Tampere, Finland,
13 October 1999

Global Perspectives on Mental Health

It is a great pleasure to be here in Tampere in beautiful Finland - and to meet with this important gathering of mental health promotion experts. Thank you all for joining in what needs to develop into a significant movement for mental health.

Let me thank Minister Eva Biaudet and the Finnish government for hosting this meeting - and for their determined efforts to put mental health right at the core of the agenda of the European Union. We need determination like this if we are to make a lasting difference for the millions and millions who have the right to expect that societies and policy makers start taking mental health seriously.

Before I took office as Director-General of the World Health Organization, I was determined to address mental health as a priority. I had seen how hard it had been to strengthen mental health policies in my own country, Norway. I had started to see some of the vast neglect that people with mental health problems faced in developed and developing countries alike. It was very clear to me: Mental health must rise to a more prominent place if we are to live up to our mandate of promoting health and human rights.

That is why I very much welcome that the ministers of the European Union and its partners share this commitment - and that all of the dedicated people in this room now come together and can give input to the policy decision-making process at a European level. WHO is there to back and support this process and we are proud of saying that we are in this together.

My task today is to share with you a global perspective of the debate on mental health promotion. When I look out of the window from my office in Geneva and beyond the glorious snow-capped mountains of the Alps, what do I see?

Three features dominate. First of all: We are living in a world of rapid change. Even in the calmest and most prosperous corners of the world, people are facing a breath-taking pace of newness. From new technology to new jobs to new fashions in entertainment and culture, we are all being swirled along in what may well be the most rapid global transformation anyone has ever seen.

In the Eastern European states, the collapse of communism has led to an even faster pace of change. In large parts of the developing world, urbanization, rapid economic development and environmental degradation are forcing billions of people to face a future so different from the life when they grew up that few of their acquired skills are able to assist them with their new challenges.

Change is in itself not a negative thing. After all, the human quest for progress is motivating much of our behaviour. And, much of the change we see today is for the better.

Yet with change also comes insecurity, unpredictability and apprehensions deeply rooted in the human mind. Although some people thrive on change, most of us cope with it less easily. Let us keep this in mind.

The second dominant feature I see is poverty. Over the past decades, the world has seen great progress on many fronts. Great technological breakthroughs. Large groups getting better off. Yes - what most of the media makes us see is richness, abundance, and expensive lifestyles.

But in spite of the spectacular growth we have seen in parts of the world since 1970, more than three billion people - that is half of the world’s population - still remain poor and live on less than two US dollars per day. Of these, 1.3 billion live on less than one dollar a day. Population growth may have increased these figures to four billion and nearly two billion respectively by 2025.

Of even more cause for concern is the prediction that most parts of the world cannot count on a substantial per capita income growth in the years to come, and that inequities prevent much of the growth we do expect from reaching the poorest.

My colleague James Wolfensohn and his staff at the World Bank recently launched a study called "Voices of the Poor", where they asked 60,000 men and women in 60 countries to share their realities, their hopes and expectations for the future.

One of their findings is that the poor seek much more than an increased income. They seek a peace of mind that comes with good health, a sense of community, safety and predictability. They seek the freedom to influence their own lives and to make choices. In short, they seek a sense of well-being that often follows higher income, but is not necessarily a part of it.

The word well-being is a key one. When we talk about mental health promotion, we are quick to stress that what we are aiming for is not only the absence of mental disorders. We want to ensure mental well-being, a state in which individuals can realize their abilities, can cope with the stresses of life, can work productively and satisfactorily and make a positive contribution.

Obviously, poverty, both real and relative, is a great obstacle to such mental well-being. The world has set a target of halving the number of absolute poor by 2015. That is a very tall order. It can be done - we need no magic pill to make it - we have all the knowledge to secure nutrition, basic health care, immunization of all children, clean water and basic education for all. But it will require real political will. Agencies such as WHO can help and support this process by mapping out concrete interventions that will make a real difference. We need a portion of decency on the part of the richer countries to pay a fair share to bring the excluded billion on board. Only four out of the richest countries – the Netherlands, Denmark, Norway and Sweden – live up to their obligation of providing at least 0.7% of their GDP for development assistance. The average is falling towards a record low 0.2%. This is – in my view – a shame, and all groups in civil society committed to development should hold their leaders to account.

