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

Translator: Joseph Geni Reviewer: Morton Bast

Prevodilac: Bojana Murisic Lektor: Ivana Korom

I want you to imagine this for a moment.

Pokušajte da zamislite

Two men, Rahul and Rajiv,

dva čoveka - Raul i Raživ

living in the same neighborhood,

koji žive u istom kraju,

from the same educational background, similar occupation,

podjednako su obrazovani i bave se sličnim poslom

and they both turn up at their local accident emergency

i oboje odlaze u hitnu pomoć

complaining of acute chest pain.

žaleći se na bol u grudima.

Rahul is offered a cardiac procedure,

Doktor Raulu predlaže intervenciju na srcu

but Rajiv is sent home.

dok Raživa šalje kući.

What might explain the difference in the experience

Kako može da se objasni razlika između načina

of these two nearly identical men?

na koji su ova dva čoveka tretirana?

Rajiv suffers from a mental illness.

Raživ ima psihičkih problema.

The difference in the quality of medical care

Razlika između načina

received by people with mental illness is one of the reasons

na koji su tretirani ljudi sa mentalnim problemima

why they live shorter lives

je jedan od razloga

than people without mental illness.

zašto oni kraće žive.

Even in the best-resourced countries in the world,

Čak i u razvijenim zemljama

this life expectancy gap is as much as 20 years.

ova razlika dostiže čak 20 godina.

In the developing countries of the world, this gap

U nerazvijenim zemljama

is even larger.

ova razlika je čak i veća.

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

Naravno, postoje i drugi načini kako mentalna bolest utiče na dužinu života.

as well. The most obvious example is suicide.

Jedan od njih je recimo samoubistvo.

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

Iznenadiće vas da je samoubistvo

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

jedan od najčešćih uzroka smrti

of the leading causes of death in young people

mladih ljudi

in all countries in the world,

u svim zemljama sveta

including the poorest countries of the world.

uključujući i one siromašne.

But beyond the impact of a health condition

Ali osim uticaja zdravstvenog stanja

on life expectancy, we're also concerned

na životni vek

about the quality of life lived.

zanima nas i sam kvalitet života.

Now, in order for us to examine the overall impact

Da bismo mogli da vidimo kakav uticaj ima

of a health condition both on life expectancy

određeno zdravstveno stanje na životni vek

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

i na kvalitet života,

a metric called the DALY,

upotrebićemo takozvanu DALY meru,

which stands for a Disability-Adjusted Life Year.

što znači godina kada se uzme u obzir određeni hendikep.

Now when we do that, we discover some startling things

Uz DALY, iz globalne perspektive

about mental illness from a global perspective.

vidimo neke zaista neverovatne stvari.

We discover that, for example, mental illnesses are

Vidimo da su mentalne bolesti

amongst the leading causes of disability around the world.

među vodećim uzročnicima invaliditeta širom sveta.

Depression, for example, is the third-leading cause

Kod dece na primer, posle proliva i upale pluća

of disability, alongside conditions such as

depresija je treća

diarrhea and pneumonia in children.

bolest koja najviše ograničava.

When you put all the mental illnesses together,

Kada uzmemo u obzir sve mentalne bolesti zajedno

they account for roughly 15 percent

one čine 15%

of the total global burden of disease.

svih bolesti u svetu.

Indeed, mental illnesses are also very damaging

Moram istaći da mentalne bolesti

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

jako ograničavaju naše živote. Osim tereta bolesti,

let us consider the absolute numbers.

ako se osvrnemo na brojeve videćemo da po proceni

The World Health Organization estimates

Svetske zdravstvene organizacije

that there are nearly four to five hundred million people

na našoj planeti

living on our tiny planet

oko četiri do pet stotina miliona ljudi

who are affected by a mental illness.

pati od mentalnih bolesti.

Now some of you here

Naravno, neki od vas

look a bit astonished by that number,

su sigurno zaprepašćeni kada čuju taj broj.

but consider for a moment the incredible diversity

Ali, ako se na trenutak osvrnemo na veliki broj različitih mentalnih bolesti

of mental illnesses, from autism and intellectual disability

od autizma do intelektualnih poremećaja kod dece

in childhood, through to depression and anxiety,

pa do depresije, anksioznosti,

substance misuse and psychosis in adulthood,

bolesti zavisnosti i psihoze kod odraslih

all the way through to dementia in old age,

ili demencije u starosti

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

videćemo da zaista svako od nas ovde

present here today can think of at least one person,

poznaje barem jednu osobu

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

koja je na neki način

in our most intimate social networks.

mentalno obolela.

I see some nodding heads there.

Vidim da se slažete sa mnom.

