China Is Not Ten Feet Tall
How Alarmism Undermines American Strategy
Four years ago, a team of scholars from the Harvard School of Public Health and the World Economic Forum prepared a report on the current and future global economic burden of disease. Science and medicine have made tremendous progress in combating infectious diseases during the past five decades, and the group noted that noncommunicable diseases, such as heart disease and diabetes, now pose a greater risk than contagious illnesses. In 2010, the report’s authors found, noncommunicable diseases caused 63 percent of all deaths around the world, and 80 percent of those fatalities occurred in countries that the World Bank characterizes as low income or middle income. Noncommunicable diseases are partly rooted in lifestyle and diet, and their emergence as a major risk, especially in the developing world, represents the dark side of the economic advances that have also spurred increased longevity, urbanization, and population growth. The scale of the problem is only going to grow: between 2010 and 2030, the report estimated, chronic noncommunicable diseases will reduce global GDP by $46.7 trillion.
These findings reflected a growing consensus among global health experts and economists. But the report did contain one big surprise: it predicted that the largest source of those tremendous future costs would be mental disorders, which the report forecast would account for more than a third of the global economic burden of noncommunicable diseases by 2030. Taken together, the direct economic effects of mental illness (such as spending on care) and the indirect effects (such as lost productivity) already cost the global economy around $2.5 trillion a year. By 2030, the team projected, that amount will increase to around $6 trillion, in constant dollars—more than heart disease and more than cancer, diabetes, and respiratory diseases combined.
These conclusions were dramatic and disturbing. Yet the report had virtually no impact on debates about public health policy, mostly because it did not manage to dislodge persistent and harmful misperceptions about mental illness. In wealthy countries, most people continue to view mental illness as a problem facing individuals and families, rather than as a policy challenge with significant economic and political implications. Meanwhile, in low-income and middle-income countries and within international organizations, officials tend to view mental illness as a “First World problem”; according to that view, worrying about mental health is a luxury that people living in severe poverty or amid violent conflict cannot afford.
In reality, in countries of all levels of wealth and development, mental illness affects almost every aspect of society and the economy. And far from lacking relevance or urgency in poor and war-torn countries, mental illness often contributes to the very dysfunctions that plague such places. Moreover, breakthroughs in therapy and treatment have significantly improved the efficacy—and lowered the cost—of caring for people who suffer from mental illness, even in places that have traditionally lacked access to mental health services. Policymakers, mental health professionals, and advocates for the mentally ill should take advantage of this progress. To do so, they first must change the way people—including they themselves—think about and talk about mental illness.
People underestimate the costs and significance of mental illness for many reasons. At the most basic level, policymakers and public health officials tend to view mental illness as fundamentally different from other medical problems. But just like other diseases, mental illnesses are disorders of a bodily organ: the brain. In this respect, they are no different from other noncommunicable diseases.
Most people also do not realize just how common mental disorders are, in part because such illnesses are stigmatized and thus often hidden. The U.S. Department of Health and Human Services estimates that in 2012, 43.7 million Americans over the age of 18 suffered from some kind of mental disorder—18.6 percent of the country’s adult population. Nearly ten million of those people, or 4.1 percent of adult Americans, struggled with serious mental illnesses, such as psychotic disorders. Even in the United States, where treatment for such problems is relatively accessible, many people do not seek or receive care until their disorders have become chronic and disabling, a length of time that one recent study found to be 11 years, on average.
Mental disorders are also far more disabling than most people realize, often preventing the afflicted from working, studying, caring for others, producing, and consuming. In a 2012 report on the global economic burden of disease, the World Health Organization noted that mental illnesses and behavioral disorders account for 26 percent of the time lost to disability—more than any other kind of disease.
The impact of mental illnesses is magnified by the fact that such disorders afflict mostly young people, in contrast to other chronic noncommunicable diseases, such as heart disease or cancer, which generally appear later in life. A 2005 study conducted by researchers at Harvard Medical School, the University of Michigan, and the National Institute of Mental Health found that 75 percent of adults suffering from mental illness reported that their symptoms began before they turned 25. The first signs of psychosis in people with schizophrenia typically arrive between the ages of 18 and 23; autism begins to affect people before the age of three. Such early onset explains why mental disorders represent by far the largest source of disability—and hence lost productivity—for people between the ages of 15 and 44, a crucial period in life during which people transition from school to work, find partners, start families, and build careers.
