 of the UN Declaration of Human Rights states: “(1) Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution. (2) Marriage shall be entered into only with the free and full consent of the intending spouses. (3) The family is the natural and fundamental group unit of society and is entitled to protection by society and the State.” Nowhere in the paragraph is the phrase “one man, one woman” as is claimed. It only refers to “men and women of full age”, these are also the people who would be allowed to marry in same-sex marriages. Furthermore, stating the current law that marriage is between a man and a woman gives no reason why this should not change.

2.Same sex couples already have civil partnerships

All the legal rights of marriage are already available to same sex couples through civil partnerships so there is no need to redefine marriage to include them. The President of the Family Division has even described civil partnerships as conferring ‘the benefits of marriage in all but name’. Such a move would also inevitably lead to calls to open civil partnerships to opposite sex couples on the basis of ‘equality’. But marriage and civil partnerships have been designed for two very different types of relationship and should be kept distinct. It is not and should not be ‘one size fits all’.

I don’t see why similarities or differences between civil partnerships and marriages should have any sway on their application to all. I have absolutely no problem with opposite-sex couples being allowed civil partnerships and same-sex couples being allowed marriage. Using different names is clearly designed to single out homosexual relationships as lesser. That may be Saunders’ opinion, but has no place in law.

3.Redefining marriage without consultation is undemocratic

None of the political leaders who are supporting the legalisation of same sex marriage announced it as a priority in their election manifestos. There is already a huge amount of opposition to the move and pressing ahead with legalisation will lead to considerable dissension and division. Legalising same sex marriage to appease a small minority is wrong and it should not be foisted on the British people without proper consultation about whether rather than how it should be done.

I do agree that the parties should have put the equalisation of marriage in their election manifestos. However, the current law is discriminatory and I feel needs changing immediately, just as if it was discriminatory against race or religious persuasion. As for “appeasing a small minority”, the most recent poll I could find shows just under half the population want gay marriage legalised, a minority perhaps, but certainly not a small one.

4.Equality does not mean uniformity

In a free democratic society we accept that many human activities are not open to everybody. Not everyone is allowed to drink alcohol, drive a car, buy property, cast a vote, own a firearm, attend university, visit Buckingham Palace or participate in a 100m women’s Olympic event. This does not mean that those who are not eligible for these activities are in any way denigrated or demeaned, but just that there are eligibility criteria. Same sex couples do not fulfil the eligibility criteria for marriage, which should be reserved for the voluntary union of one man and one woman for life.

This is just a ludicrous argument.

“Not everyone is allowed to drink alcohol, drive a car, buy property, cast a vote, own a firearm,” Is Saunders seriously suggesting that same-sex couples are like children or criminals? I don’t believe he is but that is the implication of this statement.

“attend university, visit Buckingham Palace or participate in a 100m women’s Olympic event.” I would also be against a change in the law that required a minimum threshold of ability, such as strength, speed, academic prowess etc.

The idea that equality means uniformity is not what anyone is arguing for. It’s a straw man that Saunders himself has built.

5.Protecting traditional marriage safeguards children and society

“Stable marriages and families headed by a mother and a father are the bedrock of society and the state has a duty to protect the uniqueness of these key institutions.”

No they’re not and no it doesn’t.

“Though death and divorce may prevent it, children do best when raised by a married mother and father. Whilst single parents or same sex couples may do a good job in raising children, social policy has to be concerned with what is normally the case, and children have a right if at all possible to have a married mother and a father involved in their upbringing.”

A few things: The evidence shows that children with married parents do better than children with separated parents. This is not the same thing as ‘marriage causes children to do better. Correlation does not equal causation. Secondly, the evidence shows that same sex parents do as well as opposite sex parents.

“In general the evidence shows that marriage provides a stability for adults and children which is hard to beat in terms of outcomes. There is considerable evidence to show that marriage leads to better family relationships, less economic dependence, better physical health and longevity, improved mental health and emotional well-being and reduced crime and domestic violence.”

Then clearly we should let same-sex couples marry.

6.Marriage is a unique biologically complementary relationship

Marriage is the only legal union which can naturally lead to children. It takes both a man and a woman to produce a baby. The fact that there is a natural link between sexual intimacy and procreation is what makes marriage distinctive and different. Redefining marriage will undermine this distinctness and difference and risks normalising the technological instrumentalisation of reproduction and increasing the number of families where there is confusion of biological, social and family identity.

By Saunders’ farcical argument of biology determining marriage law, infertile people should not be allowed to marry and presumably he would favour divorce once a woman goes through the menopause or has a hysterectomy etc.

7.Redefining marriage will be complex and expensive

Redefining marriage could cost billions and involve amending hundreds of pieces of government legislation. The word ‘marriage’ appears 3,258 times in UK legislation, which underlines the central role the institution plays in national law. Introducing same sex marriage is a legal can of worms which cannot be achieved without changing the common and legal definition of the word marriage and other words which define it(eg. ‘husband and wife’, ‘consummation’ and ‘adultery’). These changes will inevitably change the definition and nature of marriage for opposite sex couples by trying to accommodate these two very different kinds of relationship under one legal umbrella. According to an assessment done for gay rights group Stonewall by a former civil servant, the cost of implementing one favoured option would be around £5 billion. This figure relates to a theoretical increase in straight couples taking up the opportunity of civil partnerships, with knock-on implications to their entitlement to pension and tax benefits. This is simply not a priority for government at a time of economic recession as it will confer no new rights.

