Mental Health for All by Involving All | Vikram Patel | TED Talks

Translator: Joseph Geni Reviewer: Morton Bast

Translator: Carlos Fernández-González Reviewer: Pablo Figueiredo Palacios

I want you to imagine this for a moment.

Quero que se imaxinen isto

Two men, Rahul and Rajiv,

Dous homes, Tahul e Rajiv,

living in the same neighborhood,

os dous viven no mesmo barrio,

from the same educational background, similar occupation,

teñen a mesma formación e traballos semellantes

and they both turn up at their local accident emergency

e os dous se achegan ao servizo de urxencias

complaining of acute chest pain.

queixándose dunha dor aguda no peito.

Rahul is offered a cardiac procedure,

A Rahul fanlle probas do corazón

but Rajiv is sent home.

pero a Rajiv non: mándanno a casa.

What might explain the difference in the experience

Cal é a explicación do trato distinto

of these two nearly identical men?

en dúas persoas practicamente iguais?

Rajiv suffers from a mental illness.

Rajiv sofre unha enfermidade mental.

The difference in the quality of medical care

A diferenza na calidade dos coidados médicos

received by people with mental illness is one of the reasons

recebidos por persoas con enfermidade mental

é unha das razóns polas que viven menos tempo

why they live shorter lives

than people without mental illness.

que as persoas sen enfermidade mental

Even in the best-resourced countries in the world,

Mesmo nos paises que dispoñen de máis recursos no mundo,

this life expectancy gap is as much as 20 years.

a diferenza na espectativa de vida supera os 20 anos.

Nos paises en vías de desenvolvemento

In the developing countries of the world, this gap

a diferenza aínda é maior

is even larger.

But of course, mental illnesses can kill in more direct ways

Pero ademais, as enfermidades mentais poden matar de forma máis directa.

as well. The most obvious example is suicide.

O exemplo máis obvio é o suicidio

It might surprise some of you here, as it did me,

Pode que lles sorprenda, como me pasou a min,

when I discovered that suicide is at the top of the list

cando descubrín que o suicidio é unha das principais causas de morte

of the leading causes of death in young people

entre a xente nova en todo o mundo

in all countries in the world,

including the poorest countries of the world.

incluíndo os paises máis pobres do planeta

But beyond the impact of a health condition

Pero máis que o impacto que un problema de saúde teña na esperanza de vida

on life expectancy, we're also concerned

a nós preocúpanos o seu efecto na calidade de vida

about the quality of life lived.

Para analizar simultaneamente o impacto dun problema de saúde

Now, in order for us to examine the overall impact

of a health condition both on life expectancy

as well as on the quality of life lived, we need to use

sobre a cantidade e a calidade de vida

necesitamos usar un indicador chamado AVAD

a metric called the DALY,

which stands for a Disability-Adjusted Life Year.

e que se corresponde cos Anos de Vida Axustados por Discapacidade

Cando facemos isto,

Now when we do that, we discover some startling things

descubrimos cousas alarmantes sobre a saúde mental

about mental illness from a global perspective.

dende unha perspectiva global

We discover that, for example, mental illnesses are

Descubrimos, por exemplo,

...que a enfermidade mental é unha das principais causas de invalidez no mundo

amongst the leading causes of disability around the world.

Depression, for example, is the third-leading cause

A depresión, por exemplo, é a terceira causa de incapacidade no mundo

of disability, alongside conditions such as

xunto con enfermidades como a diarrea e a neumonía en nenos.

diarrhea and pneumonia in children.

When you put all the mental illnesses together,

Cando xuntas todas as enferidades mentais

they account for roughly 15 percent

representan arredor do 15% de todas as enfermidades do mundo.

of the total global burden of disease.

Indeed, mental illnesses are also very damaging

A verdade é que se trata dunhas doenzas moi daniñas.

to people's lives, but beyond just the burden of disease,

Pero máis alá da carga de enfermidade imos considerar as cifras absolutas.

let us consider the absolute numbers.

The World Health Organization estimates

A Organización Mundial da Saúde estima...

that there are nearly four to five hundred million people

que hai entre 400 e 500 millóns de persoas

living on our tiny planet

vivindo no noso pequeno planeta

who are affected by a mental illness.

que padecen enfermidades mentais.