The third feature I see is a process of ageing. Over the coming decades, we will see a great demographic shift in developing as well as in industrialized countries. There are currently about 600 million people in the world aged 60 years and over, and this figure is expected to rise to 1020 million within the next 20 years - a 70% increase in that age group compared to a less than 25% increase in the world’s population as a whole. By 2020, approximately 70% of the elderly population will be living in developing countries.

We are talking of a demographic and social transformation of our societies. There will be changes, opportunities and challenges. One of the challenges comes from the fact that the risk of mental disorders increase with ageing.

Already, of course, we are acutely aware that mental illness is a serious health problem. Today, as many as 300-400 million people worldwide are estimated to be suffering at any given time from some kind of neurological or psychological disorder, including behavioural and substance abuse disorders.

Mental disorders account for 12 % of the burden of all disease in 1998. It is one of the dominating causes of years lost to disease, something too few people realize. The share was greater in high income countries at 23%, than in middle income countries at 11%. This overall figure is expected to increase to 15% over the next 20 years.

We must all help take these figures to the media - bring it to the people. Many will be surprised. But we should not shy away from communicating these facts - we have to do it as part of the vital process of rolling back the many taboos that deter prevention, treatment and care.

Major depression is ranked fourth among the 10 leading causes of the global burden of disease, which includes the developing world. By 2020, it will have jumped to second place if the projections are correct. This statistic of course does not include non-clinical depression reported by a person who proffers to being depressed today, and who consequently does not function well or work that day.

Major depression is linked to suicide. Most people who commit suicide are also clinically depressed. If we take suicide into account, then the burden associated with depression increases quite significantly.

One of our main enemies in our work against depression and other mental disorders is the imbalance of recognition between mental problems and physical ones. The figures are on the table, but there is still no recognition of the magnitude of the burden of mental disease. There is a lack of recognition, of awareness, and of action. Insurance companies discriminate between physical and mental disorders. Labour policies are less open to welcoming people with a history of mental disorders than those with physical ones. And still, mental health is not getting the level of resources that the magnitude of the burden warrants.

With this discrimination follows stigma, which complicates access to those who need help, treatment, care and prevention. Stigma creates a hidden burden of mental problems, which should be added to the burden we can measure. Only when we address the stigma and discrimination together will we be able to make real progress.

Stigma can be reduced by openly talking about mental disorders in the community, countering the negative stereotypes and misconceptions surrounding mental disorders, and ensuring the existence of legislation to reduce discrimination in the workplace and in access to health and social community services.

What does all this add up to? Some great challenges, is the short answer.

WHO is facing these challenges. In Beijing next month I will announce WHO’s global mental health strategy. It will be centred around three words: advocacy, policy, and cost-effective interventions. Let me share the essence of our message:

Advocacy means raising the profile of mental health on the political, health and development agendas of governments and international organizations. In this effort, you are our allies.

Policy means integrating mental health into the health sector as part of countries’ health sector reform. This means making clear recommendations for management, financing, and legislation to ensure that mental health becomes an integral part of health systems. I believe the EU can help in taking this agenda forward.

Cost-effective interventions mean ensuring that mental health services are incorporated in the use of all levels of health services, ranging from primary health care to support for families and other social services.

The implementation of cost-effective interventions for treatment, prevention and promotion is urgent. We need to document and disseminate specific cost-effective strategies which are targeting specific major diseases such as depression, schizophrenia and epilepsy.

It is not enough to promote mental health in the status quo. We must strive to anticipate future changes and prepare people for these changes before they happen, so they are able to cope with them, and hopefully to thrive on them when they come.

Take the work-place. In its effort to cope with the competitive pressures of globalization and the demands to bring down the high figures for unemployment, Europe is bracing itself for some radical changes to its labour markets. This could hopefully lead to lower unemployment, with all the positive consequences that would have for mental health.

