the discussions - who · mental disorders; to reduce the impact upon indi-viduals, the family, and...

Summary records of statements by Ministers

The discussions

This section contains summaries of the state-ments made by the Ministers of Health par-ticipating in the round table discussions.The

statements appear in alphabetical order accordingto country and regroup the participants of all fourround tables.

Angola

Dr Hamukwaya described how the mental healthsituation in her country had been aggravated byinternal conflict and its consequences. Political,social and economic stability and prosperity wereessential to bring about improvements. She empha-sized the importance of promoting healthylifestyles and adopting psychosocial rehabilitationmeasures as part of a national policy to improvethe mental and physical health of the Angolan peo-ple. She also reaffirmed her country’s intention tofight marginalization and social exclusion by associ-ating its efforts with initiatives taken by WHO topromote mental health.

Argentina

Dr Lombardo traced the history of mental healthcare in his country from its origins in the 19th cen-tury, including the establishment in 1957 of theNational Mental Health Institute, which hadendorsed the approach of treating mental healthdisorders as health problems and not diseases.Nevertheless, developments in lifestyles, includingthe emergence of “modern” problems such as stresshad led to the increased incidence of serious men-tal disorders.The treatment of such disorders haddeveloped in parallel on an interdisciplinary andintersectoral basis, with recognition of the funda-mental importance of community participation inhealth matters. Argentina currently had a highnumber of mental health specialists, comparable tothe numbers in the most developed countries.Progress had also been made in the treatment ofmental disorders with the emergence of new drugsin the second half of the twentieth century, whilethe development of new outpatient services hadhelped persons with mental disorders to avoidsocial marginalization and stigmatization. In thatrespect, he emphasized that the isolation of manyadults in modern society was a basic reason for thedevelopment of mental health disorders.

Legislation placing emphasis on promotion andprevention was currently being adopted at variouslevels in Argentina. A National Primary MentalHealth Care Act, the principal focus of which wason prevention, had recently been adopted and hadbeen accompanied by legislation covering thetreatment of various conditions related to mentalhealth disorders. Similar legislative measures werealso being adopted by the provinces.The mentalhealth policy had been incorporated into thenational health policy emphasizing the promotionof healthy lifestyles and including the prevention ofsubstance abuse, and the development of a nationalprogramme to prevent depression and detect pos-sible cases of suicide at an early date.The basic ele-ments of the treatment of mental health disorderswere: the elimination of stigmatization; the organi-zation of multidisciplinary health services coveringprevention, health promotion, care and rehabilita-tion; and the social reintegration of patients.Gender was another fundamental aspect of mentalhealth problems, since more women than men suf-fered from mental health disorders. Attentiontherefore needed to be paid to problems of genderdiscrimination in modern societies. Finally, it wasnecessary to identify the socioeconomic elementsthat led to the development of mental disorders,including poverty and marginalization. Mentalhealth patients needed immediate reintegrationand assistance to promote their participation in thelife of the community. He welcomed the initiativetaken by WHO on one of the major health prob-lems of the coming years.

Australia

Professor Mathews said that the rapid pace ofsocial change, economic pressures, war and popu-lation movements and other factors had con-tributed to difficulties in recognizing and providingadequate support for mental health problems.Thatsocial change had also been accompanied by theloss of traditional family support in many coun-tries.Transitional societies, such as indigenousAustralians, were having difficulty with socialadjustment, and they and other vulnerable groupswere likely to suffer from drug and alcohol prob-lems, and problems related to violence and suicide,which Australia, like other countries, was takingvery seriously.

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Stigmatization was still a problem, and newapproaches to the philosophy of care and treatmentwere needed.The Australian National MentalHealth Strategy sought to promote the mentalhealth of the Australian community and to preventthe development of mental health problems andmental disorders; to reduce the impact upon indi-viduals, the family, and the community; and to pro-tect the rights of people with mental illness.

Particular emphasis had been placed on reducingstigmatization through programmes targeted atschools to increase awareness and understanding ofmental health problems, engaging with the mediato promote community understanding, and work-ing with community groups, as well as the profes-sional health sector, to promote acceptance.Australia had underpinned its work with legislativeprotection of the rights of people with mental ill-ness and had developed community plans for men-tal health support involving specialist care and aninterdisciplinary focus. Australia’s commitment topromotion and prevention had engaged theCommonwealth and state Governments and com-munity organizations, as well as stakeholdergroups, patient groups, and also the private sector.Australia fully supported the WHO mental healthinitiative and was committed to an interdiscipli-nary focus with a view to reducing stigmatizationand recognizing co-morbidities, emphasizing men-tal health promotion and prevention and rehabilita-tion.

Austria

Professor Waneck said that WHO had successfullydrawn public attention to mental health problems,which were often underestimated and misunder-stood. Great progress had recently been made inthe field of psychiatry and yet psychiatric disordersin the industrialized countries were increasing. Anew consciousness had emerged, evidenced by theburgeoning number of self-help groups, as a resultof which most people with mental illnesses wereliving within the community, able to make theirown life choices. At the global level, however,much remained to be done.The Austrian healthauthorities vigorously pursued the WHO-advocat-ed policy aimed at ending the exclusion of thementally ill, particularly in the field of hospitalpsychiatric services, which had been decentralized

and integrated, thus representing an importantstep forward in destigmatizing psychiatric disor-ders and those suffering from them. Self-helpgroups also played an instrumental role in theefforts to destigmatize psychiatric illness, as theyprovided vital back-up to the policy already inplace.

To strengthen the Austrian mental health policy, acountrywide survey of mental health provision hadbeen commissioned, bringing together, for the firsttime, data on psychiatric and psychosocial care forthe benefit of the mentally ill, their families andthose professionally concerned. Projects would beanalysed and additional measures adopted in thelight of the data produced by the survey, the sec-ond part of which was due at the end of 2001.Other important future objectives included thesatisfaction of needs, the integration of basic care,quality assurance and the participation of patientsand their relatives, care professionals, administra-tors and politicians. In conclusion, he hoped thatthe national and international efforts undertakenwould improve the information available in thefield of psychiatric care and that the stigmaattached to psychiatric illness would diminish tothe point where such health problems could beopenly discussed without taboo.

Bahamas

Dr Knowles said that he had taken comfort fromthe realization that most countries had problemssimilar to those in his own country but was sad tohear that solutions were hard to come by, regard-less of the size of a country’s gross domesticproduct.

The Bahamas, was a country of scattered popula-tions, which hindered service delivery. In additionto the country’s usual array of mental health prob-lems, it had suffered from being directly situatedbetween the major cocaine-producing LatinAmerican countries and the United States ofAmerica.The crack and cocaine epidemic of the1980s had been closely followed by the AIDS epi-demic and an upsurge in violent crime.

The Bahamas had recently reviewed its mentalhealth services and was revising its mental healthplan correspondingly. His country would welcomedirection in its efforts to provide sufficient num-

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bers of mental health workers, especially psychia-trists.That was not seen as a glamorous profession,nor did graduate nurses want to specialize in psy-chiatric care. He also asked for advice on the careof mentally ill patients in prisons, where the neces-sary psychiatric services were not available, and onthe multidisciplinary care of mentally ill adoles-cents.

Belarus

Dr Zelenkevich said that it was time to bring theproblem of mental illness out into the open. Oneof the principal challenges was how to ensure thatsuch illness was allocated its proper share of thescarce resources available, and to that end, it wasimportant to include mental health in all healthplans and policies and to involve general practi-tioners.The change-over from institutionalizedforms of care to care in the community, as well asthe increase in the number of specialists in mentalhealth being trained in medical schools, wouldcontribute to a more efficient use of resources.Greater efficiencies could also be achieved bymobilizing other sectors to assist the health sectorand by pooling resources. Nongovernmentalorganizations also had an important contributionto make.

Belgium

Mrs Aelvoet said that in her country, as in others,there had been an increasing demand for mentalhealth treatment, despite a substantial economicupsurge, which indicated that wealth per se was nosolution. Furthermore, stigmatization was stillwidespread; people with mental disorders weretreated differently from those with physical illness-es and tended to be regarded as abnormal. Duringthe past 25 years, there had been a trend towardsencouraging patients to stay in their home environ-ment, thereby enabling them to continue to workand function as usual.That had been achieved bythe development of first-level care, home supportservices and home visits by doctors, in addition tooutpatient and institutional care.

In 2001, a 10% increase in the health budget hadbeen agreed, constituting the largest increase forany government department.The concept had

been accepted that chronically ill patients, includ-ing those with mental disorders, should receivefinancial and institutional support. A system hadalso been developed to place a ceiling on theamount each patient should pay in any one year,anything over and above that amount being coveredby a reimbursement system, taking into accountpersonal socioeconomic circumstances.

In connection with gender specificity, it had beenestablished that women were more dependent onlegal drugs, whereas men tended to be dependenton alcohol. For issues of national importance, ithad been stipulated that at least one-third of themembers of all national committees should bewomen, including those concerning health.

Benin

Professor Ahyi observed that his country, likemany others, had been slow in responding to men-tal illnesses, in part because of the belief, commonin Africa, that they could be treated by traditionalmedicine.The recognition that many conditionsdid not respond to such treatment had forced anew approach and helped to raise mental health toone of the six top health priorities for Benin.Withsupport from WHO the country had begun coop-eration with Ghana and Mozambique on issues ofhealth promotion, but that concept had rapidly ledto issues of well-being and quality of life. A smallnational coordinating team had soon discoveredthat “health problems” were viewed in a prejudiciallight, there being a major general confusion aboutillness and health: as soon as one talked abouthealth promotion, that raised images of illness.Similarly, health centres and dispensaries were seenas focused on disease rather than on health. A con-clusion was that, in Benin, the training of healthcare workers needed to be revised to correct thosemisperceptions. In the past two years there hadbeen a move to educate the public at communitylevel, for example by encouraging communicationbetween generations. For instance, in one village abench had been placed by a communal path,enabling older people to come out of their homesand be more integrated into community life.People stopped and talked, and perceptions andattitudes soon changed.


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With regard to medicines, even generic drugswere rare in Benin. Moreover, those psychotropicdrugs that featured on the essential drugs list werenot ordered because the population was poor andthe demand for such drugs was considered to besmall. Further, the Bamako Initiative encouragedcost recovery. After the introduction of the healthpromotion policy, there had been a reduction inthe number of patients and the rate of cost recov-ery had also declined. A contradiction becameapparent: people preferred to have more patientsso that there would be sufficient funds to maintainthe existing system of health rather than reducingthe number of patients. Health promotion hadmeant social mobilization in order to reduce costs.A further important point was the culture ofhealth, not disease – and mental health was a casein point.The conclusion reached was that therewas no development without health and no healthwithout mental health. Mental health was the por-tal of entry for the development of developingcountries.With democratization came decentral-ization, but that had posed various problems. Forexample, social mobilization had resulted in themultiplication of demands for the expansion ofservices based on the successes of pilot projectswith the incorporation of mental health into pri-mary health care.

Bolivia

Dr Cuentas-Yáñez observed that mental healthprogrammes, whether against familial violence oralcoholism or for the administration of psychiatrichospitals, were based on a predominantly clinicalvision. He advocated a more cultural approach tomental health, and recalled that Bolivia had beenpart of the Inca empire. At that time, some 400years ago, itinerant “doctors” (cayaguayos) had dis-pensed basic mental health care. He argued thatevery mental health programme should take cog-nizance of the cultural heritage as well as of theepidemiological profile and the impact of poverty.The prevalence and incidence of mental illnesseswere known to be associated with social groups;alcoholism was closely linked with intrafamilialviolence, both of which were synonymous with themechanisms of desperation during economic diffi-culties. Culture differentiated mental health fromother health programmes, and people’s perceptions

and cultural background needed to be accommo-dated.

Bosnia and Herzegovina

Mr Misanovic said that stigmatization was animportant issue in Bosnia and Herzegovina.Thestigma arose from the subconscious fear that any-one could fall victim, permanently or temporarily,to mental ill-health. Bosnia and Herzegovina was apost-traumatic society in transition. Half the popu-lation suffered from war or stress-related psychi-atric disorders; the other half had dealt with theproblem by referring to the sufferers as “broken”people, partly out of fear that psychological traumacould be passed on to the next generation. It wasdifficult to fight stigmatization in post-traumaticsocieties because stigma was used to deny people’srights. Bosnia and Herzegovina needed a very dif-ferent procedure for eradicating the problem ofstigmatization. It needed extremely clear recom-mendations not only on how to eliminate stigma,but also on how to promote mental health and pre-vent mental disorders.

Botswana

Ms Phumaphi said that steps similar to thosedescribed by other speakers had been taken byBotswana in relation to patient integration, the set-ting up of community hospitals, and campaigns toreduce the stigma associated with mental illness.Two issues were of particular importance. First, itwas essential to recognize that mental illness was ahuman problem as well as a medical problem, andto develop programmes aimed at particular socialand economic groups.The power of peer groupscould be harnessed to promote mental well-being.Secondly, her country attached importance to earlyintervention, which was a critical element inimplementing mental health policies. She agreedthat there was a need for research into mental ill-ness and into the links between mental and physi-cal health.

In Botswana, stigmatization corresponded to fearof those with mental illnesses.That was perhapsbecause their loss of control of their lives was asso-ciated in the minds of others with disruption totheir lives.The response to the four questions


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raised by their Chairman could be summed up inthree words: information, education, communica-tion. Botswana had medical-aid societies that didnot provide adequate care for the mentally illbecause of stigma; there was a high unemploymentrate among the mentally ill because employers didnot want to hire them; and insurance payments hadbeen denied to the families of mentally ill patientswho had committed suicide.

Consideration also had to be given to the plight ofthose who already had special needs in addition tosuffering from the stigma of mental ill-health, forexample, children in difficult circumstances,women, refugees and migrants, the elderly, conflictsurvivors, prisoners, and young people engaged insubstance abuse.Those groups’ needs should beaccommodated in appropriate legislation. It wasalso vital that patients be properly managed; to doso entailed removing stigma among health careworkers. Consideration should be given to ways ofcountering the results of stigmatization by legisla-tive means, such as regulations governing patientmanagement that would help to eliminate stigmati-zation among health care workers.