Now some of you here

Algúns de vostedes parecen un pouco sorprendidos por este número

look a bit astonished by that number,

pero consideren por un momento a incrible variedade de doenzas mentais,

but consider for a moment the incredible diversity

of mental illnesses, from autism and intellectual disability

dende o autismo e a deficiencia mental na infancia,

in childhood, through to depression and anxiety,

ata a depresión e a ansiedade,

substance misuse and psychosis in adulthood,

abuso de substancias e psicose en adultos

all the way through to dementia in old age,

para chegar á demencia na vellez,

and I'm pretty sure that each and every one us

e teño para min que todos os presentes

present here today can think of at least one person,

podemos pensar polo menos nunha persoa, unha persoa

at least one person, who's affected by mental illness

afectada por unha enfermidade mental

in our most intimate social networks.

no noso círculo social máis próximo.

I see some nodding heads there.

Vexo que algúns asinten coa cabeza.

But beyond the staggering numbers,

Pero alén das cifras sorprendentes

what's truly important from a global health point of view,

o realmente importante dende o punto de vista da saúde mundial

what's truly worrying from a global health point of view,

o realmente preocupante dende o punto de vista da saúde mundial

is that the vast majority of these affected individuals

e que a grande maioría deses individuos afectados

do not receive the care

non reciben os coidados que sabemos que poden cambiar as súas vidas

that we know can transform their lives, and remember,

we do have robust evidence that a range of interventions,

e lembren que temos firmes evidencias

de que unha chea de medidas,

medicines, psychological interventions,

medicinas, intervencións psicolóxicas e sociais

and social interventions, can make a vast difference.

poden cambiar por completo a situación.

And yet, even in the best-resourced countries,

Aínda así, mesmo nos países de mais recursos

for example here in Europe, roughly 50 percent

por exemplo, aquí, en Europa

cerca dun 50% das persoas afectadas non reciben eses tratamentos

of affected people don't receive these interventions.

In the sorts of countries I work in,

No tipo de paises en que eu traballo

that so-called treatment gap

esta ausencia de tratamento

approaches an astonishing 90 percent.

acércase ao sorprendente 90%.

It isn't surprising, then, that if you should speak

Por iso non é raro

se tes que falar cunha persoa que padece unha enfermidade mental

to anyone affected by a mental illness,

the chances are that you will hear stories

escoitar historias de sufrimento oculto

of hidden suffering, shame and discrimination

vergoña e discriminación

en case tódolos ámbitos da súa vida.

in nearly every sector of their lives.

But perhaps most heartbreaking of all

Pero quizais, o máis desgarrador de todo

are the stories of the abuse

sexan as historias de abuso

of even the most basic human rights,

mesmo dos dereitos humanos máis básicos

such as the young woman shown in this image here

tal e como amosa a imaxe desta nena

that are played out every day,

que acontecen tódolos días, tristemente

sadly, even in the very institutions that were built to care

incluso nas institucións creadas para cuidar a estas persoas,

for people with mental illnesses, the mental hospitals.

os hospitais mentais.

It's this injustice that has really driven my mission

Esta inxusticia foi decisiva para que eu me propuxera como misión

to try to do a little bit to transform the lives

intentar transformar as vidas

de persoas afectadas por enfermedad mental

of people affected by mental illness, and a particularly

critical action that I focused on is to bridge the gulf

e me centro sobre todo en tender unha ponte

entre os coñecementos que temos

between the knowledge we have that can transform lives,

capaces de transformar vidas,

the knowledge of effective treatments, and how we actually

os coñecementos sobre tratamentos efectivos,

use that knowledge in the everyday world.

e o uso diario que facemos destes coñecementos no mundo.

And an especially important challenge that I've had to face

E un desafío especialmente importante co que me atopei

is the great shortage of mental health professionals,

é a grande escaseza de profesionais de saúde mental,

such as psychiatrists and psychologists,

psiquiatras e psicólogos,

particularly in the developing world.

sobre todo nos paises en vías de desenvolvemento.

