One of the oldest recognized ailments is also one of the most neglected in Pakistan
THE determinants of a national priority vary from country to country. The inferences depend on the spectacles one uses. The health scenario focuses on economics and building of national character. Sound health plays a pivotal role in this regard and mental health is behaviour. Those who want to remain healthy will adopt ways and means that are conducive to healthy living. As against this, many continue to adopt a path, willingly or unconsciously, one that leads to faulty health status.
Who has divided the diseases into two broad categories namely Communicable and Non-communicable Diseases (NCDs). Mental health issues have been placed under NCDs. Strong arguments can be offered to convince the planners and professionals that mental health is equally a strong force while dealing with communicable diseases or NCDs. It is the mind-based power that enables the person to confront day-to-day as well as in-born and acquired health issues. Starting from common cold to Aids virus infection, birth defect to acquired diseases, hereditary disease trends and unscrupulous lifestyle, acute problems and chronic disabilities all require a firm state of the mind of concerned individual as well as that of his careers to tackle such issues.
Mental health is unique in several ways. Most of the persons suffering from a mental health problems apparently “look well” except a handful who have had problems since early life.
In 1990, two Harvard researchers, working in collaboration with Who, published a pivotal book titled The Global Burden of Disease. This book provided the first objective summary of the costs of various type of illness to society throughout the world in a manner that the wealthy nations with more money are not over-represented. The term ‘Disability Adjusted Life Years’ (DALY) was introduced as a scale for combined measurement of time lost as a result of premature mortality and time lived with the disability. A loss of one DALY is equivalent to loss, of one year of life of one person.
Based on economics and demographics of diseases, it inferred that infectious diseases are still creating a heavy disease burden in developing countries, whereas the burden in wealthier nations has shifted to individuals that affect older individuals such as cardiovascular diseases.
According to the Who, 450 million people in the world currently suffer from, some form of mental or brain disorder, including alcohol and substance misuse. Within this huge number, 121 million people suffer from depression, and more than 800,000 people die of suicide each year, with young people accounting for well over half of these. Projections from 1990 to 2020 suggest that, in future, the proportion of the global burden of disease accounted for by mental and brain disorders will rise to fifteen per cent.
There is a huge gap between ‘West’ and ‘East’. The West is preoccupied with human rights, political correctness, development of new and expensive drugs, the rights of minorities, life skill, education, stigma, sophisticated technology, quality of life etc., whilst in the East, due to extreme poverty, various kinds of severe deprivations, chronic stress and diseases forgotten in the West (like for example, vitamin deficiency), people and professionals have other priorities like hunger, survival, ad hoc diagnostics, and traditional methods of living. Many countries of, the East are characterized by severe socio-economic deprivations despite availability of natural resources but otherwise flooded with war, conflicts, debts, and man-made disasters of various kinds at the expense of ‘Health Dollar’.
Mental illnesses are among the first diseases to have been recognized as discrete illness. The concept of cancer or even congestive cardiac failure is relatively new compared with the concept of mental illness. Perhaps the oldest medical document in existence, the Eber Papyrus (probably composed in 1900BC) contains references to specific syndromes such as depression. Biblical writings also contain reference to Saul as failing into serious depression. Hippocrates related mental illness to brain and Galen and his followers believed that mental illnesses were due to imbalances in quantities of body fluids.
Depression has been calculated as one of the costliest illness of the world. Of the ten leading causes of the world in persons between the ages of 15 and 44 years, four relate to mental illness namely unipolar depression, alcohol use (in case of Pakistan drug/substance abuse), manic depressive (bipolar) illness, and schizophrenia. If one includes self-inflicted injuries (i.e. suicide), violence and infliction war and other manmade disasters, the morbid behaviour related to DALYs will exceed 75 of the shared cost to society.
Two questions arise: (i) why did the message of global burden of mental illness come as such a shock? (ii) why did the biomedical community fail to recognize the importance of psychiatric disorders until so recently? Two explanations can be offered. The mental illness in some times and places were related to brain just as one organ of the body. In other times these were treated as diseases of soul and spirit, a just punishment inflicted by ‘a righteous god, the result of an evil eye, the influence of magic and some supernatural, force, etc.
The concept of disease (dis-ease) has changed to disorder (dis-order) in functions. Medical science has undertaken a long journey from disorder of system to that of organ, from fluids (blood, phlegm and yellow bile) to biochemistry, and from hereditary diseases to molecular genetics. Simultaneously, the concern has moved from mortality to morbidity, from morbidity to disability, from disability to quality of life, from quality of life to assisted or instrumental mode of living and lately from disease burden to health promotional programmes.
