Friday, 30 September 2011

MC-MH: Global Integration--6

Finding Our GI Voices

United Nations, New York

We are sharing a few thoughts on future directions for integration. Integration is a field of study which brings together the disciplines of mental health and theology in order to better understand and help humans and thus glorify God. The ongoing/additional links between member care (MC) and mental health (MH) are highly relevant for the global development of integration—global integration (GI). And GI is potentially very relevant for the global development of mission/aid and human health.

Note: This is a longer entry. For a quick overview see the yellow highlights. There are also many documents/links mentioned below. For a quick multimedia overview, watch the WHO video on NCDs. See also the Executive Summary from the World Health Organization’s Global Status Report on Non-communicable Diseases 2010.
It is 20:00, 20 September 2011. I am on a train going from New York to New London. USA. It has been a rich and full two days at the United Nations High-Level Meeting (HLM) on Non-communicable Diseases (NCDs) and at the two previous days of meetings among the global mental health (GMH) community. I attended these events in my capacity as Coordinator of the Mental Health-Psychosocial Working Group for the Geneva-based NGO Forum for Health.

To my left, the illuminated Empire State Building soars effortlessly into the night sky. To my right, hundreds of twinkling lights peep out from the Long Island shoreline. And in front of me is the 13-page Political Declaration that was agreed upon yesterday by UN member states on combating non-communicable diseases. My weary body gently sways in time to the the rhythm of the train’s lateral movements as we scurry northbound along the steel tracks. Although my eyes are heavy with tiredness, my soul is invigorated as I reflect on what I experienced during these four full days.

Reflections on the United Nations HLM on NCD
There was an unmistakable, resounding SOS, packaged in exhortations and at times rebukes, sent out right at the start of the General Assembly on 19 September (see photo). Leading the charge were UN Secretary-General Ban Ki-moon, WHO Director-General Margaret Chan, and many heads of state who in their opening speeches heralded the dire need for the world community to take action against NCDs and their causes. To paraphrase the Secretary-General, member states, civil society, and the private sectors must resolutely work together and “get tough” on NCDs, “hold everyone accountable”, and make sure that the disgraceful actions of a few (mostly levied against the tobacco, food, alcohol and media industries) do not sully the reputation of the many which are doing such important work to foster our progress.
Opening of the UN General Assembly in New York, 19 September 2011

(click here to watch a video of Ban Ki-moon's speech at the HLM)
(click here for the text of his remarks at the HLM)
(click here to watch a video of Margaret Chan's speech at the HLM)
The four NCD disease entities being focused on are cardiovascular, chronic respiratory, cancer, and diabetes. These NCDs collectively represent a massive “epidemic” that accounts for approximately 38 million deaths each year. A substantial amount of these deaths are preventable and premature. As a reference point it is somewhat akin to attrition in the mission sector among the estimated 12,000 mission workers who leave for preventable, premature, and likely permanent reasons each year— although human death through NCDs of course is far graver. (Global Member Care: The Pearls and Perils of Good Practice 2011, pages 6-8)

Four risk factors (modifiable behaviors) associated with these NCDs are repeatedly emphasized: inactivity (lack of exercise), poor diet (including high intake of tans-fats, salts, and sugars), tobacco use, and alcohol abuse. Added to these risk factors is the key area of mental health (e.g., mental health state and mental disorders) as it too plays a crucial role in the prevention, development, and control of these NCDs.

Taken together, these four NCDs and their risk factors are “lifestyle diseases” that are developed over the course our one’s life and often from one’s way of living life. NCDs must also be definitely understood in the socioeconomic context that influences and reinforces them (e.g., poverty, lack of medical care, poor nutrition). They are also “problems without passports,” since they effortlessly cross all borders be they national, generational, ethnic, gender, etc.

Relevance for Member Care and the Church-Mission Community
NCDs can affect you and me and our loved ones. And they can and do affect mission/aid workers and certainly the people with whom they work. Understanding and preventing NCDs and encouraging healthy lifestyle choices should be a core part of the member care that we provide in mission/aid and in any global health efforts for integration. For more summary information see: Global Status Report on Non-communicable Diseases 2010.