Now I trained in medicine in India, and after that

Estudiei medicina na India,

I chose psychiatry as my specialty, much to the dismay

e despois elexín psiquiatría como especialidade

para desgusto da miña nai e de toda a miña familia

of my mother and all my family members who

kind of thought neurosurgery would be

que pensaban que a neurocirurxía sería unha opción máis respectable

a more respectable option for their brilliant son.

para o seu brillante fillo.

Any case, I went on, I soldiered on with psychiatry,

Sexa como fora eu seguín coa psiquiatría,

and found myself training in Britain in some of

e atopeime estudando en Inglaterra nalgún dos mellores hospitais do país.

the best hospitals in this country. I was very privileged.

I worked in a team of incredibly talented, compassionate,

Fun un privilexiado. Traballei nun grupo moi talentoso,

compasivo, pero o máis importante moi ben formado e especializado

but most importantly, highly trained, specialized

mental health professionals.

en saúde mental.

Soon after my training, I found myself working

Pouco despois de rematar os estudos

first in Zimbabwe and then in India, and I was confronted

comecei a traballar primeiro en Zimbabue e despois na India

by an altogether new reality.

onde atopo unha realidade totalmente nova.

This was a reality of a world in which there were almost no

Foi a realidade dun mundo

mental health professionals at all.

no que casi non había profesionais da saúde mental

In Zimbabwe, for example, there were just about

En Zimbabue, por exemplo, apenas había unha ducia de psiquiatras

a dozen psychiatrists, most of whom lived and worked

a maioría deles vivían e traballaban na cidade de Harare,

in Harare city, leaving only a couple

to address the mental health care needs

quedando só un par deles ao coidado das necesidades de saúde mental

of nine million people living in the countryside.

dos 9 millóns de persoas que vivían no campo.

In India, I found the situation was not a lot better.

Na India non atopo unha situación moito mellor.

To give you a perspective, if I had to translate

Para que se fagan unha idea,

the proportion of psychiatrists in the population

se na India houbera a mesma proporción de psiquiatras que en Gran Bretaña

that one might see in Britain to India,

debería haber 150.000 psiquiatras na India

one might expect roughly 150,000 psychiatrists in India.

In reality, take a guess.

Adivinen cantos hai.

The actual number is about 3,000,

Nestes momentos arredor de 3.000

about two percent of that number.

case o 2% dos que debía haber.

It became quickly apparent to me that I couldn't follow

En seguida me din de conta

de que non podía seguir os modelos de coidados de saúde mental que estudiara

the sorts of mental health care models that I had been trained in,

one that relied heavily on specialized, expensive

baseados en profesionais caros e altamente especializados

mental health professionals to provide mental health care

in countries like India and Zimbabwe.

para paises como a India e Zimbabue.

I had to think out of the box about some other model

Tiña que pensar noutro modelo de coidados.

of care.

It was then that I came across these books,

Foi así que atopei estes libros,

and in these books I discovered the idea of task shifting

e neles descubrín a idea da delegación de tarefas na saúde global.

in global health.

A idea é moi simple.

The idea is actually quite simple. The idea is,

A idea é, cando dispoña de poucos profesionais

when you're short of specialized health care professionals,

use whoever is available in the community,

utilice calquera persoa dispoñible na comunidade,

train them to provide a range of health care interventions,

fórmeos para prestar uns coidados mínimos.

and in these books I read inspiring examples,

Nos libros lin exemplos inspiradores

for example of how ordinary people had been trained

por exemplo, como se formou a xente non preparada para atender partos

to deliver babies,

diagnose and treat early pneumonia, to great effect.

ou diagnosticar e tratar pneumonía, con bos resultados.

And it struck me that if you could train ordinary people

E pensei que si se lles pode preparar para facer tarefas tan complexas

to deliver such complex health care interventions,

then perhaps they could also do the same

quizáis tamén se lles poda preparar para prestar coidados en saúde mental.

with mental health care.

Well today, I'm very pleased to report to you

Hoxe, compráceme informarlles que se ten experimentado moito

that there have been many experiments in task shifting

na delegación de tarefas en saúde mental

in mental health care across the developing world

na última década nos paises en vías de desenvolvemento,

over the past decade, and I want to share with you

e quero compartir con vostedes os resultados de tres experimentos

the findings of three particular such experiments,

all three of which focused on depression,

todos eles enfocados na depresión, a enfermidade mental máis común.

the most common of all mental illnesses.