Brazil

Dr Yunes said that mental health was one of hisGovernment’s main priorities. Historically, it hadbeen given a low priority despite the fact thatmental disorders represented a heavy burden onthe quality of life of patients and their families, aswell as on the economy. In Brazil, as in many othercountries, hospital-based care was still predomi-nant, swallowing up most of the financial, technicaland human resources available and limiting accessto treatment.There was a need for strategies toenhance primary and community-based care.

A reform had been launched in the early 1990saiming to decentralize the mental health care sys-tem and to redistribute resources from hospitals tocommunity-based services; to disseminate infor-mation on the effectiveness of new models oftreatment on patient rights and on the importanceof combating stigma and discrimination; and todesign and implement broad-based programmesfor the social reintegration of long-term patients.The obstacles to the implementation of communi-ty-based mental health services in Brazil were the

lack of trained health professionals, including gen-eral practitioners who could act as psychiatrists inremote areas, and the insufficient availability ofdrugs. His Government had introduced a pro-gramme to finance basic kits of psychiatric drugsfor distribution, free of charge, at outpatient clin-ics, but since outpatient services were still insuffi-cient the drugs were not yet reaching all thosewho needed them.

It had also addressed stigmatization and humanrights problems by conducting regular inspectionsof psychiatric hospitals. Legislation had beenadopted to protect the rights of mental patientsand to promote their social integration, and servic-es had been introduced to support women living inviolent domestic environments.

Brunei Darussalam

Mr Matnor noted that WHO had not paid mentalhealth the same attention as it had to other issues,and therefore needed to organize activities to pro-mote awareness. In many countries, developmentsin the approach to mental health were guided bythe outcome of discussions on the issue at interna-tional and regional forums. In his country, closedmental clinics within hospitals had been replaced in1982 by a single specialist hospital providing out-patient care and counselling, and steps had beentaken to decentralize primary health care so that itcould be provided at community level. Brunei wasable to provide free medical care and drugsbecause of its small population and land area.

One of the country’s approaches to the problem ofstigmatization of mental illness had been to changecertain names. For example, the term “ward 5”commonly associated with mental problems, andhence “bad” people, had been replaced by “psychi-atric ward”, and the new hospital had comfortablerooms instead of the cages and bars formerly usedto hold mentally ill patients.The Lunatic Law hadbeen renamed the Psychiatric Act.The word “men-tal” was no longer used; the terms “stress” or “lightdepression” were more acceptable to young peopleand made them more willing to come forward fortreatment. Because those identified as having men-tal problems often lost their jobs, the Governmentprovided allowances to encourage them to undergotreatment. Brunei’s main problem was how to


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encourage the formation of a nongovernmentalorganization to care for the mentally ill.The stigmaattached to mental disease was apparently still toohigh for that to come about.

Burkina Faso

Mr Tapsoba described the evolution of mentalhealth care in his country, which included decen-tralizing the health system and incorporating men-tal health care into the responsibilities of districtlevel structures. Lack of coordination had resultedin a lack of adequate supervision, insufficient epi-demiological data, lack of enough properly trainedstaff, insufficient financial and material resourcesfor mental health services, and inequitable accessto medicines owing to the slow introduction ofcheaper generic psychotropic drugs. A nationalmental health programme had been formulated tomeet the main areas of concern and would beimplemented, despite financing problems, as partof the national development plan which extendedto 2010.

In regard to gender issues, he drew attention to aparticular problem in Burkina Faso, that of a cate-gory of woman known as the “devourer of souls”.These women, because they lived alone, were wid-ows or had no resources, were often driven out oftheir villages although healthy in mind and bodybecause they were alleged to be the cause of mys-terious deaths. Eventually they either committedsuicide, disappeared into the bush or suffered men-tal health problems. Only women – never men –were so accused.The public authorities and reli-gious associations were aware of the problem butdid not have enough resources to provide adequatesupport. He appealed for help from WHO.

Canada

Mr Rock, welcoming the exchange of views oncommon problems, said that his country’s experi-ence was similar to that described by previousspeakers.The Canadian Government had recog-nized the importance of integrating mental healthinto primary health care systems and had recentlyfunded a pilot project to make mental health serv-ices available within the community. As almost20% of primary health care patients presented

with mental health problems, it had been consid-ered important to ensure that the training of healthprofessionals included the identification, recogni-tion and treatment of such problems.The impor-tance of early intervention in children to preventmore complex difficulties later on could not beoveremphasized. Disease prevention was given highpriority in Canada, and the development of anational approach towards early childhood devel-opment was encouraged.Thus, a “children’s agen-da” had been created, covering prenatal nutritionfor young mothers, programmes focusing on thecrucial years of brain development between birthand the age of three years, early identification ofsigns of emotional maladjustment, and emphasis onthe prevention of foetal alcohol syndrome anddefects that limited personal development and ledto social cost and disruption in later life.

Many of Canada’s communities, especially those ofindigenous peoples, were rural and remote andexperienced harsh winter weather. Increasing andsuccessful use had been made there of moderninformation and communication techniques, suchas telemedicine, teleradiology and telepsychiatry.Rather than being a barrier to the personal rela-tionship between therapist and patient, the tele-vised connection appeared to facilitate full partici-pation in the consultation.

A new approach to the organization, coordinationand financing of health research, including mentalhealth, had been adopted with the creation of vir-tual mental health research institutes consisting ofnetworks of researchers. One such institute wasdevoted to mental health and involved researchersin clinical and biomedical fields, the provision ofservices, and population health and health determi-nants. By bringing those four perspectives togetherand substantially increasing the level of financing,Canada’s research enterprise was more effectiveand better use was made of its research funds.Investment in mental health was being increased toreflect more appropriately the importance attachedto that area in the health system. Canada would behosting the World Assembly for Mental Health inJuly 2001, bringing together people from aroundthe world with valuable perspectives and insightsinto the ways in which national health systemscould better organize, coordinate and deliver serv-ices for mental health, and he encouraged theinvolvement of all Ministers present.


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Chad

Mrs Kimto recalled that her country had sufferedmany years of civil war. Added to that was a diffi-cult economic situation and the fact that healthcoverage reached only 11% of the population.Theneed for mental health care was enormous, forinstance, for children, people with HIV/AIDS, warwidows, alcoholics, prisoners and refugees.Furthermore, mental disorders were traditionallyconsidered as deriving from evil spirits or curses.At the time of independence in 1970 the countryhad one asylum in the capital, where patients wereshut away and made the objects of curiosity andmockery.The building had been destroyed in thecivil war. Currently the psychiatric unit of themain national hospital acted as a referral centreand provided an open service with care and treat-ment.The Government accorded mental health atop priority.The national programme of mentalhealth had organized a consensus workshop in1999 which had helped to identify the current situ-ation, priority areas, strategies, interventions,funding and the main actors.To achieve socialmobilization in favour of mental health issues, theMinistry of Public Health had involved traditionaland religious authorities in the programme.Thenumber of associations concerned with mentalhealth had grown and were linked in a network.Every year a mental health day was celebrated on10 October in order to mobilize public opinionand to raise awareness of the need to prioritizemental health, particularly as Chad was in a post-war situation.WHO’s World Health Day offered agood opportunity to undertake additional activi-ties, for instance in communities and schools,including the use of mass media. A community,multidisciplinary approach was considered to bethe most logical.Within the ministry an intersec-toral, interministerial committee for mental healthhad been created, charged with the task of creatinga coordinated mental health programme coveringcare, social reinsertion, awareness and informa-tion, and advocacy at the highest levels.The majorrole of traditional medicine in Chad justified coop-eration with relevant structures and bodies.

Legislation enacted on mental health had beeneffective, but practical difficulties remained.Qualified staff, psychotropic drugs, infrastructureand funds were all lacking.The Government aimed

to strengthen the national programmes for thepromotion of mental health, to formulate a nation-al plan for the distribution of drugs and to createreferral centres. A new centre was being built inN’Djamena.The Government was also integratingmental health into the health activities of districthealth authorities.

Chile

Dr López stressed that close alliances between allthose involved in treating and caring for peoplewith mental illness, including their families, wereneeded in order to raise the profile of mentalhealth and attract more resources. For the past 10years, Chile had therefore been promoting theestablishment of such groups at national andregional levels.The initiative had been accompa-nied by efforts to raise general awareness of thepublic health implications of mental health disor-ders and to improve the ability of local health serv-ices to respond to the problem. Chile had benefit-ed from access to national and international epi-demiological research studies that had enabled thescientific community and health professionals todevelop better treatment and prevention strate-gies. As a result of its greater visibility, mentalhealth was now regarded as an important compo-nent in Chile’s health reform programme.

The public sector had an important role to play inensuring that psychiatric treatment was made avail-able at the primary health care level to people withfew resources. Indeed, the population should haveaccess to the specialized services they requiredregardless of their ability to pay.

In addition to the type of mental health disordersprevalent in developing countries, Chile also hadto contend with those associated with more devel-oped countries, such as schizophrenia and bipolardisorders.Treating them was proving to be a con-siderable challenge and had led to the establish-ment of outpatient clinics and specialist units ingeneral hospitals.

Depression was a major cause for concern, partic-ularly among women. A programme designed todetect and treat depression was being developed atthe primary health care level and 40% of generalmedical practices currently provided access to apsychologist. In addition, the new generation of


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safer antidepressants was being made more widelyavailable. Alcohol and drug dependence constitutedanother serious mental health problem which Chilewas confronting through the development of a sys-tem to provide treatment to those in need withsupport from non-profit organizations. Othermajor areas of concern, about which more infor-mation was urgently required, included the mentalhealth of schoolchildren and indigenous people,and work-related mental health problems.

In 2000, Chile had launched a national mentalhealth plan, and additional resources had beenmade available that would increase the proportionof the total health budget allocated to mentalhealth by between 1% and 1.4% in the first year.

China

Dr Peng Yu described how the transition to a mar-ket economy in China had been accompanied by anupsurge in mental health problems; for instance,mental disorders were the single most importantfactor in university student drop-out rates.Whilerecognizing the need to adapt its policies and activ-ities to reflect the new health situation, theGovernment had insufficient numbers of healthprofessionals with adequate training in the diagno-sis and treatment of mental disease. AlthoughChina had sufficient supplies of domestic andimported psychotropic medicines, limited funds inremote areas restricted the access of farmers andagricultural workers to the drugs they needed.TheGovernment was focusing its efforts on providingbasic and community-based training, delivered, inthe case of remote areas, through the use oftelecommunications.

In the 1990s, China had launched a programmeaimed at assuring the rehabilitation of some 200million persons and providing training in mentalhealth for primary health care physicians. Its cur-rent goal was to reach as many as 400 million peo-ple nationwide, drawing on the help of WHO,among others, in order to launch pilot projects andhonour its commitment to promoting mentalhealth.

Croatia

Dr Gilic recalled that, more than 50 years previous-ly, his countryman Dr Andrija Tampar, one of thefounders of WHO, had proposed the inclusion ofmental health among other components in the def-inition of health for the WHO Constitution.

Socioeconomic conditions were a prerequisite formental health and welfare, as the example ofCroatia illustrated. One in six of Croatia’s popula-tion had been displaced during the recent war.Wardamage had also had a dramatic effect upon pro-ductivity and unemployment, and had causedpoverty and related mental health disorders.Although the new Government was addressing theongoing effects of the war, in 1999, three out ofevery five cases of illness were associated withmental disorders, such as schizophrenia, alco-holism, and reaction to stress.The Croatian healthauthorities were giving effect to WHO recommen-dations such as the transfer of patients sufferingmental disorders from hospitals to primary healthcare, the focus on community-based mental healthcare, emphasis upon training of mental health careworkers, and seeking to prevent stigmatization anddiscrimination against mental health patients, so asto enable them to participate to the fullest possibleextent in the life of the community.

In conclusion, with improving social and economicconditions in Croatia, a reduction in mental disor-ders was to be expected in the near future.

Cuba

Dr Dotres Martínez stressed the importance ofproviding adequate care to all patients with mentaldisorders and of considering mental health fromthe point of view of both health services and suchsocial factors as poverty, inequity, violence andother risk factors.

In Cuba, where health care was universally provid-ed free of charge, priority was given to mentalhealth.The trends since 1995 had been towardscommunity-based care mediated through trainingand education of families to enable them to livewith sufferers.Thus, 137 municipalities had estab-lished community mental health centres.Work wasunder way to restructure psychiatric hospitals and


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redefine their mission and functions both from theviewpoint of increasing primary health care cover-age and of focusing attention on mental health.

Improvements had been made in information sys-tems and in the identification of indicators to eval-uate the impact of mental health measures.Theidentification of risk factors played a fundamentalrole in community-based care of patients withmental disorders and should be addressed as partof a preventive strategy that included family mem-bers and the community. In Cuba, the shift towardsmental health had been carried out by trainingdoctors, nurses and specialists at all levels.Thecountry had a large number of psychiatrists provid-ing care to adults and children, while mental healthconcepts had been incorporated into training ofprimary health care physicians and family healthspecialists.

The participation of communities and of communi-ty organizations in providing services and rehabili-tation to patients was vital for the management ofrisk factors, and ensuring that the goals set couldbe achieved in a sustainable manner.

Legislation was important: public health law, thefamily code and even the criminal code shouldinclude provisions to protect psychiatric patientsand all disabled persons.Those persons should beguaranteed social benefits, opportunities to partici-pate in society and to gain access to employmentand education, and thus to avail themselves of anintegrated system of care. In that regard, one ofCuba’s greatest difficulties was that the economicembargo imposed on it by the United States ofAmerica restricted access by patients to the psy-chotropic drugs they needed. In spite of the diffi-culties, Cuba remained committed to communityparticipation and health education as the bestmeans of reducing the incidence of mental disor-ders.

Cyprus

Mr Savvides said that since the 1980s Cyprus hadshifted the emphasis of its national policy awayfrom outmoded mental asylums, characterized bystigmatization of the disease and violation ofpatients’ human rights, to community-based serv-ices and the integration of mental health care intoprimary health care. Most patients were now

released into half-way houses or hostels and totheir families, and only the oldest and most institu-tionalized of patients remained in the old-styleinstitutions.

Among the measures introduced in the context ofcare in the community were the retraining of psy-chiatric nurses and establishment of communitypsychiatric services; the deployment of multidisci-plinary teams at the community level; and collabo-ration with nongovernmental organizations andlocal authorities in setting up various centres, clin-ics, and types of accommodation. Although muchhad been achieved, significant problems remained,including a shortage of trained personnel, poorcoordination with social services, inadequate cov-erage in rural areas, inadequate training of primaryhealth care workers and poor information andcommunication systems.

