Last week was mental health awareness week in the UK. Mental ill-health and relatedly alcoholism is inextricably tied up with impoverishment and chronic poverty, as demonstrated in a couple of publications from the Chronic Poverty Research Centre. It is something that CPAN has not yet adequately focused on, though we’ve thought about it. We are not alone – few development actors do support work on mental health, and the resources devoted are miniscule. This is the message of a new ODI report launched today in the UK’s mental health awareness week.
The prevalence of common mental health disorders is massive – the 2010 Global Burden of Disease study found that mental, neurological and substance use disorders accounted for a substantial proportion of the global burden of disease in terms of Disability Adjusted Life Years and other measures, though there was significant variation across world regions (Whitehead et al).
CPAN is now engaged with the International Disability Alliance and Action on Disability and Development in a piece of research and policy engagement in Bangladesh focused on exploring disability and poverty dynamics. Here we’ve found that: while surveys don’t adequately report on mental health issues – even the Washington Group questions now included in many household surveys don’t tackle it – linked qualitative research can pick it up powerfully.
Of the large number of households (161) where life histories were taken in 2007, in a study which was not particularly looking for disability or mental health issues, over a third had been affected by a disability at one time or another, with effects on household well-being. Of those currently affected, roughly equal proportions (1/3) of households included people who were mentally ill, physically disabled and chronically ill (which produced similar effects to a disability). Mental illnesses seemed to have a particularly high cost - it can in fact push households into poverty, or keep them there, especially in front of the high costs of medicines and other treatments - and there is inadequate access to care. Similarly, stigma and superstition widely associated with mental illnesses increase the vulnerability of those disabled along with their families. It’s not rare that some family members become vulnerable to violence associated with mental illness. Suicide is also a risk for mentally ill people without appropriate support, which is not easy to ensure due to the high caring burden for household members and probable loss of income. Access to proper diagnoses and appropriate treatment and care is difficult especially in rural areas, with the result that often traditional healers (kobiraj) are approached and provide treatments based on superstition and belief in evil spirits (jinn) - practices that reinforce misunderstanding and stigma and exacerbate the negative impact on individuals and their households.
Additionally, the lack of care, support, and information for families with a mentally ill household member can lead to inappropriate and harmful measures being taken to restrain or control a person with mental illness. It’s not rare that mentally ill people are chained to prevent them from hurting others and when brought to hospital, assistance might not be available. The one government hospital for mental illness is in Pabna, has around 500 beds, and struggles with a small number of doctors and staff. Not only does less than 0.5% of government health care expenditure goes towards mental health, of this, around two thirds is devoted to the hospital.
Other social impacts of disabilities observed were marriage problems, dowry disputes, threats of divorce or abandonment of women, and inability to secure suitable work opportunities’ (Davis, 2016).
To achieve the SDG poverty eradication target (‘By 2030, eradicate extreme poverty for all people everywhere, currently measured as people living on less than $1.25 a day’) we need to do three things (Chronic Poverty Report 2014-5): tackle chronic poverty, stop impoverishment and sustain escapes from poverty. From our current skimpy knowledge base, stopping impoverishment and tackling chronic poverty would seem to have serious mental health aspects. It’s not just a matter for the individuals concerned, but also for their carers, and for the wellbeing of whole households.
As mentioned, the services to support people with mental health problems are almost non-existent at scale (a ratio of one mental health professional to hundreds of thousands of people in many cases). Starting from such a low base it will be impossible to scale up in a conventional way, so services will have to be integrated with others, community based, and para-professional. There is some evidence that these can work (eg Barry et al, 2013). On our side, CPAN is now in the process of updating our life histories, collecting some new ones, and analysing the linked panel data to provide more ground. This is certainly an issue of paramount importance and CPAN is planning to deepen its understanding and to create a possible CPAN policy guide on the issue.
Peter Davis contributed to this blog post.
Barry, M., Clarke, A., Jenkins, R. and Patel, V. (2013) A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health 2013, 13:835
Davis, P (2016 forthcoming) Poverty dynamics and disability in rural Bangladesh: learning from life-history interviews. Chronic Poverty Advisory Network, Disability and Poverty Dynamics Working Paper 1. www.chronicpovertynetwork.org
Whiteford, H. A., Ferrari, A. J., Degenhardt, L., Feigin, V., & Vos, T. (2015). The Global Burden of Mental, Neurological and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010. PLoS ONE, 10(2), e0116820. http://doi.org/10.1371/journal.pone.0116820
World Health Organization, WHO-AIMS Report on Mental Health System in Bangladesh, WHO and Ministry of Health & Family Welfare, Dhaka, Bangladesh, 2006, available at http://www.who.int/mental_health/bangladesh_who_aims_report.pdf)