Another little-understood aspect of mental disorders is that they are not merely disabling; they are deadly. Although many factors lead people to end their own lives, the American Foundation for Suicide Prevention estimates that mental illness plays a role in 90 percent of suicides. The World Health Organization estimates that some 800,000 people commit suicide every year, 75 percent of them in low-income and middle-income countries. Globally, more than twice as many people die from suicide as die from homicide each year, and suicide is the second-largest source of mortality for people aged 15 to 29, topped only by traffic accidents.
Finally, mental disorders act as a gateway to a range of other costly public health problems. Suffering from a mental illness increases one’s chances of contracting HIV and of developing heart disease, pulmonary diseases, and diabetes; it also raises one’s risk of homelessness, poverty, and institutionalization, including imprisonment—all of which represent further burdens on society.
Despite these profound costs, mental illness receives surprisingly little attention and resources from governments and international organizations. Globally, annual spending on mental health amounts to less than $2 per person; on average, low-income countries spend less than 25 cents per person. The median amount that countries spend on mental health equals less than three percent of the median amount that they spend on all health care, even though mental illness accounts for over 20 percent of all health-care costs. And the poorer the country, the worse the problem: the World Health Organization estimates that the majority of countries at low and lower-middle levels of income devote less than two percent of their health budgets to treating mental disorders. In such countries, up to 85 percent of people with severe mental illness receive no treatment at all.
Even wealthy countries devote few resources to mental disorders relative to the economic costs they impose. According to the Centre for Economic Performance at the London School of Economics, mental illness costs the British economy around 70 billion pounds in lost productivity and health-care expenditures every year and accounts for 23 percent of the burden that disease places on the United Kingdom, and yet the National Health Service devotes only 13 percent of its expenditures to mental disorders. Nor are international organizations any better attuned to the problem: mental illness went completely unmentioned in the UN’s Millennium Development Goals (MDGs), and until recently, most of the major organizations addressing global health and disaster relief paid little attention to the mental health needs of the populations they served.
Owing to this lack of attention and awareness, the costs of treating mental illness often fall outside health-care sectors. In the United States, for instance, most states have almost completely dismantled the system of mental hospitals that once oversaw care for the mentally ill. As a result, Americans with serious mental illness are ten times as likely to be imprisoned as to be in hospitals. In a sense, through welfare programs, social services, and jails and prisons, many countries wind up spending on the effects of mental illness—such as unemployment, homelessness, and incarceration—rather than the underlying causes. In the United States, such indirect costs represent two-thirds of the economic burden of mental health problems—a figure that makes sense considering that 30 percent of the country’s chronically homeless and more than 20 percent of the people incarcerated in the United States suffer from a mental disorder.
A FIRST WORLD PROBLEM?
Compared with wealthy countries, low-income and middle-income countries face an even starker challenge when it comes to mental health: a lack of expertise and a shortage of professionals. Residents of wealthy countries enjoy a relatively high concentration of mental health specialists: high-income countries have, on average, nine psychiatrists for every 100,000 people. But almost half of the world’s population lives in countries where, on average, there is only one psychiatrist for every 200,000 people; in many African countries, there is only one psychiatrist per every one million people.
In the short term, these numbers are not likely to improve much. But people suffering from mental illness in poorer places could benefit from a relatively new trend in the field: the so-called task-sharing approach, in which professionals train a range of providers—from nurses and social workers to peers and family members—to care for those with mental illness. Controlled trials have already demonstrated the promise this approach holds, even in places with few established mental health resources. In a report published in The New England Journal of Medicine in 2013, a team led by Judith Bass, a mental health specialist at Johns Hopkins University, described a controlled trial it had carried out in 2011 involving around 400 women in 16 villages in the Democratic Republic of the Congo who had suffered sexual violence and exhibited symptoms of posttraumatic stress disorder, depression, or anxiety. To test the efficacy of a task-sharing approach to caring for these women, clinical experts from the United States spent five or six days training local women in how to provide cognitive-processing therapy, which focuses on helping people to stop avoiding their problems and instead solve them by changing their behavior.
The local assistants used that approach to treat one set of the victims of violence, 70 percent of whom suffered from symptoms of depression and anxiety disorders before the trial began. A control group of other victims, 83 percent of whom were experiencing such symptoms, received only individual support from the assistants. The results were remarkable: after six months, only ten percent of the women who had received the cognitive-processing therapy still appeared to be suffering from depression or anxiety disorders, compared with 42 percent of those who had received just individual support.