Among the most important actions taken byCyprus to counter stigmatization and human rightsviolations was the enactment of a law in 1997 forthe provision of psychiatric treatment, whichincorporated the 10 principles recommended byWHO.The media had been enlisted to draw atten-tion to mental health issues, making patients morevisible, emphasizing the availability of successfultreatment and providing information and educationto professionals and the public at large.The factthat World Health Day 2001 had been devoted tomental health had offered an opportunity to inten-sify efforts in that domain.

Since knowledge of the extent of mental illnessand neurological problems in Cyprus was poor, anepidemiological study would be conducted in 2002and the results would be used to direct policy.Future measures would include more training ofprofessionals, greater multisectoral cooperation,public education, research and the removal of allbarriers that prevented the full reintegration ofpatients into society.

Czech Republic

Professor Fise welcomed the round-table discus-sion, particularly since psychological and psychi-atric disorders were increasing in importance in hiscountry.The highest prevalence rates were for neu-rotic disorders, affective disorders and schizophre-nia.The number of suicides of men in the Czech


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Republic was also increasing, while the suicide rateof women was decreasing. Although higher thanthe average in the European Union, the suicide rateof 15.5 per 100 000 population in his country wassignificantly lower than, for example, the countriesof the former Soviet Union.

One of the most serious problems faced by hiscountry in the field of mental health was the short-age of specialists in psychiatry; more were beingtrained in psychiatry, psychology and psychothera-py, although problems persisted in financing thattraining, and that of general practitioners and nurs-es in modern aspects of psychology and psy-chotherapy. Psychiatric patients were traditionallylocated in specialized institutions, which were veryfrequently isolated and oriented towards the long-term, and sometimes lifelong hospitalization ofpatients, thus underlining the segregation of thementally ill and contributing to discriminationagainst both the discipline of psychiatry and againstthe patients themselves. In recent years, the num-ber of places in institutions for the mentally ill hadbeen increased by one-third. It was planned toorganize psychiatry departments as sections oflarge hospitals, with modern equipment, designedfor short stays with intensive diagnostics and treat-ment, to be followed by outpatient care. It wouldalso be necessary to organize a system of care forchronic alcoholics and persons affected by otherkinds of addiction. However, the necessary meas-ures would require substantial funding.

Finally, he welcomed the possibility of cooperating,through his country’s Research Institute ofPsychiatry and the Society of Psychiatry, withWHO and its office for Europe in the field ofmental health.

Democratic Republic of the Congo

Professor Mashako Mamba said that mentalhealth problems in his country had been neglectedbecause of the prevalence of major factors affectingphysical health, notably infectious and parasitic dis-eases. Such neglect also stemmed from the Africanbelief that more emphasis should be given to con-crete than to abstract health problems.The warthat his country was experiencing, which had dis-placed and killed many people and split up fami-

lies, had resulted in various kinds of depression andstress caused by psychological trauma. Anothermajor problem was the abuse of psychoactive sub-stances, particularly cannabis.

Faced with a lack of mental health institutions andspecialized human resources, his Government haddecided to integrate mental health into primaryhealth care, although such integration raised theproblem of adequate training.The community-based health care system reduced the risk ofpatient rejection or stigmatization, but treatmentoften required the prescription of psychotropicdrugs, whose high cost placed them beyond thereach of most patients. In that respect, he appealedfor a North-South partnership so that his country’srequirements for such drugs could be met.

Denmark

Mr Rolighed said that, in his country, all personshad free and equitable access to the health systemirrespective of sex, age, social status and the prob-lem from which they suffered. It was important toensure that mentally ill patients were given appro-priate treatment, and to that end the Danish med-ical authorities worked closely with research, edu-cation and quality assurance programmes.

Dominican Republic

Mrs Caba described how the traditional barriers toimproving mental health in her country, such asattitudes of health workers and managers towardspeople with mental disorders, remainedunchanged.The formulation of mental health serv-ices was thus restricted, particularly in generalhospitals. Integration of mental health into primaryhealth care needed money and time, the high costof drugs forming part of the problem. As part ofhealth sector reform, the Government was work-ing on a subsystem of mental health care withcommunity and nongovernmental organizations inorder to strengthen the provision of services at dif-ferent levels.

The theme of World Health Day 2001 had provid-ed a unique opportunity to enlist allies in theprocess of improving mental health care. A cam-paign had been launched to strengthen the humanrights of people with mental disorders, and to try


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to improve the way they were treated. Its targetsincluded people in the business sector and theworkplace, where issues such as alcohol abuse andstress needed to be addressed. In addition hercountry was working to improve its present inade-quate system of monitoring and record-keeping.Coverage of primary mental health care needed tobe improved, too. Although for some 22 yearsthere had been good results with community-basedmental health care, the network was concentratedin the capital. Crisis care centres were urgentlyneeded in hospitals, but that development had beenthwarted by the resistance of health care person-nel, often hospital administrators.The lack of a cri-sis intervention unit for children and young peoplepresented a serious gap in the system.Rehabilitation and social reinsertion programmeswere also needed.

With regard to gender issues, progress had beenmade through work with nongovernmental organi-zations, other ministries such as those for women’saffairs, the judiciary, and in particular the police.Campaigns had been run on prevention of anddealing with violence in the family, and “solidaritynetworks” for women had been establishedthroughout the capital and in some other cities.The Government was trying to re-educate healthpersonnel to have a more positive attitude to men-tal health care. In the education sector, consider-able support in the early detection of the effects ofdomestic violence came from teachers.The currentfocus was on violence against women, children andyoung people, together with ensuring routinescreening for risk factors of domestic violence.Refuges for the victims of such violence wereplanned.

Ecuador

Dr Jandriska drew attention to four issues associ-ated with mental health problems in his country:the fact that Ecuador was located in a high-risk dis-aster area; the number of persons displaced as aresult of the “Plan Colombia” strategy; the highlevels of migration away from families in order tofind work; and the level of political instability. Itwas important to analyse mental health in relationto society.To that end, his Ministry had set up aseries of mobile units in poor areas from whichwage earners were often forced to migrate and a

psychologist had been attached to each unit toanalyse the resulting community problems.

Since 1994, there had been greater awareness ofmental health in Ecuador, and it was hoped that thedraft legislation developed in that regard wouldenter into force as soon as possible. Ecuador faceda wide range of mental health disorders withprevalence of alcohol misuse particularly high inyoung people. A multifaceted approach was neededto ascertain the causes of substance misuse and vio-lence, in particular violence directed at women.Ecuador and a neighbouring country planned todevelop joint legislation on psychotropic sub-stances.

Affirming the need to pay attention to indigenouspopulations, he said that his Government was tak-ing steps to provide those in Ecuador with healthcare services of good quality based on local needs.

Egypt

Professor Sallam emphasized the importance ofdifferentiating between mental health and addic-tion and between mental illness in children andcriminals. Prevention of mental illness and rehabil-itation were not high priorities in developing coun-tries. Egypt had undertaken a major reform in thatregard, and a Presidential Decree had been issuedto the effect that, while psychiatric hospitals werestill needed, the system should be reformed. Manyspeakers had advocated incorporating mentalhealth care into primary health care; could WHOestablish an agenda for that, according to the dif-ferent countries’ needs?

There was an urgent need in developing countriesto act promptly against early addiction.Waysshould be sought of “immunizing” children againstaddiction with a service set up for people at highrisk and for first-time users. Countries like hiswould greatly benefit from assistance from interna-tional donors for prevention of addiction and reha-bilitation.Therapeutic measures such as music andagriculture could be helpful in transforming psy-chiatric hospitals into rehabilitation centres.Similar treatments could be applied to violentbehaviours.That problem, linked to psychologicaldepression, was affecting the entire world. Hewould welcome the introduction of a social com-ponent into mental health strategies. As things


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stood, sufferers were often ignored by their rela-tives and friends; a change in attitude was the firststep towards improvement.

Fiji

Mr Nacuva noted the need to consider mentalhealth problems in the specific context of each par-ticular country, taking into account changes such asthe moves from colonial status to independenceand from traditional societies to cash economies. InFiji, the health budget was small and it was difficultto find the funds for mental health services.However, the sense of responsibility for caring forothers was strong and it had therefore been possi-ble to build on community involvement.TheMinistry of Health had opted for a multisectoralapproach involving all aspects of civil society in thepromotion of mental health and the prevention ofmental disorders. Fiji had one specialized psychi-atric hospital.The emphasis on community-basedservices and vigorous clinical management had ledto a dramatic decrease in the bed occupancy rateand length of stay despite an increase in the num-ber of new cases. Relevant legislation was alsobeing reviewed. It was vital to change social atti-tudes to mental health care and Fiji was addressingthe problem in its own particular context and inspite of budgetary constraints.

Finland

Dr Eskola noted that WHO had been active in themental health area since the 1970s. Although men-tal health had received a lower priority in the1980s, it was a cause for satisfaction that greateremphasis was now being placed on it. As theFinnish approach to mental health was very similarto that described for Sweden, he focused on thereduction of the specific problems of suicide anddepression in his country, areas in which consider-able success had been achieved.

The rates of suicide in Finland had increased rapid-ly from the 1950s through the 1980s, rising from26.5 to 41 per 100 000 for men, with a figuredouble that for women. A 10-year, nationwide sui-cide prevention strategy had been launched in the1980s and had achieved a reduction of suicide ratesof nearly 20% in relation to the peak period. An

evaluation of the project had shown that thestigmatization of mental health disorders had beengreatly reduced and on that basis a programme toaddress the problem of depression had beenlaunched.

During its presidency of the European Union twoyears previously, Finland had identified mentalhealth as the number one health problem. Fromthat experience, his Government had concludedthat clear changes were needed in mental healthpolicies. First, mental health should be brought outof its political isolation into the broader sphere ofpublic health. Second, instead of concentrating onmental health at the individual level, there was aneed to strengthen the approach to mental healthfor the population as a whole, in particular as ameans of promoting the integration of mentalhealth into public health policies, strategies, andprogrammes.Third, emphasis must be shifted fromthe negative concept of mental disorders to a morepositive mental health model.The key importanceof mental health was encapsulated in Finland’s slo-gan: “There is no health without mental health.”

France

Dr Kouchner said that mental health was a conceptwith wider social ramifications than traditionalpsychiatry. Although the drugs developed over thepast 20-30 years had allowed some progress in thetreatment of mental disorders, they had also cam-ouflaged the difficulties. People with mental healthproblems were always stigmatized. Furthermore,psychiatrists, psychologists and social workers didnot agree on their practices or general objectives.The general medical community and psychiatristsdisagreed about the extent of the mental healthsector.Was social work a marginal component ofthe sector or was it fully integrated? Psychiatristswere unwilling to become involved in what theyconsidered to be social problems, such as depres-sion and suicides among young people.There waspoor follow-up on the part of hospital emergencyservices and society in general of young peoplewho attempted suicide. It was known that one intwo succeeded on a second attempt and that half ofthose who had committed suicide had consulted ageneral practitioner the week previously. Generalpractitioners did not have the training to deal withsuch problems.


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There was insufficient communication betweenpsychiatrists and social workers in developed coun-tries. In France, the problem of drug addiction hadinitially been viewed as a psychiatric illness,whereas it was now considered a social problem. Itappeared that 30% of prisoners suffered frommental illness, and 20% had been imprisoned forthat reason.Was their mental health dealt withadequately? Were domestic violence and alcoholabuse psychiatric problems? Those problemsremained unsolved because of a lack of under-standing between social workers, general practi-tioners and psychiatrists.

Efforts had been made to close down psychiatrichospitals and provide care in small communitystructures in general hospitals, close to thepatients’ families and to patients’ associations.However, some psychiatrists complained that theywere swamped by social problems and that closureof the large psychiatric hospitals meant that nobeds were available for patients with severe psychi-atric conditions such as schizophrenia or manicdepression.

Georgia

Dr Gamkrelidze said that the significant social,political and economic changes that had occurredin Georgia at the beginning of the 1990s had had anegative effect on the country’s medical care sys-tem and particularly on psychiatric care. Owing tomajor shortages of psychotropic medicines and adrastic deterioration of the conditions in hospitals,patients had left, and the mortality rate in theinstitutions had increased. In March 1995, theGeorgian Parliament had passed a law on psychi-atric care which had become the legal basis for theState programme. Hospital and outpatient care wasprovided by a network of hospitals, regional clin-ics, psycho-neurological clinics and consultingunits.The State covered the treatment costs ofabout 30 000 patients registered as suffering fromschizophrenia, affective disorders, organic andsymptomatic psychoses, post-traumatic psychosesand other psychiatric disorders. However, morethan 70 000 patients registered in psychiatric insti-tutions outside the public programme requiredprofessional psychiatric care.The budget of theprogramme was greatly in deficit. In order to func-

tion optimally, it would require US$ 4.5 million,whereas the actual allocation was about US$ 1.5million.

Nevertheless, the Government had managed toextend its programme. Regional psychiatric clinicshad been opened, and a programme of psychoso-cial rehabilitation for children and young peoplehad begun functioning in 2000. A service forurgent psychiatric care was planned for 2002. In2000, a national health policy had been developedin the Ministry of Health, in cooperation with theEuropean Regional Office of WHO and theGeorgian Society of Psychiatrists, with a strategicplan for implementation during the comingdecade.The main strategic goals for developmentand reform of the psychiatric care system were:

■ extension of the public programme of psychiatriccare and a gradual increase in free medical care;

■ creation of a system of social rehabilitation andsocial assistance to patients with mental disor-ders;

■ creation of a system of psychiatric care for chil-dren and young people;

■ a reduction of the suicide rate in the generalpopulation; and

■ reduction of the incidence of psychiatric diseasesdue to social stress.

The plan envisaged the creation of five centres forthe psychosocial rehabilitation of patients by theyear 2009, in addition to the centre functioning inthe capital; nine psychosocial assistance units hadbeen opened in various regions of the country.Theprolonged economic crisis did not permit full, reg-ular financing of the state mental health care pro-gramme and made it difficult to ensure optimalfunctioning of the system of psychiatric care in hiscountry.

