The Most Neglected Disease in Global Health

Neon Brain
Neon Brain
Flickr, by Dierk Schaefer

Is it Kala-azar black fever? Elephantiasis? African sleeping sickness? Guinea worm?

How about mental illness?

“Mental health is the Rodney Dangerfield of international health,” says Paul Bolton, an expert in evaluating treatments at Johns Hopkins University, paraphrasing the comedian’s signature line: “It gets no respect.”

But it should, Bolton says, if our goal is to improve lives rather than simply cure or prevent disease.

Hundreds of millions of people in the developing world suffer from emotional, neurological or behavioral disorders, according to the World Health Organization.

Okay, but we also have loads of people in poor countries dying from AIDS, malaria and TB — to name just a few — and you want to talk about depression?

Given the limited resources available for global health, we need to prioritize. Most of us consider mental health as too complex, too subjective or too scientifically squishy compared to the simple-yet-effective health interventions like vaccinating children, handing out bed nets or digging wells.

Surely, mental health can wait until we knock off the bigger problems.

Actually, Bolton and two of his colleagues from the University of Washington say it can’t — and needn’t.

“Depressed moms have a hard time taking care of their kids,” says Debra Kaysen, a clinical psychologist at the UW who works with Bolton in Iraq and, soon, in the Congo. Mental health is a necessary component of physical health, Kaysen says, and some common mental illnesses can be treated easily, quickly and cheaply.

More on that quick, easy, cheap — and successful — mental health therapy in a moment.

A Revelation: The Global Burden of Disease report

Bolton started out working as a “tropical medicine” doctor, studying infectious disease in Australia and then working with refugees on the Thai-Khmer border in the late 1980s. But he soon became frustrated treating and re-treating people whom he felt needed mental health treatment if they were ever going to make progress.

Paul Bolton
Johns Hopkins University

“Then I read this report that just laid out the hard data showing that mental health issues were huge contributors to disability worldwide,” recalls Bolton.

The report was the Global Burden of Disease, authored in 1990 by Alan Lopez and Chris Murray, the latter now director of the UW’s Institute for Health Metrics and Evaluation.

“That finding surprised a lot of people, including me,” says Bolton.

It also set him on a mission, of identifying the most effective methods for treating mentally ill people in poor and under-resourced communities.

Seattle Duo Test Trauma Treatment in Iraq, Tanzania and Congo.

Bolton is joined in his mission by two UW professors of clinical psychology who could not appear more different if they tried.

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Kaysen is a dark-haired, black-clad, self-described Goth (though she seems to laugh a lot for a Goth). Shannon Dorsey is a fair-haired, smartwool-clad, self-described “girlie” backpacker who retains a slight southern accent.

“We do look like an odd pair, that’s for sure,” laughed Debra Kaysen.

Debra Kaysen and alter ego
by Tom Paulson
Shannon Dorsey, usually outdoors
by Shannon Dorsey

But what binds them closely is their desire to help traumatized people heal themselves.

“There’s this idea that mental illness is difficult and always time-consuming to treat,” says Kaysen. That’s usually not the case, she says, when it comes to PTSD (post-traumatic stress disorder) — if treated correctly.

“Most therapists still use therapies that don’t work and most physicians prescribe medications that are actually contra-indicated,” says Kaysen.

Kaysen is a specialist in a highly effective — as well as quick and cheap — therapy for people with PTSD. Called Cognitive Processing Therapy, it’s an approach that was pioneered by her UW mentor, Patricia Resick, who now works on PTSD for the U.S. Department of Veterans Affairs in Boston.

“I started working mostly with female rape victims,” Kaysen says. With Bolton, she is now working with the Kurds in northern Iraq, people who lost family members or suffered injuries and abuse under Saddam Hussein.

Dorsey, who also works closely with PTSD expert Kate Whetten at Duke, uses a slightly different approach known as trauma-focused Cognitive Behavioral Therapy to work with children. She is focused on orphans in Tanzania (many of them parent-less due to AIDS) as well as sexually abused children in Cambodia.

“In Tanzania, we were asked to come in because the caregivers often don’t know how to help these kids,” Dorsey says. “They might now have access to HIV care, to medications or other forms of health care but they have almost no resources for getting mental health services.”

So what exactly is this cheap, easy and simple treatment for PTSD?