Health promotional programmes and in this case mental health promotional activities have been arbitrarily divided into primary, secondary and tertiary types of prevention instead of rigid compartmentalization of health problems into treatable and untreatable categories. Based on treat-ability requirement, primary prevention relates to intervention long before the disease develops. Immunization/vaccination programmes and drug prevention education can be cited as examples of primary prevention as both the types of interventions operate on the same scientific principles. In vaccination, a small calculated dose of germ or virus whether killed or alive (antigen) is introduced into the body in order to create minimal symptoms of the said disease. The body thereafter reacts by producing defence (anti-bodies) system, which subsequently leads to inculcation of an immune response. Drug prevention education, stress coping, strategies, healthy lifestyle programmes etc., are also based on the same principle. Highly pertinent, easily acceptable and minimally invasive messages are transmitted to individual consistently in order to create fight against social evils such as drug addiction, alcohol use, halal, haram acts or things as well as development of stress coping strategies in order to assume safe behaviour. The information/knowledge thus received is processed and later develops into a power to resist indulgence in undesirable activities and risk behaviours. Belief system and faith also get deep rooted in one’s psyche in the same way. In later years of life this is replaced by formal treatment in the form of counselling, psychotherapy, and behaviour modification. In the absence of or in conjunction with pharmacotherapeutic interventions, psychological treatment becomes the mainstay of prevention even in secondary prevention (conventional treatment options when the individual is struck with a problem) and tertiary prevention (rehabilitation).
Mental illness can be broadly classified into minor or major types of illness. The term ‘illness’ relates to individual connotation of a disease as compared to sickness, one that reflects societal connotation. Phrases like “I am sick of you, morning sickness, home sickness” look down one’s suffering. Sometimes a person not feeling well subjectively seeks treatment voluntarily. As against this, a person broken down by an episode may have to be brought to the doctor against his will. Former is an example of minor illness and latter that of major illness. But such an easy distinction is sometimes difficult to make just like the slogans such as minor surgery or major surgery. Developments in neuroscience have led to spectacular advances in the treatment of otherwise untreatable maladies. Segregations and chaining was replaced by chemical restraining and lately by relatively newer or atypical drugs with minimum of side-effects. Emphasis has shifted from long term retention in asylum to community containment. Similarly, the treatment of depression with newer anti-depressants has resulted in a much-improved quality of life. Depression hits not only the individual but also those others in his immediate environment. A depressed person loses economic productivity, lacks emotional warmth, and becomes gloomy. Likewise a patient suffering from psychosis (such as schizophrenia) is apparently unwell himself but exhaust others in his vicinity. The theory of ‘drift hypothesis’ explains how much blow to household economy and in turn that of community and nation is incurred with this illness. Based on health economics, depression has been equated with blindness and schizophrenia with paraplegia. Redefining ethical standard (earlier known as moral treatment) has led to more humane treatment of mental disorder.
Finally, one may question the role of psychiatrist! Psychiatrist treats and monitors patient, accords psycho-education to his family, struggles against stigmatisation of mental illness, liaises with colleagues and allied mental health professionals, contributes to social control against disease related adverse impacts, tells the truth in plain and simple words, maintains confidentiality, fights for the rights of the patient in a given social and legal frame work, and continues to update himself professionally with the latest know-how in the best interest of the patient and the society, in general.
Growing consensus on bio-psycho-social mode of diseases has evolved into the concept of holistic medicine thereby incorporating all kinds of health professionals on one platform. The diseases can now be fought with people and professionals together. Such a revolutionary change will require additional as well as re-allocation of resources.
Investment in ‘health’ is invisible but highly rewarding. Neither government nor philanthropy alone can generate funds as the affordability criteria keeps on changing. Promotion of healthy lifestyle is both inexpensive and guaranteed form of primary prevention. Alternatively, pharma industry will continue to bat on crease. As the Father of Nation, Quaid-i-Azam Muhammad Ali Jinnah indicated this strategy on 22nd April 1948 at the opening ceremony of the First Pakistan Olympic Games at Karachi “........ the success of our people in all walks of life depends upon the cultivation of ‘Sound Minds’ the natural concomitant to ‘Sound Bodies’.”
One of the oldest recognized ailments is also one of the most neglected in Pakistan 
