Editor—Thornicroft and Maingay highlight the inadequacy of international responses to mental illness.1 In low income countries the burden of mental illness is amplified by financial insecurity, poverty, and partition of families, if not by violence and war. Prevention in mental health is intimately linked with overall human development. Individual care is also necessary. In some societies religious or traditional healers still provide culturally relevant and socially acceptable responses to problems labelled as mental illness. Nevertheless, mental suffering is manifest among users of modern medical services, where it goes largely unrecognised.
Besides poor availability of drugs, human resources are of utmost importance in understanding the apparent neglect of mental health problems. Doctors and nurses in low income countries are often described as rude to their patients,2 partly because they have low salaries and poor professional perspectives, which affects their morale, self confidence, and dedication.3 Some have problems similar to those of their patients—for example, domestic violence or living with HIV. Some are not prepared to face the emotional burden of listening to patients' suffering. Adequate professional support is unusual, and dealing with emotions is seldom valued by the organisational culture.4
If health care in low income countries is to be oriented towards more biopsychosocial approaches, efforts have to include improving first line care facilities and support for providers. Well functioning first line facilities are crucial to integrate mental health programmes accessible to the population. This does not rule out specialised services, but these tend to remain concentrated in cities and are often of limited accessibility financially. In the case of mental health services, stigmatisation furthermore limits their acceptability to potential users.
The integration of mental health programmes in first line care facilities should of course not be detrimental to the comprehensive character of the service delivered. The purpose is not to divert available resources to serve a specific programme but to take advantage of the existing relations between a service and a community to widen the scope of responses provided locally. Health care in low income countries is increasingly thought of as a series of vertical programmes, so the need for access to regular health care is crucial, and specific programmes must strengthen general services rather than weaken them. Indeed, mental health programmes may improve first line care. Concerns for mental health are likely to promote listening skills, to foster patient centred care, and to broaden the professional identities of care providers, currently focused on biomedical issues. This could be an important step on the way to quality general practice adapted to social and cultural contexts.5
References
- 1.Thornicroft G, Maingay S. The global response to mental illness. BMJ. 2002;325:608–609. doi: 10.1136/bmj.325.7365.608. . (21 September.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Soc Sci Med. 1998;47:1781–1795. doi: 10.1016/s0277-9536(98)00240-8. [DOI] [PubMed] [Google Scholar]
- 3.Segall M. Human development challenges in health care reform. Studies in Health Services Organisation and Policy. 2000;16:7–17. [Google Scholar]
- 4. Van Balen H, Van Dormael M. Health service professionals and users. Int Soc Sci J 1999;313-26.
- 5.Unger J-P, Van Dormael M, Criel B, Van der Vennet J, De Munck P. A plea for an initiative to strengthen family medicine in public health care services of developing countries. Int J Health Serv. 2002;32:799–815. doi: 10.2190/FN20-AGDQ-GYCP-P8R6. [DOI] [PubMed] [Google Scholar]