Frankly, this is completely unimportant. The current legislation is discriminatory and should be changed. If marriage had been defined as being restricted to white people, would it be argued that it should not be changed because of the cost? If not, then I hope those who use this argument can see why people who consider LGBT people equal to heterosexual people do not consider the cost.

8.Schools will be forced to teach about the new definition of marriage

Under existing education law schools will be required to teach children that marriage can be between a man and a woman, between two men or between two women. This will confuse children whose parents may wish to teach them according to their own values and worldview. Those parents who object could be undermined in their children’s eyes, stigmatised as homophobics and bigots and prevented from full involvement in schools.

Excellent. Children should be taught that LGBT people are just like everyone else and that discrimination against them is wrong.

9.Redefining marriage will not stop with same sex marriage

In Mexico same sex marriage was followed by two year fixed term marriage. In Canada legalising same sex marriage has led to supporters of polygamy demanding in the courts for their unions to be recognised. If the legal definition is changed to accommodate same sex couples other minority groups with a vested interest (eg. Muslims, Mormons, Bisexuals and Polyamorists) will have a much stronger case to argue for the legalisation of polygamy and group marriages. The best defence against this is to keep the legal definition of marriage unique and distinct – ‘one man, one woman, for life’.

I think all consenting adult relationships should be allowed to enter into such marriage contracts. On another note, does Saunders think bisexuals want to marry someone other than a man or a woman?

10.Redefining marriage will lead to faith-based discrimination

“If same sex marriage is legalised faith-based employers who provide special health benefits to married employees would be required by law to extend those benefits to same-sex ‘spouses’.”

Excellent. If they were giving health benefits to only white employees, I would feel the same.

“They would also face lawsuits for taking any adverse employment action – no matter how modest – against an employee for the public act of obtaining a civil ‘marriage’ with a member of the same sex.”

Brilliant. You shouldn’t be able to affect someone’s job prospects or even fire them for getting married.

“Faith-based adoption and fostering services that place children exclusively with married couples would be required by law to place children with persons of the same sex who are civilly ‘married’. Marriage counsellors from faith backgrounds would be denied their professional accreditation for refusing to provide counselling in support of same-sex ‘married’ relationships.”

Smashing. If you’re providing a public service, you shouldn’t be able to refuse to serve someone simply because they’re gay or black etc.

“All these moves would place faith groups in the invidious position of being forced to act against their consciences or face marginalisation, exclusion and litigation…”

I imagine the same thing happened with enforcement of racial equality legislation.

“…and would further fuel social fragmentation, sectarianism, antagonism and civil unrest.”

Nonsense with no supporting evidence.

 

This article was originally published on Global Health Interest Forum. Many thanks to Ruth Young for reviewing this article and drawing my attention to the African evidence on schizophrenia.

In global health, there is often a great deal of discussion about the amount of funding or attention an issue receives compared with the importance or burden of that issue. I’m sure we could all fill in our own version of the sentence “[disease/disorder] receives a disproportionate amount of funding” or “Nobody in global health seems to be paying attention to [disease/disorder]”. Well I’m afraid this is another article about the latter.

There is a particular field within global health which I believe receives nothing like enough attention from the global health community. Annually, it directly affects 100s of millions of people globally, kills about 1 million people, is responsible for 13% of global DALYs (disability adjusted life years), and is estimated to cost upwards of US$2.5 trillion. I’m talking of course about mental health.

Global DALYs

I say ‘of course’, but then I wouldn’t be surprised if some of those reading this article had no idea of the importance of mental health on global disease burden. At global health events I have attended, mental health has barely been mentioned and when it has, it has been very much a peripheral issue considered of little importance. After someone (briefly) mentioned global mental health at a recent seminar, I heard some members of the audience talking about how we should “sort out the important issues first” and that ideas of helping people with mental illness in poorer countries were “pie in the sky”. I have found this to be a fairly typical attitude among some people working in global health and I firmly believe that it is an unacceptable attitude to take.

There are two common responses to the question “Why are we not doing more about global mental health?” The first is “Isn’t mental health a problem of wealthier countries?” The answer to that is an emphatic “no”. Mental health is very much a global concern. As can be seen in the figure below, mental illness is indeed a smaller proportion of disease burden in poorer countries, but it still constitutes 18% of years lived with a disability (YLDs) in Africa, compared to 43% in Europe and the Americas. Furthermore, while there is a scarcity of data from Africa in particular it is estimated that 85% of suicides occur in low and middle income countries and 90% of untreated schizophrenia cases are in developing countries.