In a 2008 article in The Lancet, a team of researchers reported similar results from a controlled trial in rural Pakistan, in which the team trained community health workers to provide a form of treatment resembling cognitive-behavioral therapy to women struggling with prenatal or postpartum depression. Women in 20 rural areas received treatment from the trainees; a control group of women in 20 other areas received care from workers who had not been trained. When the treatment period ended, only 23 percent of the women who had received care from the trained workers showed symptoms consistent with prenatal or postpartum depression, compared with 53 percent of those in the control group.
The results in Congo and Pakistan suggest that task-sharing approaches can produce results equal to or even better than those achieved by such treatments in wealthy countries, where they have been used, to cite one example, to care for U.S. military veterans struggling with posttraumatic stress disorder. And in both Congo and Pakistan, women who received psychotherapeutic treatment showed not only substantial decreases in symptoms but also improvements in overall health and well-being. Nor were they the only beneficiaries: the women who received such treatments in Pakistan were also more likely to obtain crucial vaccines for their children.
PAGING BILL GATES
Another obstacle hindering mental health care in the developing world is that many donors, public health specialists, and government officials believe that mental illness cannot be addressed with the kinds of low-cost, simple interventions that have made such a difference in the fight against other diseases in poor countries—think of polio vaccines and bed nets to prevent the spread of malaria, for example. In fact, similarly safe, effective, and inexpensive treatments exist for the most prevalent mental disorders.
Medications that relieve the most disabling symptoms of depression, psychosis, anxiety, and bipolar disorder have been available for five decades and now exist in relatively inexpensive generic formulations. A 2012 World Health Organization study showed that among 58 low- and middle-income countries, a typical course of such psychiatric medications costs, on average, approximately four percent of an individual’s daily income. Although such treatments must be prescribed and managed by medical professionals, the paucity of psychiatrists in poorer countries would not necessarily present an obstacle to making psychiatric medications more widely available. After all, even in the developed world, most antidepressants and anti-anxiety medications are prescribed not by psychiatrists but by primary-care practitioners.
But perhaps the most promising new treatments for the most common mood and anxiety disorders have emerged thanks to technological innovation. As the Internet and mobile technology have spread, psychological treatments are no longer limited to those who can visit a psychotherapist’s office. More than five billion people all over the world now have access to mobile devices that could allow them to receive psychotherapeutic interventions ranging from text messages that provide self-help strategies to computer games that incentivize positive changes in behavior. A group of psychiatric researchers in Australia recently found that a Web-based program reduced depressive and anxiety symptoms by allowing users to complete interactive modules on topics such as “managing fear and anxiety” and “tackling unhelpful thinking.” And even in places where few people have smartphones, the spread of basic cellular service means that providers can still reach far more potential patients by phone than ever before.
OUT OF THE SHADOWS
Even if donors, international organizations, and governments came to better understand the massive costs associated with mental illness and the feasibility of treatments, genuine progress would still rely on a number of systemic changes. First, there is a basic need for increased awareness of the scope of the problem. In rich and poor countries alike, mental health advocates must do a better job of explaining to officials and the public the true costs of mental illness, encouraging people to understand how the problem affects not only individuals and families but also entire communities and economies. “No health without mental health” has become a rallying cry for reformers, but such slogans frequently fall on deaf ears. Mental health advocates could win more allies within the medical profession by drawing attention to the fact that improved mental health leads to better overall health.
Second, countries at every economic level must better integrate mental health care into their broader health-care systems. In wealthy countries, two simple steps would help: preparing more primary-care providers to treat mental disorders and creating incentives for mental health specialists and general medical practitioners to share facilities and establish partnerships, which would make it easier for people to get psychiatric and psychological care. In poorer countries, one step toward better integration would be to give community health workers, who already monitor basic health needs, the ability to screen for common mental disorders, as well. For example, nurses who help patients stick to their HIV medication regimens could incorporate mental health screening into their routines.
Finally, the international community needs to make a formal commitment to reducing the global economic burden of mental illness. Although mental illness affects the achievement of several of the UN’s MDGs, such as empowering women, reducing child mortality, improving maternal health, and reversing the spread of HIV, the goals made no mention of mental health. Now, the process of drafting successors to the MDGs, the so-called Sustainable Development Goals, is well under way. Mental health advocates involved in the process are pushing for the establishment of specific targets, including a ten percent reduction in suicide by 2020 and a 20 percent increase in treatment for severe mental disorders by the same date. These are achievable goals, but meeting them will require political will, public and private investment, and coordination among the health, financial, social-service, and educational sectors.
Such steps will go a long way toward reducing the damage mental disorders inflict on societies and economies all over the world. But for such measures to succeed, policymakers and experts must first pull mental illness out of the shadows and into the center of debates about global public health.