Ghana

Dr Anane welcomed the choice of mental health asthe theme for World Health Day 2001. In Ghanamental ill-health was typically regarded as aggres-sive or strange behaviour; general society did notconsider the milder but distressing forms such asdepression and anxiety as mental disorders. Mentalhealth programmes had begun in 1888, with theenactment of the Lunatic Asylum Ordinance.That


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Act had been improved in 1972 with a mentalhealth decree, followed by upgrading of facilities,strengthening of personnel and an expansion ofinstitutional care, with a decentralization policyleading to the setting up of mental health units ingeneral hospitals. However, progress in that areahad slowed sharply with the economic decline inrecent years. Owing to financial constraints, insti-tutions were not giving the required attention tothe subject, professional development programmeswere constrained and many trained staff werelured abroad to better paid jobs – the proportionhad reached 30% of mental health care providers,nurses in particular, in the previous year.Currently, the country had one psychiatrist for 1.5million population. Low pay and the stigmatizationassociated with mental illness did not encouragerecruitment. Although the Ministry of Health hadimplemented a motivational programme for allhealth professionals, that step had been limited byfinancial constraints and offset by the increasingincidence of mental illness, especially depression,which might underlie the fatalism engendered byspreading poverty. Ghana therefore supported theview that coordinated global efforts to mitigate theravages of poverty would be a major step to count-er mental illness.

Ghana had set its priorities.The Government’smental health policies stressed decentralization ofmental health services, not only through the estab-lishment of units in tertiary and regional hospitalsbut also through the integration of mental healthinto primary health care. Also, even with the cur-rent meager resources, model programmes fortraining of both medical and non-medical staff inprevention, identification and treatment of mentaldisorders had been drawn up. Major focuses wereattitudinal change, particularly for senior healthworkers and policy-makers, and the need to ensurethat all health professionals were knowledgeableabout mental health. Finally, the focus should be ona biophysical model for mental health care, whichrecognized the biological, psychological and socialroots of mental disorders. A purely medicalapproach would be bound to fail; a sector-wideapproach including communities was needed foreffective care. Prevention must be seen to be asimportant for mental health as for general health.Effective communication, including parentingskills, crisis management and the use of non-pro-

fessionals in the community would be vital for pre-vention of mental health problems. Since 1978Ghana had had a three-monthly training pro-gramme for community psychiatric nurses, whowere subsequently placed in all districts.

He noted that gender issues might often be seen asmental health problems. Societal attitudes aboutexpected gender roles, including the childbearingrole of women, often caused intense stress: femaleinfertility was an instance. As in other countries,more women reported depression than men.

In order to achieve success, mental health workerswere needed to take the lead, but they were inshort supply. He urged support for disadvantagedcountries in training and retaining personnel.

Greece

Professor Spyraki said that the mental health sys-tem in Greece had significantly changed in thepast two decades, including the introduction of amodernizing legislative framework.With assis-tance from WHO and with financial support fromthe European Union, Greece had reformed itssystem of mental health care, thereby graduallybringing about significant qualitative and quanti-tative changes. Legislation passed in 1999 hadgiven priority to primary care, outpatient care,de-institutionalization, pyschosocial rehabilita-tion, community care and the provision of infor-mation to the community; mental health serviceswere to be decentralized and divided into sectors;social enterprises were being set up for personswith mental health disorders, and a committeehad been established for the protection of theirrights.

Within the framework of psychiatric reform, anaction programme to develop mental health servic-es throughout the country had been launched in1997, which was reviewed and updated every fiveyears.The recent creation of a large number ofpermanent government posts related to the pro-gramme, at a time of relative economic austerity,had been a measure of the priority assigned to themental health care system by the Government. Inthe current year, a committee of persons workingin the media had been set up for the purpose ofincreasing awareness of mental health issuesthrough television, radio and other means.


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Greece

Professor Spyraki said that fighting stigmatizationwas important not only to overcome mental illnessbut also to improve society. In response to theChairman’s first question, about the measures putin place to fight stigma, he said that Greece hadoffered services for the mentally ill in psychiatricunits in general hospitals and mental health cen-tres; that had changed perceptions for both thepatient and the relatives. Secondly, campaigns wereimportant to teach children tolerance at an earlyage. Children had to realize that while mental ill-ness had biological and genetic determinants,social disparities were also crucial factors.Everyone should ask themselves to what extentthey were responsible for the mental illness of oth-ers and what they could do to help.

Grenada

Dr Modeste-Curwen said that her country hadtried to fight stigmatization by shifting the empha-sis from institutionalization of patients to the startof treatment in the community. However, becausemany of the mentally ill had never had a job orwere unable to hold one, they returned to theinstitution shortly after being sent out to the com-munity. Grenada had therefore started on a policyof industrial therapy to develop or teach skills,essentially in agriculture. She had recently touredan agricultural area in the presence of media repre-sentatives so that they would show mental healthpatients as productive rather than nonproductiveor destructive persons. A multisectoral organiza-tion (involving health sector representatives andthe community) was helping those with mentaldisorders by organizing activities such as sportsmeetings in which healthy members of the com-munity participated alongside the patients.Recently, a long-term institutionalized patient hadbeen helped to launch a book of poetry.The mediahad been extremely supportive throughout in pro-moting understanding of the productivity of thementally ill.

Guinea

Dr Saliou Diallo said that his country had earlierintroduced a mental health policy and programmewith a strategy of decentralizing all the healthstructures that would facilitate referrals.Thatmeant the integration of mental health into thebasic minimum package of health activities, partic-ularly in primary health care.That requiredchanges in attitude and culture with regard tomental disorders by decision-makers, health carepersonnel and the general population, with promo-tion of healthy lifestyles. Unfortunately manyobstacles were being met, such as the great gapbetween supply and demand, the paucity of trainedstaff, the high cost of drugs, the civil disturbancesin Liberia and Sierra Leone with the resultinginflux of refugees and incursion of rebels, all ontop of poverty and exclusion.With a calming oftensions and the implementation of decentraliza-tion, Guinea looked forward to an improved situa-tion.

Honduras

Dr Castellanos said that the prevalence of hurri-canes on the Caribbean and Atlantic coasts and thePacific Rim Fault, which gave rise to frequentearthquakes, were special factors affecting mentalhealth in his country.They precipitated both eco-nomic difficulties for the country and mental dis-orders among the people.The most frequentlydiagnosed problems in Honduras included violence(30%), depressive illnesses (27%), epilepsy (11%),psychological disorders (6%), and behaviouralproblems beginning in childhood (5%). In 1975,the Ministry of Health had established a mentalhealth department to deal specifically with suchproblems. Intensive work throughout the countryhad formed the basis for the mental health pro-gramme.

In 1998 Hurricane Mitch had killed three thousandpeople and wreaked extensive infrastructural andagricultural damage with lingering effects on thepopulation. Following a detailed analysis of thegeneral health situation, a poverty-reduction strat-egy had been devised that included a major pri-mary mental health care component.Workingdirectly with the victims of Hurricane Mitch, spe-


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cific attempts had been made to enhance commu-nity participation through decentralization. Astrong response had been received from both thepeople of Honduras and from such organizations asPAHO,WHO, and other friendly institutions andgovernments which had provided support.Currently under development was a strategy onmental health in disaster situations.

Gender issues figured largely in the efforts beingmade to bring about change in the country. Manywomen had been participating, particularly youngsingle mothers from rural areas who were suffer-ing mental disorders. In that connection, much hadbeen done to enact laws against family violenceand a special national institute for women’s issueshad been established.The Ministry of Health haddevised a national sexual and reproductive healthprogramme, and work was proceeding on a speciallaw on HIV/AIDS. Destructive as it had been,Hurricane Mitch had strengthened the unity of thepeople of Honduras and had provided an incentiveto confront mental health problems.

Hungary

Mr Pulay said that awareness-raising campaignshad targeted various groups, the first being deci-sion-makers, including the Minister of Health.With a view to a better allocation of resources, itwas important to convince ministers of finance ofthe significance of mental health problems. Forexample, in Hungary, it had been decided that newantidepressant drugs should be made available ataffordable prices, since the chronically mentally illwere among the poorest members of society.Hence national insurance now covered 90% of thecosts for such drugs. A second target group con-sisted of the patients themselves. Although theywere insured, lack of objective information andfear of stigmatization prevented them from comingforward for treatment. Other targets had includedprimary health care workers, who were crucial incombating gender discrimination, and detectingviolence and mental illness in the family andschools. As the Director-General had stated in heraddress to the current Health Assembly, it wasessential to act now to create a better future forthe children of the world.

Iceland

Mr Gunnarsson, noting that mental health wasvitally important to the well-being of nations andto human, social and economic status, said that ithad been included as one of seven target areas inIceland’s new health plan. In that connection, thespecific objectives of his Government included thereduction, within the next 10 years, of suicides by25% and of mental disorders by 10%.The actionplanned to attain those objectives included: betterregistration of mental disorders; better training forhealth care personnel; provision of better informa-tion to the public, in particular by enlisting thecooperation of the media; improvement of accessto mental health care; the offering of more treat-ment options; and improvement of coordinationbetween schools and the mental health services.The focus was on children, young people and theelderly, especially those in rural areas. It was hopedthat the health plan would help to reduce thestigmatization of those suffering from mentalhealth disorders and discrimination against themand their families.

Studies had shown that those suffering from mentaldisorders tended to be from the less well-off sec-tors of society and, despite the fact that Icelandhad a strong social welfare infrastructure, stepswere being taken to strengthen the system still fur-ther. Efforts were also being made to reduce gen-der disparity: the longevity of women as comparedto men, together with other factors such as theirgreater exposure to stress, made it necessary todistinguish between the health needs of womenand those of men and to take such factors intoaccount when planning mental health care. In con-clusion, he recalled that most mental illness couldbe treated and that many mental illnesses werepreventable.

India

Dr Thakur said that mental health disorders hadbeen treated in India by yoga since ancient times.India had launched a mental health programme in1982.The integration of mental health in the pub-lic health programme had aroused criticism at first,but was currently recognized as having been cor-rect. Efforts were being made to improve services


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in mental hospitals in order to make them morepatient-friendly.While he agreed with ProfessorLadrigo-Ignacio that problems such as natural dis-asters and wars caused mental disorders, therewere also area-specific problems. For instance,men from Kerala often worked in neighbouringcountries, and their absence led to family prob-lems, even suicide, while in poorer states such asBihar the suicide rate was much lower.

With the development of genomic research, itwould be possible to investigate whether somemental disorders were of genetic origin.The roundtable might identify the need for such a study, asgene therapy could then be used in treatment.

Mental disorders should not be considered as dis-eases but as part of life. It was his day-to-day expe-rience in medical practice that many persons suf-fered from slight depression. Addressing theirmental health would help them to function better.Efforts should be made to combat the stigmaattached to mental deterioration.

Indonesia

Dr Sujudi said that, as a result of legislation passedin 1960, Indonesia had adopted a social approachtowards mental health care offering more open andcomprehensive facilities and services. In 1974,mental health care had been integrated into select-ed district hospitals and health centres. Inadequateresults in the identification and care of patients hadled to the introduction in 1993 of training in thediagnosis and treatment of psychiatric patients forsubstantial numbers of personnel in such hospitalsand health centres. Subsequently, the detection ofmental health disorders among outpatients hadincreased from 0.47% to 2.15%. Communitymental health activities had been promoted on anationwide scale; they would support the develop-ment of relevant policies and strategies forimprovements at provincial and district levels.Much remained to be done, as indicated by theunsafe environmental conditions and unhealthybehaviour which prevailed, but Indonesia was seek-ing to adopt strategies that emphasized welfare-oriented and community-based mental health care,as well as the inpatient services, and promotionand prevention, activities which were important toenhancing the overall development of health.

Iran, Islamic Republic of

Dr Farhadi observed that the problem of theincreasing gap between physical and mental healthservices was particularly acute in developing coun-tries, owing largely to lack of awareness, low polit-ical commitment, an acute shortage of trained pro-fessionals, weak intersectoral collaboration and theabsence of community services. All too often,mental health services were neither affordable noraccessible.The only way forward was to integratemental health services into general and primaryhealth care systems, thus ensuring the provision ofthe most basic level of services for the seriously ill.

Iran had taken that initiative following a pilot proj-ect in 1987, aimed at promoting awareness ofmental health issues and making essential mentalhealth care available to all. Following wide-rangingtraining programmes for medical personnel andcommunity workers and the establishment of alarge number of rural and urban mental healthcentres, mental health care was now available to6% of the rural population and 12% of the urbanpopulation. In addition, innovative programmeshad been developed, such as an urban mentalhealth programme, the integration of a preventiveprogramme for substance abuse disorders, withinthe primary health care system, a school pro-gramme and integration of mental health into the“Healthy Cities” project.

With a view to expanding mental health services in2001 and beyond, Iran’s national mental healthprogramme was being revised, a new mentalhealth act was in preparation, and efforts werebeing made to increase inpatient and outpatientmental health facilities and counselling services.

Iraq

Dr Mubarak recalled that his country was experi-encing a difficult situation in view of the sanctionsimposed and almost daily bombardments. Cases ofmental ill-health had increased, caused by the fearof air raids and the constant trauma of bombingattacks, which particularly affected children,women and the elderly.Those difficulties were wellknown; the lengthy duration of such problems wasanother source of trauma.The current situationmeant that it was very difficult to measure the


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social consequences of mental health problems, asit was impossible to obtain research data. Despitethe signature of a memorandum of understanding,the measures taken under the pretext of protectinghuman rights, and particularly the positions takenby certain representatives on the United NationsSecurity Council Committee established byResolution 661, made it difficult to achieve anyprogress in the health situation in Iraq. Close coop-eration was required with WHO to develop betterapproaches to mental health disorders, particularlythrough hospital treatment.

It was difficult to persuade trained practitioners towork in the field of mental health. HisGovernment did not have the capacity to providethem with scholarships to study abroad, and it wasdifficult to bring in qualified personnel to trainhealth practitioners in Iraq. Measures adopted toencourage newly graduated health professionals towork in the field of mental health included the cre-ation of training programmes and rotation systemsfor new graduates, including incentives for them tospend two years working in mental health.Thesanctions meant that the drugs required to treatmental disorders were classified as non-urgent andwere in very short supply.