Mental Health Burden By Region

Mental Health Burden By Region, from WHO World Health Report 2001 (click to enlarge)

The second common response is that mental illness is difficult or expensive to treat. Again this is not true. Many effective treatments can be performed for very low costs and the effect of good mental health treatment is often to reduce other healthcare costs for those individuals. Recent studies have shown that training local people in psychological treatments can reduce costs while remaining effective. The WHO estimates that schizophrenia can be effectively treated for only US$2 per person per month.

The case of schizophrenia is particularly interesting as there is evidence that approaches taken in developing countries can actually be more effective than Western approaches:

“Explanations for this phenomenon are still at the hypothesis level, but include: a) greater inclusion or retained social integration in the community in developing countries, so that the person maintains a role or status in the society; b) involvement in traditional healing rituals, reaffirming communal inclusion and solidarity; c) availability of a valued work role which can be adapted to a lower level of functioning; d) availability of an extended kinship or communal network, so that family tension and burden are diffused, and there is often low negatively “expressed emotion” in the family.”

None of these hypotheses are suggesting interventions that strike me as particularly expensive. What is more, the value gained from a psychologically healthy population is much greater than that lost through treatment. When considering mental illness, we cannot just look to the individual suffering, but also to greater effects on the family, community and country: effects such as the reduced capacity of a sufferer to look after their children; stigma and discrimination against the mentally ill; the reduced productivity and loss of income; criminal justice costs etc. A recent study from Harvard came to the conclusion that more than two-thirds of the cost of mental illness globally comes through indirect costs such as loss of productivity.

This is not a problem we can sweep under the rug until we’ve solved every other health problem. As has been said so many times, “there is no health without mental health”. Mental illness kills as many people each year as malaria and causes more disability than any other illness. There are huge advantages to be gained both to societies and to individuals by including mental health as a key part of the global health agenda instead of a fringe issue to be sniffed at.

Figure references (all other references linked in text):

WHO World Health Report 2001. Mental Health: New Understanding, New Hope.

WHO Investing in Mental Health.

This article was originally published on Global Health Interest Forum

There are a number of good reasons for us to look at health from a global perspective, especially looking at resource-poor countries. The first, and most obvious to most of us, is simply compassion. It is an oft-repeated statistic, but it is important to remember that Sub-Saharan Africa has 10% of the world’s population, 24% of the disease burden, 3% of the healthcare workers and 1% of the healthcare spending. For many of us, this is reason enough to do our best to look at the world as a whole and try to deal with health issues which may be less prevalent in our own countries. However, there are a number of advantages we can gain for our own countries by looking at the developing world.

The most immediate of these benefits is prevention of pandemics and spread of infectious disease. In the 14th century, Black Death took three years to cross Europe. In the 21st century, SARS took three days to cross the globe. Political borders are no barrier to the spread of disease. The extensive travel which helps spread diseases should also give us pause for thought about our own travel. What healthcare do you expect to receive should you be visiting a resource-poor area? As Ernest Madu put it so pithily in a TED talk he gave in Tanzania, “What will happen if you go back to your room at night and you start getting chest pains, shortness of breath, sweating; you’re having a heart attack. What are you going to do? Will you fly back to the US, Germany, Europe? No, you will die.” If you plan on travelling to a resource-poor area of the world at any point in your lifetime, you should be interested in the quality of their healthcare.

“Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world.” – Louis Pasteur

However, this is not the sort of the benefit I am talking about. I would like to advocate for looking to resource-poor areas of the world for ideas to improve health in countries with greater resources. It is an agenda growing in popularity and expounded by the likes of Nigel Crisp in his excellent book “Turning the World Upside Down” (I can’t recommend it enough). There is a tendency for wealthier countries to export their healthcare ideas to poorer countries in the belief that the former’s healthcare system is the ideal to which the latter should be aspiring.  However, I believe there are good reasons to think that resource-poor countries can be excellent sources for new ideas:

  1. Many of these countries are starting from scratch. They are not fighting to gradually change an already existing health system and as such can effect ideas which might be seen as ‘too radical’ in an established system with vested interests.
  2. The very fact that these countries have low resources means that any solutions found will be cost-effective. In a time of more and more constrained budgets, this is a very major consideration.

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So I thought an easy way to start the blog would be just to advertise my first paper which has just been published in Malaria Journal. It’s a brief methodology paper detailing a method for absolute quantification of proteins from the blood-stage of the Plasmodium falciparum parasite. P. falciparum is the parasite which causes malaria in many parts of the world and is the species which causes death by malaria. I suppose I should probably give a general overview of malaria in another post, but for now, I just want to give this paper.

Although the method was used to investigate blood-stage P. falciparum, it is generally applicable to any protein system and allows absolute quantification of proteins of low abundance, in this case folate pathway enzymes. Enjoy!

A mass spectrometric strategy for absolute quantification of Plasmodium falciparum proteins of low abundance

Selected reaction monitoring mass spectrometry has been combined with the use of an isotopically labelled synthetic protein, made up of proteotypic tryptic peptides selected from parasite proteins of interest. This allows, for the first time, absolute quantification of proteins from Plasmodium falciparum. This methodology is demonstrated to be of sufficient sensitivity to quantify, even within whole cell extracts, proteins of low abundance from the folate pathway as well as more abundant “housekeeping” proteins.

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