But beyond the staggering numbers,

Osim velikog broja obolelih

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

sa tačke gledišta globalnog zdravlja,

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

bitno je shvatiti i zabrinuti se

is that the vast majority of these affected individuals

koliko je mali broj mentalno obolelih

do not receive the care

koji su na neki način zbrinuti.

that we know can transform their lives, and remember,

Istraživanja potvrđuju

we do have robust evidence that a range of interventions,

da različite vrste lečenja

medicines, psychological interventions,

poput lekova, psihoterapija

and social interventions, can make a vast difference.

i socijalnih promena zaista pomažu.

And yet, even in the best-resourced countries,

Ipak, čak i u najrazvijenijim zemljama

for example here in Europe, roughly 50 percent

ovde u Evropi oko 50% obolelih

of affected people don't receive these interventions.

ne dobija nikakvu mentalnu pomoć.

In the sorts of countries I work in,

U zemljama u kojima ja radim

that so-called treatment gap

taj procenat

approaches an astonishing 90 percent.

dostiže neverovatnih 90%.

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

Zato i nije iznenađujuće

to anyone affected by a mental illness,

da ako popričate sa osobom sa mentalnom bolešću,

the chances are that you will hear stories

čućete priče

of hidden suffering, shame and discrimination

o skrivenoj patnji, sramoti i diskriminaciji

in nearly every sector of their lives.

u skoro svakom segmentu njenog života.

But perhaps most heartbreaking of all

Možda je najtužnije od svega

are the stories of the abuse

videti kako pate ljudi

of even the most basic human rights,

kojima su uskraćena najosnovnija ljudska prava.

such as the young woman shown in this image here

Primer je devojčica na slici.

that are played out every day,

Nažalost, ova patnja može se uočiti

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

i u psihijatrijskim bolnicama

for people with mental illnesses, the mental hospitals.

koje bi trebalo da ovim ljudima pomognu.

It's this injustice that has really driven my mission

Moja želja je da učinim makar malo

to try to do a little bit to transform the lives

da promenim život ovih ljudi koji pate.

of people affected by mental illness, and a particularly

Najviše bih želeo

critical action that I focused on is to bridge the gulf

da pomognem svima da shvate kako naše znanje

between the knowledge we have that can transform lives,

može da promeni živote, znanje o uspešnim terapijama,

the knowledge of effective treatments, and how we actually

i kako ga možemo upotrebiti

use that knowledge in the everyday world.

u svakodnevnom životu.

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

Jedan od najvećih izazova za mene je bio to što ima

is the great shortage of mental health professionals,

veoma mali broj stručnjaka za mentalne poremećaje,

such as psychiatrists and psychologists,

poput psihijatara i psihologa,

particularly in the developing world.

pogotovo u zemljama u razvoju.

Now I trained in medicine in India, and after that

Završio sam medicinu u Indiji,

I chose psychiatry as my specialty, much to the dismay

a nakon toga specijalizirao psihijatriju.

of my mother and all my family members who

Došlo je do negodovanja pogotovo kod moje majke

kind of thought neurosurgery would be

koja je mislila

a more respectable option for their brilliant son.

da je za njenog bistrog sina bolje da postane neurohirurg.

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

U svakom slučaju, ja sam nastavio sa mojim studijama

and found myself training in Britain in some of

i došao u Britaniju

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

gde sam stažirao u nekim od najboljih psihijatrijskih bolnica.

I worked in a team of incredibly talented, compassionate,

Radio sam u timu izuzetno talentovanih, saosećajnih,

but most importantly, highly trained, specialized

ali najvažnije veoma obučenih i specijalizovanih

mental health professionals.

stručnjaka za mentalno zdravlje.

Soon after my training, I found myself working

Ubrzo nakon moje prakse, počeo sam da radim

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

prvo u Zimbabveu, a potom i u Indiji

by an altogether new reality.

i video nešto potpuno novo.

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

U ovim zemljama broj stručnjaka

mental health professionals at all.

bio je zaista mali.

In Zimbabwe, for example, there were just about

U Zimbabveu, na primer,

a dozen psychiatrists, most of whom lived and worked

radilo je oko desetak psihijatara

in Harare city, leaving only a couple

od kojih je većina živela u glavnom gradu zemlje.

to address the mental health care needs

Samo mali broj njih mogao se brinuti

of nine million people living in the countryside.

o devet miliona ljudi koji su živeli u manjim mestima.

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

Ni u Indiji situacija nije bila mnogo bolja.

To give you a perspective, if I had to translate

Recimo, ako uzmem u obzir broj psihijatara u Britaniji,

the proportion of psychiatrists in the population

proporcionalno čovek bi očekivao

that one might see in Britain to India,

oko 150 000 psihijatara

one might expect roughly 150,000 psychiatrists in India.

u Indiji.

In reality, take a guess.

Pokušajte da pogodite koliko ih je bilo.

The actual number is about 3,000,

Samo oko 3 000

about two percent of that number.

što je svega 2% od predviđenog.