Iraq’s situation was having a severe impact on soci-ety, and particularly on women. Frustration wascoming to the surface and confrontations weredeveloping between family members. Childrenexperienced frustration when they saw toys adver-tised to which their access was restricted or pro-hibited, and women, confined to their houses,were experiencing depression.To relieve the situa-tion, legislation had been adopted and other meas-ures devised, including soft loans, to enablewomen to work from home.The Government wascooperating with nongovernmental and otherorganizations in civil society to deal with mentalhealth disorders. Heavy penalties were imposed oninstitutions and enterprises discriminating againstpersons with mental disorders.

The treatment of mental health should be a subjectof close cooperation between countries at regionaland international levels and should not be treatedas a political issue. Although there could not beone standard approach to mental health whichwould fit all countries,WHO should lead in devel-oping action in that field.

Israel

Dr Leventhal said that the future of mental healthlay not in hospitals, but in the community; it wasthe concern of society as a whole, not just of men-tal health professionals.

Israel had taken the opportunity provided by WorldHealth Day 2001 to extend the event to a week ofawareness-raising on mental health. He thankedWHO for providing excellent supporting material.

Mental health affected the whole community sincevirtually everyone experienced some form of men-tal health disorder at some point in their lives,although mostly to a very minor degree.The prob-lems associated with mental ill-health were part ofliving in a modern society. Prevention of thoseproblems and mental health promotion wereimportant at all levels. He regretted the shortageof material available for preventive activities andasked WHO to provide leadership in that field;such material would have the added advantage ofensuring that the public was well informed.

In conclusion, he commended the admission of aformer prime minister of Norway that he too hadsuffered from depression, thus highlighting the factthat such issues affected privileged as well as disad-vantaged members of society.

Israel

Dr Leventhal considered that the present roundtable and the World Health Day campaign werepart of the fight against stigmatization. Societycould only fight stigmatization if the health sectorplayed a leading role.The health sector should bereoriented to incorporate consideration of mentalhealth issues in physical health. It had to set a goodexample. However, the fight against stigmatizationconcerned not just the health system but also theeducation and welfare systems. All should con-tribute to the fight against stigmatization.

In answer to the Chairman’s fourth question, vio-lence had in the past been associated with mentalillness because mental health institutions had oncebeen considered prisons.To avoid that, patientsshould now be given access to health servicesbefore their illness reached the point where theyrequired institutionalization. In Israel’s experience,


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only the courts could strike the balance betweenrespect for human rights and enforced admissionto a mental health institution. Since Israel hadadopted the policy of using the courts, more peo-ple were reflecting on the question. Health profes-sionals were in effect asking society as a whole toshare in taking such decisions, which resulted in abetter balance.

Italy

Dr Oleari said that the Italian experience in thearea of mental health dated from the 1978 law toreform psychiatric services and specifically toeliminate institutionalization. However, institution-alization could continue as a problem, even in theabsence of psychiatric hospitals, just as stigmatiza-tion and marginalization could still occur, unlessthe patient was treated as a full citizen.What wasneeded was a network that included health, socialand community services.

Many problems had been encountered after theadoption of the 1978 law, in particular in connec-tion with specific mental health programmesinvolving the participation of associations of thefamilies of psychiatric patients, which was consid-ered to be essential.Treatment necessarily involvedinpatient mental health centres, care for acutepatients in general hospitals, and residential struc-tures that were conducive to the reintegration ofthe patient into society.

Many national health services had encountered theproblem of how to finance social and health servic-es. Such economic difficulties had not yet beenfully surmounted in Italy also. Mental health fund-ing was not related to expected outcomes, and aneffort was being made to weight the per capitacontributions through which health services werefunded, by taking into account such sex-relatedfactors as neonatal mortality and infant mortality,rather than purely socioeconomic criteria. Muchmore remained to be done along those lines. InItaly, 5% of the health service budget was current-ly allocated to mental health.

All psychiatric hospitals had been closed, and gen-eral hospitals had been given responsibility fortreating acute patients. He considered that theItalian approach was both positive and in line withthe experience of other countries, and expected

future efforts to place emphasis on the rights ofmental health patients as citizens and on the pre-vention of mental health problems.

Japan

Mr Kondo said that the competition inherent in afree-market economy had resulted in rising inci-dences of stress, distress and mental disorders inhis country, underlining the importance of placingmental health high on the agenda. He welcomedthe decision to devote World Health Day 2001 tothat problem.

Until recently, Japan had placed considerableemphasis on the hospitalization of psychiatricpatients.The results were too many long-termpatients, and the raising of several human rightsconcerns. Currently, efforts were being made toensure that patients acquired greater autonomy aspart of their reintegration into society.TheMinistry of Health, Labour and Welfare nowfocused on community-based care, and adequatesupport mechanisms were being set up, includingemployment opportunities for patients with men-tal disorders. Suicide was a significant social prob-lem in Japan, often caused by financial difficulties.Adequate services to improve the social environ-ment should be provided at the regional and work-place levels to prevent such difficulties. It wouldalso be important to conduct research into thecauses of depression.

As in other countries, stigmatization of patientswith mental disorders was a major problem.Measures were being taken to eliminate prejudiceand achieve social integration of sufferers througheducation and information campaigns, such asthose carried out by and through WHO.

Jordan

Dr Kharabseh explained that his country faced twoobstacles to the improvement of mental health careprovision: lack of resources and a shortage of spe-cialized workers in the mental health sector.Thosetwo barriers were the result of war, human rightsviolations and other injustices.


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He emphasized the importance of integrating men-tal health and general health programmes, and ofmaking treatment affordable in order to care forthe poor properly.

Lao People’s DemocraticRepublic

Dr Boupha congratulated WHO for highlightingmental health and bringing that important topic tothe attention of Member States.

Among its strategies for addressing mental health,her country had promoted a series of activitiesusing video productions and school contests withina community-based approach, as part of a deliber-ate strategy to tackle mental health issues.

She stressed that mental health factors relating towomen had generally been overlooked.There weresome 75 million unwanted pregnancies in theworld each year. Unwanted pregnancies could havetragic consequences for the women, their familiesand society as a whole.The issue was one ofempowerment: women should be allowed todecide when and whether they wished to becomepregnant. A great deal of distress and depressioncould thus be avoided. She urged WHO and theauthorities in each country responsible for mentalhealth programmes to take into consideration theproblems related to women’s health.

Lesotho

Mr Mabote said that, historically, mental healthservices in Lesotho had been marginalized, as wasreflected in both legislation and budget allocations,with stigmatization and discrimination rife. Mentalill-health accounted for a significant proportion ofDALYs lost, with the largest proportion of the bur-den due to epilepsy and depression, the latterbeing more common in women than in men.Substance abuse, especially of alcohol, was risingand his country recognized the need for vigilancein that area. For many years, mental health serviceshad failed to pay sufficient attention to emerginggender-related issues and violence.TheGovernment was now giving serious attention togender-sensitive policies and a specific ministrywas dealing with the question. Moreover, an asso-ciation of women lawyers was playing a leading

role in raising private and public awareness of gen-der issues in many areas. Mental health policy wasbeing revised to incorporate contemporary gen-der-related issues, such as the effects of unemploy-ment, and to encourage disclosures concerningviolence and emotional abuse. In addition, publicawareness campaigns, seminars and workshopswere providing a strong foundation for policy for-mulation concerning effective prevention of gen-der-related mental health problems. Preventivemeasures included poverty-reduction strategiesinvolving income-generation projects.Training wasneeded to sensitize health care workers and others,such as the police, to the mental health conse-quences of gender-related violence, and to theneed to provide tactful counselling and support.

Madagascar

Professor Ratsimbazafimahefa observed thatmental health was an integral part of WHO’s defi-nition of health, although it had long been over-looked in the developing countries because of thepriority given to control of communicable dis-eases. At Madagascar’s present stage of epidemio-logical transition, the number of mental disordersand disabilities, the legal battles concerning peoplewith mental problems, the increasing number ofsuicides and of patients who remained hiddenaway, unable to face the difficulties of adapting tolife in society, all served to highlight mental healthas a top priority.

The celebration of World Health Day 2001 had fur-ther widened the country’s understanding of theissue by seeking to redefine mental health and itsimplications for quality of life. It had also under-lined that mental health was a means and an indica-tor of economic, social and cultural developmentso that failings in mental health led to poverty atevery level.Thus her country had attached particu-lar importance to the management of mental ill-ness, which was handled chiefly by the publichealth system. Severe cases could be referred toprovincial psychiatric centres, but otherwise men-tal health was part of primary health care.However, deficiencies both in number and qualityof personnel had led to the appointment of a men-tal health coordinator to review the national men-tal health policy.That policy would include preven-tion and treatment of mental illness with social


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reintegration, and would especially emphasize thedevelopment of human resources with training formental health nurses and psychiatrists. Doctorsworking in primary health care had training guidesto teach them about mental health.The lack ofinternational solidarity on mental health issues wasto be deplored. She asked WHO to seek ways ofdeveloping partnerships to give fresh impetus tothat new world priority.

Malaysia

Mr Chua Jui Meng recounted a visit to a mentalinstitution that had a clock tower with no clock;that had brought to his mind the thought that, onentering the place, there was no time, no realityand, for many inmates, no hope – they had beenmarginalized and stigmatized by society and, worstof all, by their own families. For the whole of theprevious year, the Government had run a healthylifestyle campaign in the mass media on the themeof mental health, including prevention. He echoedthe description by the delegate of Trinidad andTobago of the mass media as allies; every year,Malaysia, had given awards to journalists for thebest writing on HIV/AIDS, as well as to the news-papers they worked for. As poor or unbalancedreporting about mental health issues could sparkfear and discrimination, he proposed that similarawards be given to the journalists and the massmedia which projected a more positive picture ofwhat mental illness meant; that would be a start.

Maldives

Mr Abdullah welcomed WHO’s initiative to placemental health actively on the global agenda.Awareness-raising on behalf of the complex andforgotten issue of mental illness could be just assuccessful as that on behalf of HIV/AIDS.WHOshould vigorously persuade Member States to dedi-cate a significant part of their national health budg-ets to improving treatment and facilities for thementally ill, thereby enabling a large number ofpeople to return as productive contributors to themainstream of society. He called upon his fellowministers to attach greater importance to mentalhealth and to step up their contributions to it.

Maldives

Mr Abdullah said that the biggest stumbling blockin the fight against mental ill-health was the stigmaattached to it. He endorsed the view that informa-tion, education and communication provided a wayforward. He was gravely concerned by the break-down of family values and strongly believed thatspending more time with family and childrenwould help to solve the problems. Research hadproved that time spent with one’s family removedfear and prevented the development of mentalafflictions. People were being killed by the hecticlives they led, which gave rise to social problemsfor their families, including mental illness.Thehealth sector could not tackle the growing prob-lems on its own. An integrated approach wasrequired, involving the education sector, the com-munity and nongovernmental organizations.

Mauritius

Mr Jugnauth, speaking as a lawyer rather than as amedical doctor, asked why it had taken so long forgovernments and international organizations torecognize the issue of mental health.What werethe problems, and the related solutions, in the fieldof mental health? In response to those questions,he said that the key words were: recognition, iden-tification, and treatment. Because those sufferingfrom mental illness often attempted to hide theirproblem, such illness was both denied by theaffected person and unrecognized as a real illnessby their families. Accordingly, those who neededhelp were excluded from treatment.

Barriers to implementation of mental health serv-ices included public attitudes, resulting in a fearamong individuals which prevented them fromcoming forward with their problems. A centrally-based institution in Mauritius had been constructedin a remote area as a high-security hospital for dis-ruptive psychiatric and acute psychiatric patients,with different rules and regulations from thoseapplied to general hospitals.Those admitted to thatinstitution could not receive relatives or closefriends.

The main barrier had been the failure to recognizemental illness, which was essential if the necessarytreatment were to be provided.To achieve such


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goals and overcome such barriers, he suggestedthat countries might follow the example ofMauritius in adopting a mental health act thatclearly identified the fundamental freedoms andbasic rights of those affected by mental illness, andprovided for the protection of minors sufferingfrom mental illness, life in the community andtheir rehabilitation in society. Other provisions ofthe act included the determination of mental ill-ness, medical examination, confidentiality, the roleof the community and culture, standards of careand treatment on a basis of equality with otherpatients, conditions in mental health facilities,resources for those facilities, admission principles,review bodies, procedural safeguards, access toinformation and equal treatment of criminaloffenders.

Decentralization of mental treatment had beenmoving forward but with acute patients remainingin the psychiatric hospital.Wards for psychiatricpatients in the regional hospitals were situated soas not to affect the rest of the patients.

Although Mauritius had eradicated malaria,poliomyelitis and tuberculosis, about 30% of thepopulation still suffered from some kind of mentalillness. Decentralization had been essential to reachthose people and to make mental health servicesmore available; to assure cost-effectiveness of serv-ices; to promote greater awareness in the commu-nity; and to suppress stigmatization of mental andpsychiatric problems.

The main problems were societal, but there werealso financial constraints, particularly in Africanand other developing countries, which made it dif-ficult to decentralize. Another problem involvedshortages of medical personnel, owing particularlyto the emigration of trained medical personnel.

Mexico

Dr Frenk Mora underlined the double burden ofdisease that was afflicting developing countries.They faced mental health problems linked to back-wardness and poor hygiene, such as epilepsy andmental retardation, as well as new types of mentaldisorder more commonly associated with devel-oped countries, such as depression and psychosis.Moreover, current epidemiological and demo-graphic trends, such as population ageing, indicat-

ed that the burden of mental disease was set toincrease in the future in all countries.

Mental health problems served to magnify existingdeficiencies in the overall health care system inrespect of quality of treatment and care, respectfor the human rights of people with mental healthdisorders, and fairness in financing, including thelack of health insurance cover for the mentally ill.Consequently, mental health should be treated as apriority in efforts to reform health systems. Animportant first step in increasing awareness of theproblems associated with mental disorders was todocument the scope of the problem. In thatrespect, Mexico had carried out several surveyswhich, in conjunction with WHO’s ATLAS project,should provide scientific evidence for treatingmental health as a priority area.

The public sector had a vital, proactive governancerole to play in articulating the importance of men-tal health, protecting the human rights of thosesuffering from mental disorders and combating thestigma attached to mental illness. In Mexico, prior-ity had been given to devising new mental healthprogrammes, in particular to tackle alcohol anddrug dependence, depression, schizophrenia,dementia, psychological disorders in children, andepilepsy. New pilot projects were under way tointroduce innovative approaches that included theintegration of prevention and treatment of mentalhealth disorders in general health care systems;early detection of learning disabilities and socialrehabilitation of patients in half-way houses, shel-tered workshops and residential accommodation tofacilitate their gradual reintegration into the com-munity.