In rural Uganda, Paul Bolton and his colleagues,

Na Uganda rural, Paul Bolton e os seus colaboradores

using villagers, demonstrated that they could deliver

demostraron que os aldeáns podían facer psicoterapia para a depresión

interpersonal psychotherapy for depression

and, using a randomized control design,

e mediante un estudo aleatorio controlado

showed that 90 percent of the people receiving

demostró que o 90% das persoas que recibiron esta intervención se recuperaron

this intervention recovered as compared

to roughly 40 percent in the comparison villages.

fronte a un 40% no grupo control.

Similarly, using a randomized control trial in rural Pakistan,

Noutro estudo aleatorio controlado en áreas rurais de Pakistán,

Atif Rahman and his colleagues showed

Atif Rahman e os seus colaboradores demostraron que as mulleres visitadoras

that lady health visitors, who are community maternal

que eran traballadoras de saúde maternal da comunidade

health workers in Pakistan's health care system,

pertencentes ao sistema de saúde pakistaní

could deliver cognitive behavior therapy for mothers

poideron prestar terapia cognitiva conductual

who were depressed, again showing dramatic differences

a nais que sufriron depresión

in the recovery rates. Roughly 75 percent of mothers

demostrando grandes diferencias nas tasas de recuperación.

recovered as compared to about 45 percent

Cerca do 75% das nais se recuperaron fronte ao 45% no grupo control.

in the comparison villages.

And in my own trial in Goa, in India, we again showed

E no meu propio estudo en Goal, na India,

that lay counselors drawn from local communities

novamente mostramos como conselleiros oriundos das comunidades locais

could be trained to deliver psychosocial interventions

poden ser entrenados para facer intervencións psicosociais

for depression, anxiety, leading to 70 percent

para a depresión ou a ansiedade,

recovery rates as compared to 50 percent

acadando taxas do 70% de remisión

in the comparison primary health centers.

en comparación co 50% nos centros de atención primaira.

Now, if I had to draw together all these different

Se tivese que reunir todos estes experimentos de delegación de tarefas,

experiments in task shifting, and there have of course

been many other examples, and try and identify

e hai moitos outros exemplos,

what are the key lessons we can learn that makes

e intentase identificar os aspectos clave

for a successful task shifting operation,

que contribúen ao éxito na delegación de tarefas

I have coined this particular acronym, SUNDAR.

resumiríano co acrónimo SUNDAR que eu veño de acuñar.

What SUNDAR stands for, in Hindi, is "attractive."

SUNDAR, en Hindi, significa "atractivo".

Eu creo que hai cinco leccións clave que amoso nesta diapositiva

It seems to me that there are five key lessons

that I've shown on this slide that are critically important

for effective task shifting.

para unha axeitada delegación de tarefas.

The first is that we need to simplify the message

A primeira é que necesitamos simplificar a mensaxe que utilizamos

that we're using, stripping away all the jargon

eliminando toda a xerga que rodea a medicina.

that medicine has invented around itself.

We need to unpack complex health care interventions

Temos que dividir as intervencións complexas de coidados

into smaller components that can be more easily

en unidades pequenas para poder transferirlas fácilmente

transferred to less-trained individuals.

ás persoas menos entrenadas.

We need to deliver health care, not in large institutions,

Hai que prestar os coidados non en grandes institucións,

but close to people's homes, and we need to deliver

senón perto dos fogares da xente

e cómpre facelo

health care using whoever is available and affordable

utilizando a quen estea accesible e dispoñible na comunidade.

in our local communities.

And importantly, we need to reallocate the few specialists

E, moi importante,

temos que reubicar aos poucos especialistas que hai

who are available to perform roles

such as capacity-building and supervision.

para desenvolver labores de formación e supervisión.