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

Postalo mi je odmah jasno da u Indiji i Zimbabveu

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

neću moći primeniti iste modele

one that relied heavily on specialized, expensive

kao one koje sam primenjivao tokom moje prakse,

mental health professionals to provide mental health care

a koji se zasnivaju

in countries like India and Zimbabwe.

na skupoj zdravstvenoj nezi.

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

Morao sam da počnem

of care.

drukčije da razmišljam.

It was then that I came across these books,

Tada sam naišao na ove knjige

and in these books I discovered the idea of task shifting

u kojima sam video

in global health.

ideju prenosa zaduženja.

The idea is actually quite simple. The idea is,

Jako je jednostavna.

when you're short of specialized health care professionals,

Radi se o tome da kada nema dovoljno specijalista

use whoever is available in the community,

mogu da pomognu čak i ljudi koji nisu specijalizovani.

train them to provide a range of health care interventions,

Treba ih samo naučiti.

and in these books I read inspiring examples,

U ovim knjigama video sam primere običnih ljudi

for example of how ordinary people had been trained

koji su naučili kako da uspešno

to deliver babies,

porađaju žene

diagnose and treat early pneumonia, to great effect.

ili da primete rane znake upale pluća i da je leče.

And it struck me that if you could train ordinary people

I zaista me je podstaklo na razmišljanje to da

to deliver such complex health care interventions,

ako tako obični ljudi mogu da nauče tako komplesne intervencije,

then perhaps they could also do the same

onda bi sigurno ti isti ljudi

with mental health care.

mogli da nauče kako da pomognu mentalno obolelima.

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

Sada mogu reći da sam zaista srećan

that there have been many experiments in task shifting

jer mogu da vas obavestim da su urađeni raznovrsni eksperimenti

in mental health care across the developing world

u kojima je ustanovljeno da u zemljama koje su u razvoju

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

u poslednjih deset godina obični ljudi zaista mogu da nauče

the findings of three particular such experiments,

kako da tretiraju mentalno obolele.

all three of which focused on depression,

Podeliću sa vama tri takva eksperimenta.

the most common of all mental illnesses.

Sva tri se odnose na depresiju koja je najčešća mentalna bolest.

In rural Uganda, Paul Bolton and his colleagues,

U selima u Ugandi, Pol Bolton i njegove kolege

using villagers, demonstrated that they could deliver

uvideli su da obični seljaci mogu da pomognu

interpersonal psychotherapy for depression

depresivnim ljudima putem interpersonalne terapije.

and, using a randomized control design,

Koristeći eksperiment sa nasumičnom kontrolom,

showed that 90 percent of the people receiving

pokazali su da se 90% onih koji su primili

this intervention recovered as compared

ovakvu intervenciju oporavilo,

to roughly 40 percent in the comparison villages.

u poređenju sa oko 40% njih koji nisu dobili nikakvu vrstu nege.

Similarly, using a randomized control trial in rural Pakistan,

Slična situacija je i u Pakistanu

Atif Rahman and his colleagues showed

gde su Atif Rahman i njegove kolege pokazali

that lady health visitors, who are community maternal

da su žene zdravstvene radnice

health workers in Pakistan's health care system,

u pakistanskom zdravstvenom sistemu,

could deliver cognitive behavior therapy for mothers

mogle putem kognitivno bihejvioralne terapije

who were depressed, again showing dramatic differences

da pomognu depresivnim majkama, pokazujući velike razlike

in the recovery rates. Roughly 75 percent of mothers

u stopama oporavka.

recovered as compared to about 45 percent

Oko 75% depresivnih majki uspelo je da se oporavi

in the comparison villages.

u odnosu na samo 45% u selima u kojima pomoć nije bila ponuđena.

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

U eksperimentu koji sam nadgledao u oblasti Goa u Indiji,

that lay counselors drawn from local communities

došli smo do zaključka da ljudi mogu da se obuče

could be trained to deliver psychosocial interventions

kako da pravilno ponude psiho-socijalne vrste terapija

for depression, anxiety, leading to 70 percent

za lečenje depresije i anskioznosti, vodeći do 70% oporavka

recovery rates as compared to 50 percent

u poređenju sa 50%

in the comparison primary health centers.

u centrima primarne zdravstvene zaštite.

Now, if I had to draw together all these different

Kad bih morao da analiziram ove različite eksperimente,

experiments in task shifting, and there have of course

a zaista ih ima mnogo,

been many other examples, and try and identify

i da pokušam da identifikujem

what are the key lessons we can learn that makes

ključne lekcije o tome šta čini

for a successful task shifting operation,

ovakve programe uspešnim,

I have coined this particular acronym, SUNDAR.

smislio sam jedan akronim, SUNDAR.

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

SUNDAR na hindu jeziku znači zgodan.