He agreed with Dr López on the need to focusspecial attention on the mental health of indige-nous people, taking into account their particularcultural circumstances.

Mongolia

Professor Nymadawa observed that, while mentaldisorders were increasing in all Member States,they were a particular problem for countries intransition. In the previous 10 years, Mongolia hadundergone drastic socioeconomic changes in itsefforts to build up a multiparty democracy and amarket economy.That difficult task had rendered


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social problems more acute, resulting in increasedprevalence of depression, alcoholism, accidents,suicide and crime, especially among the poor.According to a recent study, 51% of the adult pop-ulation used alcohol and the suicide rate had risenfive-fold between 1989 and 2000.TheGovernment had introduced several measures topromote stabilization and provide social protec-tion. Since 1990, cost-sharing mechanisms hadbeen introduced into the previously universallyfree health service and a social health insurancescheme had been set up in 1994. However, thecosts of treatment for chronic mental health condi-tions continued to be met by the State in the sameway as some other priority health services such asimmunization programmes and pregnancy andchildbirth care.

He expressed appreciation for WHO’s support incoping with the mental health problems arisingfrom economic transition. Mongolia faced a severechallenge from increasing mental health disorders,especially alcoholism and depression, and hoped tolearn from the experience of other countries withdifferent conditions and structures.

Morocco

Mr El Khyari observed that lack of knowledge washampering efforts to tackle mental health prob-lems, many of which were influenced by complexsocial factors. Moreover, the financial and humanresource costs of long-term treatment and supportfor those with mental disorders were beyond thereach of many developing countries. Many wereexperiencing economic transition and its conse-quences, such as the splitting of families anddecreasing belief in traditional medicine, at thesame time as undergoing as severe resource con-straints. Mental health disorders required theinvolvement of several different ministries andmany different aspects of civil society; they calledfor solutions that went beyond the conventionalhealth care framework. He therefore welcomedthe interest being shown by the international com-munity through WHO.

Mozambique

Dr Ferreira Songane described the developmentof his country’s mental health programme in 1990,based on prevention, training and partnership, in amultisectoral approach. Although Mozambique’spsychiatric hospitals had largely become redun-dant, it lacked the resources to eliminate thestigmatization of the mentally ill. In practice, manysufferers were simply left on the streets to die.

Since it had insufficient specialists and wanted todecentralize services, Mozambique was providingpsychiatry training for doctors at the middle level ofthe system, including a significant public and socialhealth component.The physicians worked closelywith traditional practitioners who also had expertisein the use of drugs, and who thus could help over-come social resistance to seeking treatment.

The streets of Mozambique revealed children asyoung as five years of age who were forced out towork or to seek food and were deprived of theeducation and care they needed to enjoy mentalhealth in later years. His Government hoped that,with the help of WHO and through its highly effec-tive Regional Office for Africa, such phenomenacould be effectively eradicated.

Myanmar

Mr Ket Sein described how the launch of hisGovernment’s mental health programme in 1998had started to break down the misconceptions pre-viously attached to mental health disorders.Awareness had been enhanced by the activities ofhealth education teams and projects. Communityparticipation in activities designed to provide moralsupport for sufferers had also been important inimproving acceptance by the community and inencouraging community-based care.The engage-ment of well-known artists and cartoonists to openand promote exhibitions of paintings and drawingsby people with mental disorders had contributedgreatly to the change in people’s perception ofmental illness and to minimizing discrimination.

The community-based approach to mental disor-ders covered the training of basic health care work-ers. New care guidelines had been issued, and thesupply of basic psychotropic drugs had improved.


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Nongovernmental organizations were encouragedto promote mental health activities, including theprevention of substance abuse among young peo-ple. Health education activities had been intro-duced in schools and in the community. A maternaland child welfare association had started to pro-mote health and well-being, including programmesfor education and income generation. Nationalcommittees for women’s affairs had sponsored theestablishment of counselling centres for victims ofviolence.

At the national level, a concerted effort was beingmade as a result of the mental health theme forWorld Health Day 2001 to secure adequate sup-plies of affordable, good quality psychotropicdrugs. Meditation, which was already part ofMyanmar’s culture, continued to be encouragedfor the harmonious mental state that it promoted.

Namibia

Dr Amathila, noting that the stigma of mental ill-ness had been eclipsed in Namibia by that associat-ed with HIV/AIDS, said that gender disparities hadbeen actively addressed in her country, and that nohealth service excluded women. As far as mentalhealth was concerned, women in Namibiaappeared to be stronger than men; however, thelevel of violence against women was increasing.The health authorities had set up centres forwomen and children who had been abused, and inthe previous year, an organization entitled “Menagainst violence against women” had been set up bymen to provide counselling to abusive men.

Unemployment, poverty, alcoholism andHIV/AIDS were important factors in the rise inmental instability in Namibia, especially amongyoung people.The refugees from neighbouringwar-torn Angola also experienced mental healthproblems. It would therefore be important to cre-ate employment opportunities where possible, andto improve the country’s economy. HIV/AIDS hadresulted in an increased incidence of depressionand suicides; counselling services were not alwaysaccessible to the young, and immediate, confiden-tial support, which should also cover mental healthissues, should be provided.Traditional healers werenow based at rural clinics to deal primarily withmental illness. Pensions for persons aged 60 years

and over had helped to reduce depression amongthe elderly. However, the elderly were having totake care of an increasing number of AIDSorphans, and additional steps should be taken tosupport them in that regard.

Namibia currently had only one psychiatrist, andthere was a clear need for additional investment inhuman resources and training to improve care forthose with mental illness. Some 15% of the grossdomestic product was devoted to health services,and it was important to ensure that due attentionwas given to mental health.

Nepal

Mr Tamrakar observed that further study wasneeded in order to determine whether certainbehaviours and lifestyles might be conducive tomental illness, and to investigate the mitigatinginfluence of spiritual aspects of individuals’ lives,such as meditation. His country had adopted anational mental health policy. In the past, the sizeof the problem had not been recognized, owing tothe stigma attached to mental disease, as well as tothe shortage of trained personnel. A community-based pilot project was gradually being introduced,involving traditional healers and civil society as awhole in an awareness-raising campaign. However,it was difficult to allocate adequate resources inthat area, and Nepal would welcome support fromWHO to find funding for mental health projectsand to provide drugs for a limited period.

Netherlands

Dr Borst-Eilers said that her country had also seena growing demand over the past 10 years for helpfor mental disorders, due to the increasing inci-dence of such problems and to the fact that helpwas being sought at an earlier stage, largely as aresult of de-stigmatization.The change hadundoubtedly been promoted by well-known per-sonalities who had openly admitted to sufferingfrom certain disorders.The availability of effectivetreatment for mental health problems such as anxi-ety and depression in primary health care centres,by family doctors, psychiatric nurses, social work-ers or primary care psychologists, was also respon-sible for the growing demand.


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Like France, the Netherlands had also begun toshift from institutional to community care, wherepatients received support and various kinds ofambulatory treatment. In order for the shift to besuccessful, budget cuts were inadvisable, as com-munity care was not necessarily cheaper than insti-tutional care in view of the personal supportrequired. It was also important not to push theconcept further than the community could toler-ate. Some vulnerable patients with chronic psy-chotic conditions and those who posed a threat toothers needed the protected environment of aninstitution and should not be exposed to life in acommunity. One of the most important aspects ofcommunity care was the building up of broad pub-lic support by making it clear to the local commu-nity that professional help was readily available inthe event of a disturbance. Community care hadbeen introduced into a number of cities in theNetherlands with great success.

Niger

Mr Adamou said that, since the independence ofhis country, mental health care had been providedat the national hospital in the capital and at threehospitals that had psychiatric units; however, withwaning funds and resources, their performance haddeteriorated. On the occasion of World Health Day2001,WHO had provided certain psychotropicdrugs, which had enabled the country to resumeits activities in that field. Clearly, in a country asvast as Niger, three hospitals were insufficient tocover all mental health care needs.The mentallyill, whether hospitalized or not, were rejected bytheir families and were looked after by the State. Inhis country, traditional medicine existed side-by-side with modern medicine.The traditional healerswere not witch doctors and did cure some mental-ly ill people.The intention of the authorities was topromote primary health care for mental disordersand to decentralize that care through personneltraining and the provision of sufficient drugs.Niger’s mental health programme was new, andthere was need still to formulate policy, coordinatethe activities of all those involved in mental healthcare and to raise awareness. All that was neededwas financing. He had found the round table usefuland would make good use of some of the sugges-tions that had been made.

Nigeria

Professor Nwosu commented that in Nigeria men-tal health care had initially been the responsibilityof families and communities, and had then beentransferred to hospitals before being restored tothe community.The disintegration of the extendedfamily system in Africa had placed an enormousburden on the community for the management ofmental health care. In that regard, poverty allevia-tion was a crucial instrument for integrating men-tally ill patients into society and giving them ade-quate care.While traditional healers played a majorrole in treatment, the community also needed edu-cation and awareness programmes so that tradi-tional care would be effectively integrated into theorthodox health care system.

She asked that WHO devise a special programmeon postpartum psychosis, a neglected area of men-tal illness.

Norway

Mr Tønne said that as a result of a study conduct-ed a few years earlier, which had led to someshocking conclusions about the state of the mentalhealth care system in Norway, his Governmentwas working on a long-term plan to bring the sys-tem up to acceptable standards. In reply to thethird question put by the Chairman, he said thatopenness and inclusion were two of the key issuesbeing addressed.The history of mental health carein Norway, as in many other countries, had beenone of non-information, lack of openness, closedinstitutions, stigmatization, exclusion, shame andfear.The reform of that situation had been a longprocess which had required changes in culture,attitude and behaviour amounting to a completere-education of society.The second key issue,inclusion of those afflicted and affected, was close-ly connected to the first, because it could not beattained without the active participation ofpatients and their families.That implied participa-tion in the development of the mental health caresystem and treatment offered, participation in thedesign and performance of information and educa-tion programmes, and, perhaps most importantly,individual participation in self-help and self-treat-ment.


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Research in Norway indicated that 20% of thepopulation suffered from mental illness at leastonce during their lifetime, and that mental illnesswas a growing factor in causing school drop-outs,unemployment and absenteeism. In the debate onmental health some difficult and controversialquestions had arisen, for example the question ofwhether a general recognition of mental healthproblems as illness might not entail the risk oflowering the threshold of illnesses requiring treat-ment, thereby reducing the capacity of individualsto cope with their own problems.

Norway

Mr Tønne said that the broad answer to theChairman’s four questions was that information, inthe sense of education of society as a whole, wasthe best remedy. All efforts to fight stigma hadactively to involve everyone who suffered frommental health problems and stigmatization.

With regard to the comments made by the dele-gate of Israel, it was important to distinguishbetween mental illness and the mental problemsthat arose in normal society. Care had to be takenthat efforts to promote mental health did not pro-duce stigma by turning normal problems into ill-nesses and disorders.Thresholds should not belowered; rather, work should continue on educa-tion and information.

Pakistan

Dr Kasi said that the debate had shown that theprevalence of mental ill-health was high in all soci-eties, particularly among women. Governmentswere obviously keen to adopt preventive as well ascurative measures to eradicate mental health prob-lems, to reduce stigmatization of people withmental disorders, and promote their social reha-bilitation. However, efforts in developing coun-tries were hindered by lack of financial resourcesand technical capacity. He urged WHO and thedeveloped countries to assist the developing coun-tries in that regard. It was also essential to deter-mine the scale of the problem and how it affectedcountries’ societies and economies.The currentdiscussion would contribute to that process andPakistan looked to the international community

for further support, while following a consistentpolicy.

An area not so far discussed was the collection ofdata on mental health problems in areas of conflictand occupation by foreign forces, in particularamong refugee populations, as for example inKashmir and Palestine.There was a danger thattheir concerns might be marginalized in the gener-al debate.

Pakistan

Dr Kasi related that recent studies carried out inrural areas and urban slums in Pakistan had showna high prevalence of neuropsychiatric disorders.Mental health had also been identified as a mainpriority area in the national health policy.TheLunacy Act of 1902 had recently been replaced bythe National Mental Health Ordinance 2001 whichprovided a balanced framework for protecting thehuman rights of mentally ill people and their fami-lies.The national mental health programme hadestablished pilot projects at local level to providemental health care as a component of primaryhealth care.The media and nongovernmentalorganizations were supporting efforts to promotepublic awareness and understanding of mental ill-ness by tackling traditional myths and supersti-tions. Other public sectors, in particular theDepartment of Education, were actively involvedin the mental health programme, and mentalhealth education was being introduced in privateand state-run medical schools. Psychiatric nursingcourses were also being offered by nursing schools.Mentally ill people and their families were eligibleto receive grants, as well as social and disabilitypensions. Most health care services for the mental-ly ill were provided by the public sector, althoughthe private sector was rapidly emerging as a newplayer in that area. As yet, no policy existed to reg-ulate private sector providers and health insurancewas not available, although the Government hadrecently submitted an ordinance on the regulationof private hospitals, including mental health insti-tutions.


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Panama

Dr Gracia García said that he had found the roundtable highly instructive. It would be important todetermine to what extent mental health systemshad been affected by the economic and social poli-cies and crises imposed by the current develop-ment model. Panama resembled other LatinAmerican countries in experiencing increasedpoverty, greater unemployment and a resultant risein disease in general and in mental illness in partic-ular. One immediate effect of an unstable economywas decreased spending on health and education.

In 2000, Panama had made mental health a priorityand had implemented four programmes.The firsthad focused on obtaining accurate epidemiologicaldata on the real impact of mental illness on society.The second had ensured early diagnosis and treat-ment of mental illness in a national care systemthrough promotion campaigns and education pro-grammes for patients, their families and generalpractitioners. Joint public-private sector supportgroups for patients and their relatives had beenestablished to eradicate stigmatization of mentallyill patients by their families and society, so that thepatients could be reintegrated into society as rapid-ly as possible. A community pharmacy programmehad been established that gave patients access tohigh-quality drugs at reasonable prices.The possi-bility of State subsidies for drugs in the event ofeconomic necessity was being studied.