How do you heal the emotional wounds of torture, rape, of watching a loved one die? How could this possibly be done simply and easily?

Statue of Kurdish victim of torture
by Deb Kaysen

“It’s basically the Socratic method,” says Kaysen.

“When someone goes through a traumatic event, they have to make sense of what happened to them … Sometimes, the way people make sense of experiencing trauma is what is causing them post-traumatic stress.”

The woman who was raped believes she brought it on herself somehow. The young Kurdish man who joined the Peshmerga to resist Saddam believes he caused the death of his loved ones. The children who saw their parents die from AIDS believe, like most children, that it was somehow their fault.

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“People try to reassure them but it doesn’t work,” Kaysen says. “If it helped to tell rape victims it wasn’t their fault, we wouldn’t have any rape victims with PTSD.”

Basically, Kaysen and Dorsey explain, they help victims of trauma logically examine what happened to them through careful questioning. Why do you think you deserved to be tortured? Why do you think you are responsible for your parents’ deaths?

“With kids, you need to have a lot more game-playing to get through this, rewards for focusing and also some way for them to wind down,” says Dorsey.

She described a young Tanzanian girl who is HIV-positive and lost both parents to AIDS. To help her eventually come to grips with the need to talk about her fears, Dorsey said, the young girl came to accept the talk therapy as a necessary “bitter medicine” similar to what she must take to fend off AIDS.

So simple even I could do it.

I can’t describe in sufficient detail all of the stories Kaysen and Dorsey told me about their work trying to heal these traumatized people. But what was most amazing to me is that they are both teaching locals in Iraq and Tanzania how to do this work, often training people with little more than a high-school degree.

“This is actually very simple and easy to do,” says Kaysen, noting with exasperation that the treatment still remains little used for people with PTSD in the U.S. “It is so satisfying to see how quickly people respond to this, how quickly they get better.”

Bolton’s interest is in testing the effectiveness of these strategies.  He’s seeking evidence that they do restore people to a more functional life — and that the methods can be used and scaled-up even in poor communities lacking in health care personnel or infrastructure.

“I’m not really a mental health person,” Bolton says. “I’m interested in this because I’m interested in finding the best way to help people function. In some cases, the primary need will be clean water or educational improvements.”

“But in some places, it’s all about mental health.”

I came away from talking with these folks impressed by their dedication as well as by the evidence of need. Clearly, mental illness is a huge contributor to global instability and poor health.

But the Global Burden of Disease reported this two decades ago, and mental health remains perhaps global health’s most neglected disease. What’s going to change things now?

Maybe a nice, cheap and simple therapy that anyone can do.

What do you think?

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About Author

Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at]humanosphere.org or follow him on Twitter @tompaulson.

  • Terry Lawhead

    What an important avenue into a discussion about why bad things keep happening to good people, innocent people who absolutely do not deserve to be suffering but are in the wrong place–perhaps the inhabitants of an entire nation–at the wrong time. As a person who has been extremely lucky, repeatedly benefitting from the heroic acts of so many others and has only utterly trivial complaints that justifiably should be ignored, compared to the sorrows of the world, I should stop writing now. Since I am here adding a comment, I will go on only briefly. With so many critical issues demanding our attention, and the idea of the “Real Work” becoming so vast and challenging, your report on mental health problems, especially in the developing countries, lands like an asteroid in my basically risk free life. Not that I was completely unaware, but denial can flourish and fill all spaces, if allowed to do so. I hope I can better put my shoulder to the wheel in regards to this most neglected disease, but then again, cynicism and denial are powerful. As many have said, our only god is economics, and under economics there are winners and losers, and the winners and wanna-be winners have ever more powerful weapons. I don't know how far upstream one needs to go to have the realizations required to do sustained good work, but bless those who help traumatized people heal. And thanks for the writing, obviously part of the process…..

  • Amy Hagopian

    One of our failings in global health is that we are reluctant to take on complex problems that require multiple layers of intervention. But public health is all about the layers. Primary prevention (keep people from going crazy by preventing the rape or the torture or the war in the first place), Secondary prevention (immediate intervention to mitigate the harm the rape victim will suffer) and Tertiary prevention (long-term therapy to reduce the chance of multi-generational trauma). It's unfortunate when the policy makers can't devote enough time and attention to address all three layers. Thanks for this really great piece.

  • Ruthfrs

    Great article!! Great work!!! Great gals!!!