Take special note that approximately 80% of the deaths from NCDs occur among people in low-middle income countries (LMICs). I hasten to add that many of the world’s poor live in LMICs and are in fact part of people groups that lack a viable Christian presence (UPGs, LPGs). Who are the people and organizations that are explicitly talking about the epidemic of NCDs in terms of people groups and Christian witness/responsibility? Or for that matter who is addressing the massive untreated mental health disorders in LMICs in view of Christian witness/responsibility? There is a huge opportunity for the church-mission community to confront the NCD epidemic as part of our commitment to bring love and healing to the peoples of the earth. This excerpt from the Political Declaration on NCDs can serve as a tangible rallying point.

"We, Heads of State and Government and representatives of States and Governments….22. Note with grave concern the vicious cycle whereby non-communicable diseases and their risk factors worsen poverty, while poverty contributes to rising rates of non-communicable diseases, posing a threat to public health and economic and social development; 23. Note with concern that the rapidly growing magnitude of non-communicable diseases affects people of all ages, gender, race and income levels, and further that poor populations and those living in vulnerable situations, in particular in developing countries bear a disproportionate burden and that non-communicable diseases can affect women and men differently; 24. Note with concern the rising levels of obesity in different regions, particularly among children and youth, and note that obesity, an unhealthy diet and physical inactivity have strong linkages with the four main non-communicable diseases, and are associated with higher health costs and reduced productivity…”

Reflections on Mental Health and Global Integration
Being at the UN meetings was an enriching and somber experience. I interacted with and/or listened to health advocates, researchers, practitioners, government officials, and health ministers. The meetings were attended by dozens of heads of state. People seemed sincerely committed to make a difference. It was great to be there and great to have been working together to combat NCDs before, during, and after this high-level meeting.

Nonetheless, many in the civil society and political sectors also wanted more explicit references and action points on mental health. Over the course of the two-day high-level meetings, there was almost no mention of the crucial role of mental health in the causes and treatments, the prevention and control of NCDs. Mental health-related co-morbidity is all over the pages of the research and the lives of NCD sufferers (e.g., depression for diabetics, see the summary from the Young Professionals Chronic Disease Network et al). Mental, neurological, and substance use conditions (MNSs) currently affect—and in many cases torment--some 450 million people worldwide, with the worldwide lifetime prevalence rate being about 25%. In addition, the new publication by the World Economic Forum and Harvard School of Public Health, among other findings, puts the annual cost of mental and neurological illnesses (also classified as NCDs) at 2.5 trillion US dollars, about three times the annual cost for cardiovascular illness.

For perspective though, almost everyone is positive about the need for good mental health. No one I met was ant-mental health at all . And it is true that there are many WHO-related documents regarding GMH (issues, research, resources). However this important historical input from WHO and other GMH sources was not prioritized in the high-level meeting nor in the overall NCD action plans—at least not yet. The rationale was that mental health has already been addressed amply over the past decade, for example via the WHO’s mhGAP program and thus it is being dealt with in other venues.

Four Missing Voices
Here are “four voices” that were missing at the HLM in New York. Again for some perspective, I know that others too have their own lists of missing voices based on their concerns/emphases: e.g., those involved in human rights, poverty eradication, maternal and child health, etc. There are so many challenging issues which plague humanity, and so many relevant and respectable voices clamoring for attention!

Voice One. There was a limited, albeit encouraging voice in the 13-page Political Declaration about the importance and integration of mental health in combating NCDs. Here are the two helpful references to mental health in this document.

"We, Heads of State and Government and representatives of States and Governments….5. Reaffirm the right of everyone to the enjoyment of the highest attainable standard of physical and mental health; 17. Note further that there is a range of other non-communicable diseases and conditions, for which the risk factors and the need for preventive measures, screening, treatment and care are linked with the four most prominent non-communicable diseases; 18. Recognize that mental and neurological disorders, including Alzheimer’s disease, are an important cause of morbidity and contribute to the global non-communicable disease burden, for which there is a need to provide equitable access to effective programmes and health-care interventions;..."