Papua New Guinea

Mr Mond described his country’s 10-year actionplan for social change and mental health.The mainchallenges were: the need to increase public aware-ness and involvement; the limited financialresources; poor service coverage; inadequate train-ing of staff, community, and home care providers;a lack of psychiatrists and psychiatric nurses; aneglect of forensic psychiatry; poor intersectoralcollaboration; and, finally, insufficiently developeddata and evaluation indicators.To respond to thoseproblems, month-long awareness campaigns andtraining seminars were held for skills development,and a community-based psychosocial health carecentre had been established. Pocket-sized standardtreatment manuals were being prepared for gener-

al practitioners, nurses and other health care pro-fessionals, to help them deal with mentally illpatients in the hospital setting.

The Government’s mental health policies werelinked to social change, and included free psychi-atric care and rehabilitation as an integral part ofthe public hospital system and the establishmentand support of community-based treatment andpsychosocial rehabilitation, carried out in collabo-ration with nongovernmental organizations andother such groups.

Peru

Dr Pretell Zarate said that developing countries,with their many priorities and scant resources,needed more information on mental health inorder to raise awareness of the problem.The firststep should be to carry out national epidemiologi-cal studies. He appealed to WHO to support coun-tries in carrying out surveys on mental health atcountry level, in order to provide more accuratedata on the prevalence and epidemiological profileof mental disease. Such surveys would permit anassessment of requirements in terms of human,professional, and family resources, and of mentalhealth care provision.They would also support thedevelopment of appropriate models for developingcountries to deal with mental health problems. Heapplauded the pragmatic efforts of many countriesin providing psychiatric training for health careworkers, but he wondered what results had beenobtained from such training in terms of quality ofcare, prevention, diagnosis and referral to otherlevels. Secondly, he enquired what experience hadbeen gained in mobilizing families and communi-ties, particularly in rural areas, to avoid isolation,discrimination and stigmatization in respect of thementally ill. Lack of resources and failure to prior-itize mental health were problems shared by alldeveloping countries, and it was therefore of vitalimportance to conduct a global survey on mentalhealth.

Peru

Dr Pretell Zarate said that a significant cause ofstigmatization and segregation was the pessimisticview of mental health patients as lost causes or as a


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source of great expense to the State. It wouldtherefore be very useful to wage a major educa-tional campaign showing the scientific progressmade with regard to the causes of many of thoseproblems and the existence of new and more effec-tive methods of treatment and rehabilitation. Forexample, the World Summit for Children’s globalcampaign to iodize salt was an effective, cheap andeasy means of preventing damage to the brain andmental disease.

Poland

Professor Opala said that the Polish Ministry ofHealth and Social Welfare had approved a newmental health programme in 1994 with the aim ofensuring improved access to appropriate healthcare and support for those with mental disorders.The implementation of the programme and themental health of the population were being moni-tored. A recent study of mental health had revealedthat the number of people with a positive assess-ment of their lives had increased but feelings ofhappiness and satisfaction had declined. Highermental well-being was associated with broadersocial support, increased income, participation inreligious practices and marriage, whereas a lowersense of mental well-being affected in particularthe elderly, the unemployed, those with a lowerincome and those suffering from loneliness.Thehighest risk for mental disorder was found in per-sons over 65 years old, 51% of whom (88% inwomen) admitted to feeling sad and depressed.The Council for Mental Health Promotion haddrawn attention to some of the risk factors formental disorder and measures had been introducedto monitor and promote mental health, includingthe identification of risk groups, the introductionof educational programmes for families, the imple-mentation of school curricula to develop skills inproblem-solving and coping and the establishmentof various forms of psychological counselling andintervention for people in emotional crisis. Suchmeasures would be included in the national mentalhealth programme.

Portugal

Mr Boquinhas said that his Government hadapproved a national mental health plan in 1996 and

in the last five years had ratified a new mentalhealth act and organized new mental health servic-es around hospital and community care.Intersectoral cooperation was being promoted.

Other legislation, concerning collaborationbetween the health sector, social services and non-governmental organizations in the development ofpsychosocial rehabilitation programmes had alsobeen approved. For example, the national councilfor mental health and a number of regional coun-cils had been established, and a hospital referralnetwork put in place.The integration of mentalhealth services into the national health serviceensured their greater accessibility and adequacy.In-patient treatment was now provided in generalhospitals. Local services had been developed toreplace psychiatric hospitals, and new psychiatricservices were being funded at the communitylevel, including services for children. Drugs for thetreatment of severe mental illness were partly sub-sidized.

There was nevertheless a marked lack of progressin some areas. Stigmatization persisted, little atten-tion was paid to preventive programmes and therewas a lack of community-based facilities to bridgethe gap between hospital and home care.There wasalso a lack of epidemiological data on psychiatricmorbidity and mortality and use of the availablefacilities.There was a particular need for monitor-ing and assessment of the national mental healthpolicy, its implementation and the quality of care.Efforts were being made to promote mental healthby investing in community-based facilities for long-term patients, developing a national plan to createother facilities such as day care and continuity ofcare on medium-term and long-term bases.Epidemiological and economic studies were beingplanned at the local and national levels, and anongoing monitoring and assessment programmehad been established to ensure quality of service.

Republic of Korea

Dr Lee said that, until the mid-1990s, hisGovernment’s policy had been geared to long-termhospitalization of mentally ill patients. However,with the enactment of the Mental Health Act in1995, there had been a trend towards a communi-ty-oriented approach, concentrating on early


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detection, early treatment, rehabilitation and inte-gration in the community. Considerable improve-ments had been achieved. About one million per-sons were currently receiving treatment, repre-senting 2.7% of the total population. A large-scaleepidemiological study on mental illness was underway. Measures had been put in place to providesupport for families, appropriate jobs for thoseable to work, and entitlements to disablement ben-efits.The Government was committed to combat-ing social stigma related to mental illness throughpublic campaigns and community-based projects.Mental Health Day 2001 had been celebrated withthe design of a special emblem to draw attention tothe importance of mental health and the organiza-tion of academic seminars and rallies for mentallyill patients.

Romania

Dr Bartos explained how she had learned early inher medical career the true importance of ade-quate mental health services.The lack of such serv-ices allowed many persons with mental disordersto hide behind real or virtual barriers, some ofwhich were presented by prejudice and intoler-ance. In her country, despite the important socialchanges that had occurred, violence, unemploy-ment and a rapid deterioration in economic condi-tions and living standards were all affecting themental health of the population.The Governmentbelieved that health care was a collective socialgood to which everyone should have free and equi-table access. Better health in Romania would beachieved through a strategy of correcting theexcessive orientation towards hospital serviceswhich was detrimental to outpatient and commu-nity care.

The Ministry of Health and the Family had sub-mitted a bill to promote mental health and theprotection of persons with psychological disor-ders, to ensure that they were treated in a man-ner that fully respected their dignity, without dis-crimination and, in so far as possible, in the com-munity.WHO had supported the preparation ofthat bill and had also contributed to the evalua-tion of mental health at the national level.Romania needed a national mental health planbased on: the determination and evaluation of thereal dimension of the problem; the reform and

effectiveness of the system of mental health serv-ices; and integrated, interdisciplinary and inter-sectoral programmes to promote mental health.Family doctors needed to be involved to a greaterextent as “gatekeepers” and special assistancewould have to be provided to vulnerable andhigh-risk groups.The Ministry was also coordi-nating a project financed by the World Bank forthe establishment of a mental health centre. Shewelcomed the support provided by WHO and itsinitiatives to raise awareness of mental healthproblems, which had prompted several new activ-ities, which she hoped, would reduce certainobstacles to mental health service reform, includ-ing traditional attitudes and inertia. In transitioncountries, such as her own, one of the most diffi-cult reforms had concerned hospitals, in whichmost mental health services were located and thecall for emphasis to be given to outpatient andcommunity services. Such a course of action washard, given the lack of information on the realdimension of the problem. She therefore wel-comed the round table which, even if it did notknock down existing barriers, would neverthelessweaken them.

Russian Federation

Professor Krasnov stressed that the rise andspread of mental health problems were characteris-tic of all societies, rich, poor, or in transition. Itwas wrongly assumed that poverty eradication wasthe prerequisite to the reduction of prevalence ofmental health problems; however, those problemswere themselves factors of social and economicdevelopment.

Any long-term strategy of care and preventionrequired greater integration of psychiatric servicesinto the general health system, with families andeven former patients contributing their uniqueexperience, skills and advice on how to overcomecertain problems.The task could not be left to spe-cialists alone; it required the participation of allmembers of society, and of primary health careworkers in the first instance. Although his countryhad limited experience in that domain, it hadorganized local polyclinics facilitating early inter-vention through offering access to services thatcommunities would otherwise shun if provided bylarge institutions.


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He suggested that a global appraisal be made ofexperience in mental health care in different coun-tries in order to develop effective health care mod-els.WHO was uniquely positioned for such a task.

Many participants had described community-basedmental health care policies, but there were as manyinterpretations of the term “community” as therewere regions, countries or towns.Whereas mostvillagers knew one another, in large urban apart-ment blocks people rarely knew their neighbours.Effective community-based care should be predi-cated by a definition of “community”.

Rwanda

Dr Rwabuhihi noticed that the date for WorldHealth Day, devoted to mental health, had been 7 April. However, that day was one of mourning inRwanda to commemorate the tragedy of 1994,where in the space of only 100 days one millionRwandans had been killed by other Rwandans.Thesignificance of that date would prevent Rwandafrom celebrating World Health Day for many yearsto come. Mental health programmes in Rwandawere being decentralized in order to help to copewith the healing of an entire society. It was not aquestion of healing a few groups on the marginsbut of instituting a mental health programme forthe whole population.The need was more readilyunderstood when set against the backdrop of themore-than 120 000 persons still in prison on suspi-cion of having participated in the massacre of theircompatriots. One survey of 3000 children in 12provinces had revealed that over 90% had been indanger of being killed and more than 95% believedthat they were dead, even though they were living.Those factors gave an indication of the enormity ofthe task being faced with very few resources.Rwanda had chosen a participatory form of justicein which people who had witnessed the massacresfor three months would be able to tell the truthabout what had happened.That was the reason toask everyone to participate, including the tradi-tional health systems, the district hospitals and thehealth centres, in order to seek the truth and assistin the healing process.The traditional healers wereneeded because there was a desperate shortage ofso-called modern medical personnel.There werefewer than 200 doctors in Rwanda as comparedwith more than 10 000 traditional healers. He

thanked all those who had helped Rwanda, espe-cially in training. He expressed his particularappreciation to Switzerland for its cooperation intraining doctors and mental health specialists.

Rwanda

Dr Rwabuhihi said that mental health institutionsshould not remain in isolation but should be locat-ed in city centres. Rwanda had recently opened acentre for psychological and social consultations inthe middle of town, next to the main bus station,and had been surprised to find how many people ithad attracted. It might help to make that approachmore widespread.

San Marino

Mr Morri said that mental disorders should receivegreater attention. Since 1955, patients in SanMarino had enjoyed free, direct access to medicalcare, including care for mental and neurologicaldisorders. As San Marino had no psychiatric hospi-tals, patients requiring admission were referred toinstitutions in other countries. In addition, relevantlegislation was being reviewed to respond to newneeds, including support to care providers.

San Marino had always attached importance to car-ing for patients with mental disorders throughsocial and community-based services, and strate-gies had been improved to enhance quality of life.Rehabilitation was individually tailored, andincluded access to half-way houses for reintegra-tion into the community, occupational rehabilita-tion workshops and special training contracts.Private companies could enjoy reductions in theirsocial contributions if they employed certified dis-abled persons and were required by law to employone disabled person for every 20 employees.Thoseand other administrative and social measures wereeffective in preventing the stigmatization of per-sons with mental disorders.

Voluntary assistance contributed significantly to theservices provided by the State, and some voluntaryassociations were actively promoting informationon mental disorders, supporting rehabilitation, andencouraging the involvement of the mentally andphysically disabled in sport.


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Current commitments would need to be sustained,through, inter alia, investment in human resourcesand the implementation of preventive programmestargeted at all social groups, and the provision ofeffective and individually tailored care. It wouldalso be essential to improve understandingbetween patients with mental disorders and doc-tors.

Senegal

Mr Diop, describing the experiences in his coun-try, said that particular stress was being laid onraising public awareness of mental health matters.Through the national health education system,mental health experts were promoting a pro-gramme in the mass media, using all theSenegalese languages. In 2001, particular emphasiswas being given to epilepsy, prevalence of whichwas 8% to 11%. An information programme wasbeing developed to induce traditional practitionersto refer patients with mental disorders to special-ized care services. So far, participation by the Statein care for patients with mental diseases was stillvery low, although the Ministry of Health was cur-rently developing a national programme in thatregard.The strategies were aimed at reducingstigmatization and exclusion and encouraging fami-ly participation in caring for patients with mentalhealth problems. Some patients were cared for inpsychiatric villages, staffed by carers from the sameregion. Elsewhere specialized teams were being setup to visit patients in their own environment. Anattempt was being made to integrate mental healthcare into the basic health care programme, whichinvolved training health workers at all levels andimproving prevention, screening and treatment.Traditional practitioners were also becomingincreasingly involved in mental health care along-side professional health workers.

Sierra Leone

Dr Jalloh welcomed the decision to focus on men-tal health for World Health Day 2001 and toinclude the subject on the agenda of the currentHealth Assembly.

The Ministers of Health of Uganda and theDemocratic Republic of the Congo had raised the

issue of civil strife as a factor in mental health prob-lems. It was important for countries that had under-gone war to share their experience of the relation-ship between war and mental health. On 6 January1999, rebels had invaded his country’s capital,Freetown, and had carried out widespread and bar-baric attacks on the civilian population, includingarbitrary executions, abductions, single and gangrapes, amputations, arson and looting. At least 10000 people were alleged to have died and at presentsome 150 000 were displaced from their homes.

While most medical personnel acknowledged thatgross atrocities had been committed, they knewlittle or nothing about post-traumatic stress disor-der, which was difficult to define both conceptuallyand operationally. It was a unique diagnosis, in thatan exposure or criterion stressor was an integralpart of the disease.The criterion stressor requiredthat a person had experienced an event that wasoutside the range of usual human experience.Although specific criterion stressors might be diffi-cult to define, participation in war was generallydeemed to be such an experience.