But it is also likely to lead to less security in the work-place, less predictability and, for many, a sense of alienation and powerlessness. We need to anticipate these trends before they take effect, and we need to devise ways to minimize the stress that such changes could cause.

European collaboration - your core business - could be of great value. Not all trends arrive in all countries at the same time, yet the problems of change are often similar in many countries. There is great scope for a Europe-wide cooperation in the field of "mental health change management" - in a sense which goes beyond the borders of the European Union.

We need to reach out. Mental health professionals have a responsibility to go outside their own group and talk to politicians, to law-makers and to other professionals. Sometimes we tend to forget our roles as responsible citizens. Let us recall the words of Rudolf Virchow written 150 years ago: "Medicine is a social science and politics is nothing but science on a large scale." This has been my own life-time experience.

To be effective, public health professionals must learn to work at the heart of the political process with their elected political leaders. This is especially true when it comes to the fight against poverty: both absolute poverty as we see it in much of the developing world, but also the crippling and stigmatizing relative poverty which stains the achievements of European progress over the past decades. Unless we work to reduce poverty, we cannot hope to see the full fruits of the school programmes, the work-place programmes and the public campaigns we devise.

Rapid change for the worse, as we have periodically seen in our neighbours to the east over the past decade, is an especially fertile breeding-ground for mental illness. It is no coincidence that nine of the ten countries with the highest suicide rate in the world are in Eastern Europe.

These countries need our support.

Over the past few years, we have seen how war, violence and conflict have hit parts of Europe. We have seen how civilians rather than soldiers are the targets in these conflicts, and how psychological terror, rape and atrocities are systematically used to traumatize whole populations.

Many of us believed that the traumas caused by war, economic crises and collapsed social structures were a thing of the past, buried for good in the rubble after the Second World War. Yet, over the past decade, these horrors have reappeared on our doorstep, and in many cases, we have been forced to face them in our own neighbourhoods.

Let me tell you a story from my own country.

One late autumn day in 1995, a family of refugees arrived in a small village in central Norway. This family had witnessed how most of their own village’s population in Bosnia had been massacred, and they had been maltreated for months in prison camps. The husband, who had also served against his will in the army, had suffered a mental breakdown and was periodically psychotic and suffered from paranoia and deep trauma. Taking a chance, the local physician and the municipality’s psychologist went against the medical advice from Bosnia, which said the man needed hospitalization.

A year of close follow-up and dedicated work by the local doctor, the refugee coordinator and the local authorities had stabilized the family. The man had an internship in a local factory, the woman learned Norwegian and was included in local social activities, and the children functioned well at school.

Then the War Crimes Tribunal in the Hague wanted them to witness against the officers who had ordered the massacre in their village. This threw the man straight back into illness, with new psychotic spells and crippling attacks of anxiety. Again, the local physician chose not to go the way of the mental hospital. Instead he helped the family face their real problem - the traumas from the war. After a number of anguishing months, the family chose to testify at the Hague. By doing so, and by carrying it out, the man of the family managed to pull himself out of his own mental illness.

Today, the family lives a normal life in this village: they work, they are integrated into the local culture, and their mental health condition lies, according to the local psychologist, among the better half of the village’s population.

What do I want to illustrate with this little success story? First of all: we must not leave the promotion of mental health to the psychologists and the treatment to the psychiatrists.

Mental health work is a process that starts with the individual in the family and continues through the work place and the local community to the public health infrastructure. It is no secret that the local physician is the person who first and most often encounters mental health problems.

The experience from the Swedish island of Gotland confirms of course that physicians can play a crucial role in mental health work. The Gotland study showed that when physicians were trained to detect early signs of depression, the suicide rate was reduced considerably. In the case of our Bosnian refugees, the local physician played a key role, but also the understanding of mental health problems by the refugee coordinator, the other support staff, and even the mayor of this small village played an important role in restoring the mental well-being of this family. In the end, it was a totally external factor - the therapeutic effects of truth and justice - which made the biggest difference, a factor that lies totally outside our realm of influence.

