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Supporting people with severe mental disorders in war and other disaster settings: A need to protect the most vulnerable

Dr Mark van Ommeren, Public Mental Health Adviser, WHO Department of Mental Health and Substance Abuse

Commentary
18 May 2016

When 5000 leaders converge this month on Istanbul at the first World Humanitarian Summit, their goal will be “to stand up for our common humanity and take action to prevent and reduce human suffering”.

As heads of state, leaders of business, aid organizations, civil society and affected communities consider this overarching goal, I hope that they will also focus on the needs of people with mental disorders.

War and natural disasters can affect everyone, but people with severe mental disorders are at special risk: the health-care and social systems that they depend on can break down; long-time support providers can disappear; access to medicines can evaporate; families can disintegrate.

And, during emergencies, people with severe mental disorders require protection. In many war and disaster settings, horrible events such as abandonment or murder have happened to persons with mental disorders. One need only recall anecdotes of security forces shooting people with severe mental disorder that were not able to understand their instructions.

Given their special vulnerability, people with severe mental disorders deserve special protection even during the best of circumstances. The multitude of humanitarian emergencies that pockmark the world today are estimated to affect 125 million people. Of that number, some 4 million to 6 million people are estimated to have severe mental disorders.

They need our attention. A first step would be for organizations responding to emergencies to integrate mental health care into pre-existing disability programs, health care services, social services and education systems. We have numerous tools to use as templates, including the Inter-Agency Standing Committee Guidelines for “Mental Health and Psychosocial Support in Emergency Settings”, which were jointly developed by 25 international humanitarian agencies.

More care during times of crisis for people with mental disorders

We are moving in the right direction. In recent years, we have seen a sharp increase in the number of agencies that are willing to routinely pay attention to people with severe mental disorders during emergencies.

Dr Mark van Ommeren
WHO

This increasing list of agencies now includes WHO, the United Nations High Commissioner for Refugees, the International Medical Corps, Médecins sans Frontières, International Rescue Committee, Save the Children, the International Committee of the Red Cross, and Doctors of the World.

But their work is not enough: we need to learn more about how to make care and protection more widely available during times of crisis.

For example, though we know how to set-up small, high-quality programmes, we fall short when it comes to setting up large-scale projects that reach vast numbers of people.

Though we know how to supervise staff members to run the small programmes, we do not know how to supervise on a larger scale.

Though we know what medicines will need to be available in the aftermath of an emergency, we struggle to ensure they are available in an uninterrupted supply.

Finally, we are still learning how to balance medical and psychosocial approaches when helping people with severe mental disorders.

Success stories aplenty

Despite these challenges, we have seen many success stories.

For example, health care providers in more than 10% of Syria’s health centres are trained to treat people with severe mental disorders. And about 16% of Syrians have access to mental health care at the primary health care level. Though those figures are not enough, they represent a marked advance over the 0% who had such access just a few years ago.

And in Afghanistan’s Nangarhar province, one nongovernmental organization trained enough general health workers to treat 100 000 people in need of mental health care over the past decade, a time of nearly non-stop emergency in this country.

Oddly, emergencies can sometimes exert a positive overall effect on mental health services. For example, some countries use them as an opportunity to reorganize existing mental health services to better respond to the real needs of the community.

Before its war of 1998 and 1999, Kosovo had just 6 inpatient wards and one asylum for people in need of mental health services. By 2010, the asylum was closed, and community services were available nationwide.

In 2004, after a tsunami killed tens of thousands of people and threw Sri Lanka’s mental health system into disarray, the government made community mental health services available across the country.

‘We must not fail the people who need us’

But much more work remains to be done.

In most countries of the world, resources for people with severe mental disorder – budgets, staff, and beds - are centralized in the capital and invested in large hospitals, which is widely accepted to be an unwise way to focus resources. Instead, the consensus among experts is that resources and clinical services should be decentralized and made available at the district level. There is no better time to make this change than after an emergency, when politicians’ interests in mental health peak.

"...resources and clinical services should be decentralized... There is no better time to make this change than after an emergency, when politicians’ interests in mental health peak."

Dr Mark van Ommeren, Public Mental Health Adviser, WHO Department of Mental Health and Substance Abuse

The issues to be discussed and debated during the World Humanitarian Summit are all worthy. They include preventing and ending conflict, delivering aid to end need, addressing forced displacement, and investing in humanity.

That is an ambitious agenda of important topics. But we must not let the special needs of people with mental disorder get lost.

The summit is a call to action by United Nations Secretary-General Ban Ki-moon. “We have in front of us a singular opportunity to stand together and deliver a message that we will not accept the erosion of humanity which we see in the world today,” he said last month. “History will judge us by how we use this moment. We must not fail the people who need us, when they need us most.”

For people with mental disorder and those who love them, Istanbul could be this moment. Let us not fail to seize it.