Now for me, task shifting is an idea

Para min, a delegación de tarefas é dunha importancia transcendental

with truly global significance,

porque aínda que xurdiu do problema da falta de recursos

because even though it has arisen out of the

situation of the lack of resources that you find

in developing countries, I think it has a lot of significance

nos paises en vías de desenvolvemento

creo que tamén é importante nos países con recursos abundantes.

for better-resourced countries as well. Why is that?

E por qué?

Well, in part, because health care in the developed world,

en parte porque os coidados de saúde nos paises desenvolvidos,

the health care costs in the [developed] world,

os custos dos coidados de saúde nos paises desenvolvidos,

are rapidly spiraling out of control, and a huge chunk

estanse a ir rápidamente fóra de control,

of those costs are human resource costs.

en boa medida polo custo dos recursos humáns.

But equally important is because health care has become

Pero tamén porque os coidados de saúde

so incredibly professionalized that it's become very remote

teñen acadado unha especialización tan alta

que se teñen distanciado das comunidades locais.

and removed from local communities.

For me, what's truly sundar about the idea of task shifting,

O concepto de SUNDAR na transferencia de tarefas

though, isn't that it simply makes health care

non afecta só á accesibilidade e á economía

more accessible and affordable but that

senón á capacitación e o fortalecemento das comunidades.

it is also fundamentally empowering.

It empowers ordinary people to be more effective

Esta formación de xente sen estudos para o coidado da saúde

in caring for the health of others in their community,

doutras persoas na súa comunidade,

and in doing so, to become better guardians

axúdalles tamén a coidarse mellor a si mesmos.

of their own health. Indeed, for me, task shifting

A delegación de tarefas é o exemplo máis importante

is the ultimate example of the democratization

da democratización do coñecemento médico, do poder médico.

of medical knowledge, and therefore, medical power.

Just over 30 years ago, the nations of the world assembled

Hai pouco máis de 30 anos, os paises do mundo reuníronse en Alma-Ata

at Alma-Ata and made this iconic declaration.

e fixeron esta simbólica declaración. (Saúde para todos no ano 2000)

Well, I think all of you can guess

that 12 years on, we're still nowhere near that goal.

Creo que todos poden imaxinar

que 12 anos despois aínda estamos lonxe desta meta.

Still, today, armed with that knowledge

Hoxe, sabendo que a xente entrenada na comunidade,

that ordinary people in the community

can be trained and, with sufficient supervision and support,

con suficiente supervisión e apoio

can deliver a range of health care interventions effectively,

pode prestar un amplo abano de coidados de forma efectiva,

perhaps that promise is within reach now.

tal vez estemos máis cerca de acadar esta meta.

Indeed, to implement the slogan of Health for All,

De feito, para poñer en marcha a iniciativa "Saúde para Todos"

we will need to involve all

necesitamos incluír a todos nesa estratexia particular

in that particular journey,

and in the case of mental health, in particular we would

e, no caso da saúde mental en particular,

need to involve people who are affected by mental illness

necesitamos incluír ás persoas que padecen unha doenza mental

and their caregivers.

xunto aos seus coidadores.

It is for this reason that, some years ago,

É por esa razón que, hai uns anos,

the Movement for Global Mental Health was founded

fundouse o Movemento Global pola Saúde Mundial,

as a sort of a virtual platform upon which professionals

un tipo de plataforma virtual na que os profesionais coma min

like myself and people affected by mental illness

e as persoas que padecen unha enfermidade mental

could stand together, shoulder-to-shoulder,

poden loitar xuntos, ombro con ombro,

and advocate for the rights of people with mental illness

e defender os dereitos das persoas con doenzas mentais

to receive the care that we know can transform their lives,

para recibiren os coidados que sabemos que poden cambiar as súas vidas

and to live a life with dignity.

e para que poidan vivilas con dignidade.

And in closing, when you have a moment of peace or quiet

E para rematar, cando teñan un momento de tranquilidade

in these very busy few days or perhaps afterwards,

nestes días tan ocupados, ou senón despois,

spare a thought for that person you thought about

dediquen un momento a pensar

na persoa ou persoas que recordaron que teñen unha enfermidade mental

who has a mental illness, or persons that you thought about

who have mental illness,

and dare to care for them. Thank you. (Applause)

e atrévanse a coidalos. Gracias.

(Applause)