The second lesson I would point to is the futility of arguing the importance of mental health promotion versus mental health treatment. I really believe this perceived conflict is a false one. As you know, WHO and the EU arranged a conference on the balance between the two in Brussels earlier this year. Our view is that there should be no contest between the two. They should complement and reinforce each other.

There are weaknesses in our mental health services that need to be addressed, also here in Western Europe. However, we certainly must put a lot of emphasis on mental health promotion.

One doesn’t have to travel far before the issue of improved care for mental disorder patients becomes of acute importance. Europe still has over 100 very large psychiatric hospitals, and many of these are in a poor condition and often provide inhumane and outmoded care. The issues of effective treatment, access to drugs, and violations of human rights for mental illness patients need to be fully addressed.

But even worse: One-third of the world’s population has no access to even the most basic psychotropic drugs. It has been estimated that only 35% of the people suffering from depression in countries with established market economies receive treatment. In other countries, such as sub-Saharan Africa and China, treatment rates for depression are as low as 5%.

So far I have highlighted what we already know. Nevertheless, we are in need of more good epidemiological information to assist us in defining focused policies and planning appropriate interventions. I therefore warmly welcome Minister Biaudet’s call for a joint effort to develop a European mental health information system to map not only detailed information on mental health disorders, but also to collect data on mental health systems, activities, and on the concept of well-being.

For our part, WHO is now in the final planning stages of Mental Health Survey 2000, a large initiative which aims to obtain empirical data that will assist us in deciding how best to deal with the increasing burden of mental disorders in different parts of the world.

Mental Health Survey 2000 will assess mental disorders in comparison with physical disorders in 19 countries worldwide. Relying on modern epidemiological tools, WHO will gather real life data on both mental and physical disorders and disability, work loss, risk factors, service utilization and medications. This data is essential for WHO to monitor world health and develop evidence-based information for policy.

The more we know about the past and present, the more we learn about the future. Predictions are that the future will bring an exponential increase in mental problems. Some reasons for this I have already outlined.

Beyond doubt: mental health has to be given increased attention in our societies, by health authorities, politicians, policy-makers and decision-makers.

WHO intends to respond to this challenge and is prepared to assist Member States to develop evidence-based and effective strategies, both for health promotion and for treatment. I would hope that many of you here today, and the countries you represent, will contribute with your expertise, with your best practices and with direct assistance to our colleagues in Eastern Europe as well as in developing countries.

Minister Biaudet, ladies and gentlemen,

We need to focus on change.

When it comes to health promotion we must emphasize the role of the non-professional players in the field of mental health, and we must see mental health promotion and mental health services as parts of a continuum, not as opposite and conflicting poles.

In the picture that emerges out of these factors, one element stands out. That is the role of the family. Both in mental health promotion and in treatment and care, the family, often extended by the closest community network, has a central role to play. This, of course, is nothing new, and much of our work already focuses on the family. Still, we need to fully recognize the crucial role the family plays - and we also need to recognize that the family needs support. Much of the burden of caring for the mentally ill, or for preventing those who are in danger of becoming ill, is left to the family without providing the support, information and recognition they need to cope with this considerable burden.

I would like to commend EUFAM - the EU Federation of Family Associations of Mentally Ill People - for its 1995 "Barcelona Manifesto", which outlines the needs and perceived rights of the family of the mental patient. WHO will keep its recommendations in mind in our work.

I hope and believe that this meeting will be an important step towards greater European cooperation and dialogue on mental health issues. WHO is committed to working with the European Union to achieve our mutual goals and mandates.

But on that road we must not just address the mental health issues and problems of Europe. It is not only a moral issue, but is in our enlightened self interest to assist the rest of the world to develop cost-effective, equitable and humane ways to promote mental health and care for the mentally ill. That, I have always believed, is part of Europe’s responsibility – and opportunity.

I am confident we can do this. And therefore I invite politicians, technicians, humanitarians, social activists and colleagues in health to strengthen our working relationships, working together to improve the mental health and well-being of all peoples.

Thank you.