It seems to me that there are five key lessons

Sada ću vam pokazati koje su po meni posebno bitne lekcije

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

za uspešnu obuku ljudi

for effective task shifting.

u zemljama u razvoju.

The first is that we need to simplify the message

Prva je da pojednostavimo poruku

that we're using, stripping away all the jargon

koju želimo da podelimo sa ljudima

that medicine has invented around itself.

kako bi bila bez komplikovanog medicinskog žargona.

We need to unpack complex health care interventions

Potom da pojednostavimo zdravstvene intervencije

into smaller components that can be more easily

i podelimo ih na manje delove

transferred to less-trained individuals.

koji mogu lako da se objasne i onima koji nisu specijalizovani.

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

Zatim, moramo da se postaramo da je zdravstvena nega blizu ljudi,

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

u blizini njihovih kuća

health care using whoever is available and affordable

i da tu negu daje

in our local communities.

ko god je u mogućnosti.

And importantly, we need to reallocate the few specialists

Jako je bitno i to da taj mali broj specijalista

who are available to perform roles

koji su stručni da nadgledaju negu koja se obolelima daje

such as capacity-building and supervision.

bude pravilno raspoređen.

Now for me, task shifting is an idea

Ja mislim da je ideja prenosa zaduženja

with truly global significance,

od globalnog značaja,

because even though it has arisen out of the

jer može biti izuzetno korisna

situation of the lack of resources that you find

i u razvijenim zemljama,

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

iako je nastala podstaknuta ograničenim brojem resursa

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

u nerazvijenim zemljama.

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

Zašto tako mislim? Pa zato što troškovi zdravstvene nege

the health care costs in the [developed] world,

u razvijenim zemljama izuzetno rastu

are rapidly spiraling out of control, and a huge chunk

i veliki deo tih troškova

of those costs are human resource costs.

ide na zaposlene.

But equally important is because health care has become

Isto tako, jako je bitno reći da je zdravstvena nega

so incredibly professionalized that it's become very remote

postala toliko stručna da se udaljila

and removed from local communities.

od običnih ljudi.

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

Zapamtite da

though, isn't that it simply makes health care

SUNDAR ne daje samo

more accessible and affordable but that

zdravstvenu negu siromašnima

it is also fundamentally empowering.

već i osnažuje.

It empowers ordinary people to be more effective

Osnažuje ljude bez prethodnog iskustva

in caring for the health of others in their community,

da pomognu obolelima u svojoj zajednici

and in doing so, to become better guardians

i na taj način očuvaju i svoje zdravlje.

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

Za mene je ona primer

is the ultimate example of the democratization

toga kako znanje može da se proširi na što veći broj ljudi

of medical knowledge, and therefore, medical power.

i na taj način postane moć.

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

Pre tridesetak godina države sveta su se okupile u gradu Alma Ata

at Alma-Ata and made this iconic declaration.

i postavile cilj da se svim ljudima sveta do 2000. godine

Well, I think all of you can guess

da pravo na zdravlje. Vidite i sami da smo

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

nakon 12 godina još uvek daleko od tog cilja.

Still, today, armed with that knowledge

Danas smo praćeni znanjem

that ordinary people in the community

da obični ljudi, kada ih nadgledamo i podržimo

can be trained and, with sufficient supervision and support,

mogu naučiti da pomognu obolelima.

can deliver a range of health care interventions effectively,

Zato možda taj naš cilj

perhaps that promise is within reach now.

nije toliko daleko.

Indeed, to implement the slogan of Health for All,

Da bismo ga ostvarili,

we will need to involve all

moramo u to putovanje

in that particular journey,

uključiti sve ljude.

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

Što se tiče mentalnog zdravlja,

need to involve people who are affected by mental illness

morali bismo uključiti ljude koji su oboleli

and their caregivers.

i ljude koji se o njima staraju.

It is for this reason that, some years ago,

Upravo zato je pre nekoliko godina

the Movement for Global Mental Health was founded

osnovan Pokret za svetsko mentalno zdravlje,

as a sort of a virtual platform upon which professionals

kao virtuelna platforma, u kojem psihijatri poput mene

like myself and people affected by mental illness

zajedno sa obolelima

could stand together, shoulder-to-shoulder,

mogu da se udruže

and advocate for the rights of people with mental illness

i da se zalažu da oboleli

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

dobiju negu koja im je potrebna da bi im se životi promenili na bolje

and to live a life with dignity.

i da bi živeli dostojanstveno.

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

Voleo bih na kraju da vas podsetim

in these very busy few days or perhaps afterwards,

da nađete trenutak u vašim životima

spare a thought for that person you thought about

da pomislite na tu dragu osobu ili osobe

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

koji su mentalno oboleli

who have mental illness,

i da pokušate

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

da im pomognete. Hvala vam. (Aplauz)

(Applause)

(Aplauz)