Voice Two. There was an almost non-existent voice about mental health during the meetings that I attended, from civil society, governments, and private industry. No plenarist that I heard dealt with it. And there was almost no time allotted for participants to raise questions and make comments at the main meetings about anything, mental health or otherwise. However, the Assistant Director General of WHO, Dr. Ala Alwan, was in fact briefly queried from the floor about the absence of mental health in the discourses. He affirmed the importance of mental health and said that it would be considered when the WHO Executive Board meets in January 2012 to work towards a review procedure to measure how the Political Declaration is being put into practice by member states. (WHO is tasked with this responsibility in the Political Declaration).

Voice Three. At the HLM itself, colleagues in the GMH field seemed by and large not present (or at least not visible/audible). There were few or no resources or summary documents available on mental health and NCDs. Many excellent NCD-related materials though were on tables in the back of meetings/rooms. In the run up to these meetings though, there was substantial, credible input about mental health, via several written statements on mental health and NCDs (as well as good opportunites for civil society/NGOs to express their concerns and dialogue about NCD-related matters at special UN/WHO gatherings--Moscow, April 2011; Geneva, May 2011; New York, June 2011). These statements culminated in two final Statements sent out in August/September 2011to colleagues and organizations, Ministers of Health, and government missions to the UN. The Statements call for mental health to be included in the agenda and action plan for the prevention and control of NCDs. One of these Statements was made by the World Federation for Mental Health and the other Statement was done jointly by the NGO Forum for Health (based in Geneva) and the NGO Committee on Mental Health (based in New York and part of the Conference on NGOs--CoNGO). (click here to see the one-page Statement and the approximately 100 signatories) Another helpful document that I received at a pre-UN meeting off-site was the two-page summary on mental health and NCDs (mentioned previously) done by the Young Professionals Chronic Disease Network et al as part of their overall recommendations and concerns about NCDs.
Voice Four. All of this leads us to the focus of these weblog entries, Global Integration. There was also a missing voice from colleagues in the Christian faith-based community who are involved in integration. Could it be that integration and Global Integration did not show up? Or perhaps if it did, it did so more privately behind the scenes via people who informed by their professional work and faith, helped to shape the content and outcomes of the NCD process and documents. Very likely so. I know for sure too speaking more broadly, that many. many people of Christian faith from other disciplines and areas of concern, as is so often the case, were involved in the extremely important global NCD agenda.

My botttom line thought though is this. Integration as we know it (at last in what I call the the CANE context: Clinical-counseling, Academic, North American, Evangelical) may be quite at home and much needed in our classrooms or therapists’ offices. But Global Integration as we develop it must go beyond these familiar and important places. It must intentionally and resolutely venture into high-level conference rooms and government offices as well as settings chronically plagued  by human misery via horriffic povery, intractable conflicts, natural disasters, human rights violations, and limited to no access to adequate health care, especially mental health. WWJD....if he were a mental health professional?! 

Consultation at Cornell University Medical Center, New York, 17 September 2011.
"Mental Health as a Global Priority: One Voice, One Strategy" 
organized by the World Federation forMental Health with various co-sponsors. 

Looking Forward
I was thrilled, impressed, and grateful for the progress and commitments being made to prevent and control NCDs. I am glad social determinants of health (especially poverty and human rights) in NCDs were highlighted. I look forward to seeing the tangible outcome measures that WHO is to put together—to hopefully require (vs suggest/encourage) tough accountability for this important Political Declaration. I look forward to seeing mental health being increasingly included in the NCD agenda. I look forward to the growing coordination and unity among GMH as it gives strategic input on high-priority issues for human health. And I sincerely hope that Global Integration will increasingly find its voice in the global health agenda and the world body.

Reflection and Discussion
**Which of the NCD-related materials/ links above are of the most interest to you?
**How does or could the fight against NCDs affect your work in member care and mission/aid?
**What could be done to connect Global Integration more with the global realities related to human health?

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