The concept of post-traumatic stress disordershould be considered with care, as not all disordersarising after traumatic events fell into that catego-ry.To overcome mass traumatization, as in the caseof Sierra Leone, the healing capacity of familycommunity systems should support people in cop-ing with severe stress and with more severe mentalhealth problems.The number of traumatic experi-ences and their duration were important risk fac-tors in the development of post-traumatic stressdisorder. Sufferers from traumatic stress often hadphysical complaints, the so-called psychosomaticstress symptoms, although they were often misdi-agnosed by medical practitioners who were notpsychiatrists. It was important to consider not onlyconventional forms of depression and schizophre-nia, but also the stress disorders that arose as aresult of war.

Singapore

Professor Ee Heok Kua said that it was importantto convey a positive message indicating that manypeople did recover from mental health problems.To that end, Singapore’s health authorities workedclosely with nongovernmental organizations, held


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public forums every two months on common men-tal illnesses including depression and anxiety, andcollaborated with the mass media to destigmatizemental illness and to ensure that correct informa-tion was provided.

It was important for governments to ascertain theextent of mental health illnesses in order to planservice. Following a national survey in Singapore,action had been taken in three areas: teachers andcounsellors had been trained to recognize andmanage mental health problems in schoolchildren;personnel and managerial staff had also beentaught to recognize the common signs of mentalillnesses in the workforce, as well as counsellingtechniques; and retired professionals had beentrained to provide counselling support to the eld-erly. In all cases, if a problem could not be man-aged, the individual concerned was referred to aspecialist.

He hoped that mental health would remain a focusof attention for WHO, and that, in the future, theOrganization would coordinate programmes andmake sure of their effectiveness.

Slovakia

Mr Hlavacka said that because mental health carewas dominated by medical specialists the relatedstrategies did not involve other professionals, suchas social carers, patients and families.The role ofthe family was crucial, not only in terms of diagno-sis (as the family was often the first to identify theproblem), but also in enhancing access.The familycould bring the patient for treatment and assist inreintegration.Thought should be given to a socialenvironment that optimized the ability of the fami-ly to care for the patient. Often, the problem wasnot one of education or understanding, but of theeconomic ability to care.

Like other countries, Slovakia had formulated amental health strategy.The difficulties lay in moni-toring implementation and in establishing indica-tors of performance. Evaluation of treatmentstended to be based on costs, the number of drugsused and the number of treatment centres avail-able. However, there were few indicators to meas-ure responsiveness of care.The views of the caregivers, the families and the individual patientsshould be sought on how to improve the service.

There was also a place for the type of benchmark-ing that WHO was carrying out. Finally, as to therole of WHO and other international organiza-tions, the causes of mental illness, such as povertyand stress, must also be tackled.

Slovenia

Mr Marusic said that alcohol consumption and sui-cide each accounted for 30 deaths per year per 100000 population.The current national health pro-gramme contained little on the subject of mentalhealth, so a national mental health programme andnational legislation on alcohol and tobacco con-sumption were currently in preparation. Primaryprevention had already been introduced into thework of general practitioners, who were requiredto put questions to their patients concerning theirmental well-being.Those with the highest risk fac-tors were then involved in group therapy. A pro-gramme to encourage healthy schools and work-places had also been launched. In order to reducestigmatization, a patient advocacy act that stressedthe need to protect the human rights of those withmental disorders was under discussion.The thirdand final reading of that act was to take place inthe near future.

South Africa

Dr Tshabalala-Msimang said that one of herGovernment’s objectives was to promote an inte-grated approach to health care. Health care wasnot regarded as being the responsibility of theDepartment of Health alone and it had been possi-ble to achieve an increase in social spending inrecent years. A mental health bill, to be submittedto Parliament in the near future, would provide aframework for the delivery of care at all levels ofthe health system and would promote rights forthose disabled by mental illness. South Africa wasalso finalizing a special training instrument toimprove the skills of staff. An important challengewas the provision of appropriate services for peo-ple emotionally traumatized as a result of, forinstance, rape, child abuse and family break-up.Prevention of mental disorders was crucial andoften involved intersectoral collaboration. SouthAfrica had initiated a programme aimed at theprevention of violence in schools and projects


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along the lines of the WHO parent-child bondingprogramme.The next step was to improve pri-mary mental health care. One-stop centres hadbeen established for abused women, and healthworkers were being trained to deal with basicproblems, to counsel on victim empowerment,and to recognize the need for referral. Futureactivities should include expansion of the networkof referral centres and attention to the needs ofhealth workers who took care of people withmental disorders.

Recent research had indicated that high blood alco-hol levels were associated with well over half of allnon-natural deaths including homicides and trafficaccidents. Greater emphasis should be given toreduction of demand and supply of alcohol; pre-vention work in that area would have many humanand financial advantages.The spread of HIV/AIDSamong psychiatric patients was also a serious con-cern. A project aimed at developing comprehensivelife skills in schools, which covered HIV/AIDS andsubstance abuse prevention, had been introducedunder the WHO/UNDCP Global Initiative onPrimary Prevention of Substance Abuse. Lastly, shedrew attention to the need to develop appropriatecommunity services and to shift budget resourcesaccordingly.

Sri Lanka

Mr Seneviratne said that, although his country hadachieved high levels of health with a relativelysmall financial investment, developments in mentalhealth had lagged behind other aspects. Sri Lankawas facing high suicide rates and psychosocial dis-abilities related to stress, in connection with thesocioeconomic effects of the war in the northernand eastern areas of the country. Lack of awarenessof mental disorders, social stigma and the low pri-ority attached to mental health continued toobstruct the development of mental health servic-es. A series of measures had been taken in recentyears to develop mental health services and todecentralize mental health care.The greatest prob-lems faced by Sri Lanka were the lack of qualifiedpsychiatrists, which he hoped would be alleviatedby the training of medical officers; and the highrate of suicide among the young, which he hopedcould be addressed through research conducted incooperation with other countries.

Sweden

Mr Engqvist said that, in 1995, Sweden had chal-lenged the traditional views of mental health serv-ices, shifting from large-scale institutional psychi-atric care towards municipality-based rehabilita-tion and integration programmes.The aim was toensure that people with mental health problemswere closer to the main stream of health services.Despite major investment and a positive responseto the structural changes introduced, however, theprofessional and other available resources had notmet the required high standards of care. A nationalcentre had therefore been established to providesupport for individuals suffering mental or func-tional impairment and to ensure maintenance oftheir dignity and respect, in which connectionpersonnel training was important. Moreover, anational action plan presented in 2000 would sub-stantially increase health care funding and focusefforts on improving primary health care and carefor the elderly and the mentally ill.The importantrole and the responsibilities of general practition-ers in prevention and early intervention wereequally underlined. Under Swedish legislation(compliance with which was annually monitored)patients had the right of access to information, aswell as the right to a second opinion and a voice intheir care and treatment. Special attention wasdevoted to patient empowerment and the valuableassistance of patient organizations was recognized,both in the development of legislation and guide-lines and in the evaluation of reform and otherchanges.

Although mental health conditions had generallyimproved in Sweden, mental ill-health hadincreased at an alarming rate, particularly amongteenagers and young women. Special measureswould therefore be taken. Mental illness wasstrongly connected to poverty and substance abuse.Notwithstanding the significance of genetic factorsin many conditions, social support systems werecrucial in diminishing the consequences of mentalillness, in which context he highlighted the advan-tage of multiprofessional approaches and theimportance of cooperation between the differentactors, including nongovernmental organizations.

Together with a well-developed preventive healthsystem, a proper education system was the key to


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providing the basic conditions needed to ensurethat young people developed self-esteem andadopted healthy lifestyles. In that context, encour-aging progress had been recorded in Sweden’sefforts to tackle domestic violence, including thedevelopment of a new training programme forprofessionals in the fields of health, social servicesand law enforcement. Sweden had also investigatedgender differences in the provision of health careand was endeavouring to eliminate conditionsattributable to gender discrimination.

Switzerland

Ms Dreifuss, responding to the Chairman’s secondand third questions, suggested that the primeresponsibility of the public sector was to ensurethat everyone had access to care. In Switzerland,that meant that mental health was covered byhealth insurance on an equal footing with physicalhealth. However, access to mental health care washampered by the public’s poor level of knowledgeof mental disorders. A second responsibility of thepublic sector was therefore to promote under-standing of how mental disorders evolved in orderto allow early intervention.Whereas certain issuessuch as drug dependence, because of their effecton public order, were well known and tackled,such disorders as depression quietly took holdbefore treatment could be delivered and before thecommunity or the family became aware of theirexistence.

It was also the State’s responsibility to develop andto ensure good quality mental health care, to con-duct epidemiological studies, research and train-ing, and to safeguard the human rights of patientswith mental illnesses as persons fully integratedinto society.

The approach to mental health problems shouldtarget different segments of society.Young people’sproblems, as manifested in drug abuse, suicidesand depression, differed from the problems of thevery old, characterized by serious depressions, andthe problems of work-related stress and the work-place in general.Those approaches needed to beadjusted to take account of differences betweenmen and women. Switzerland had had to developspecific responses to the problems of migrants anddisplacement. Caring for refugees and the particu-

lar traumas they brought with them required a dif-ferent perspective on diagnosis. In summary, shestressed the need for widespread information, butalso a targeted approach according to populationgroups, in order to promote understanding ofmental health.

Thailand

Dr Winai Wiriyakitjar remarked that his countryhad experienced two major crises in the pastdecade: HIV/AIDS and the economic recession.There was an increasing number of mental healthproblems, including suicide: the annual rate hadincreased from 7.2 to 8.6 per 100 000 populationover the past five years.The Government had triednot to cut health expenditure but to use the eco-nomic crisis as an opportunity to review its healthstrategies.

The World Health Day theme and related activi-ties showed that discrimination and access tomental health care were major concerns in mostcountries.Thailand’s experience with psychotrop-ic drugs was that side-effects increased stigmatiza-tion and reduced compliance. Newer drugs hadfewer side-effects but were more expensive. Forthat reason he proposed that access to such drugsshould be given high priority in the WHO revisedmedicine strategy. Also, he wanted WHO to con-sider recommending that Member States ensurethat such drugs were appropriately representedon essential drug lists. He concluded by express-ing the hope that the output of the round tableswould be more than a report; he expected a con-crete result that would improve mental health andalleviate the suffering of those with mental disor-ders.

The former Yugoslav Republic of Macedonia

Dr Nedzipi said that mental health care in hiscountry was inadequate, and lack of resources forhospital and community care deprived many men-tally ill persons of their basic human rights.WithWHO’s support, however, the Ministry of Healthhad elaborated a master plan to improve humanresources and had proposed new legislation toenhance patients’ rights and combat stigmatization.


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Community mental health services had been set upin three pilot areas in partnership with threeEuropean municipalities. Day-care centres, protect-ed homes, social enterprises and social clubs weresupported by the public service and by nongovern-mental organizations, in a multisectoral approach.Mechanisms were in place to ensure the sustainabil-ity of the community-based approach, and initia-tives had been taken to increase the resources ofthe project and replicate it in other pilot areas.

Trinidad and Tobago

Dr Parasram said that, after a long period of neg-lect, mental health had become an integral part ofhis country’s health sector reform programme.Thenew mental health plan currently being imple-mented took into account the relationship betweenmental health, social pathology and other exacer-bating conditions and sought to provide a range ofintegrated services, with the emphasis on primarycare of the individual within the community. It alsocomprised activities such as a legislative review,restructuring, an assessment of health needs andhuman resources, training, health promotion andthe development of regional plans in associationwith provider agencies. Approval had been givenfor the establishment of a suicide-prevention taskforce; the current system of drug procurement anddistribution was under review; and new genera-tions of drugs were available at public mentalhealth care institutions. Such policies and reviews,however, were insufficient in themselves to reversethe stigma of mental illness and related problems, aprocess which demanded continuous efforts. In hiscountry, fruitful forums had been held with themedia.That group could serve as an important allyin overcoming the challenges entailed in movingthe mental health care agenda forward. On thatscore, he looked forward to the continuation ofnational, regional and international action aimed atimproving the quality of mental health for theworld’s citizens.

Tunisia

Dr Abdessalem said that mental health had longbeen neglected for a number of reasons. Onceindependent,Tunisia had immediately tackled suchscourges as infant mortality and had embarked on a

countrywide immunization campaign. Since 1990,it had included mental health in its general healthstrategy, with emphasis on legislation, organizationand human resources.

The first major component of that strategy hadbeen the integration of the mental health pro-gramme into existing structures dispersedthroughout the country, to take those services clos-er to the users.The second component, still beingfinalized, was the establishment of the structuresnecessary for the various categories of mentalhealth care. Counselling units had been set up insecondary schools, higher education establish-ments, and in some small hospitals. A decision hadyet to be taken with regard to voluntary and invol-untary hospitalization. A third important measurewas to attack the myriad risk factors for mentaldisorders through education, affording all childrenthe opportunity to continue their studies and thefight against poverty with the creation of jobs foryoung people. Action was being taken to protectvulnerable groups, particularly children and theelderly, especially with respect to violence againstwomen and children.The authorities were alsoendeavouring to ensure that persons who were orhad been mentally ill were reintegrated into thecountry’s social and economic systems.

He endorsed the view expressed by many speakersthat legislation on its own did not provide effectivemental health care. A change of mentality wasrequired among all persons involved in mentalhealth care, including psychiatrists, who weresometimes unwilling to share their power andknowledge. It was equally important to train socialworkers, specialized nurses, psychologists and psy-chiatrists, and to provide psychiatric training forgeneral practitioners. In short,Tunisia’s strategyfocused on prevention and reduction of risk andaffording its citizens better access to proper care indecentralized clinics, sponsored by university fac-ulties of medicine and psychiatry.

Uganda

Dr Kiyonga had seen evidence in his country thatstigmatization could be overcome.When he hadbeen a medical student in the late 1970s, no stu-dent would have dared to admit to being near amental hospital, yet when a psychiatric clinic had


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recently been closed in town and mental healthpatients had been asked on radio to go to an out-of-town hospital for treatment, the reaction hadbeen good. Furthermore, people were now con-tacting physicians about mental illness. In two fur-ther major developments, former sufferers fromschizophrenia had formed an advocacy group toeliminate stigmatization of the disease, and the par-ents of epileptic children had created an associationto seek care for their children and to promote themessage that epilepsy was a manageable condition.In order to give people confidence, the health sec-tor had to demonstrate that treatment worked andthat people got better. Sufficient confidence had tobe generated in the population that people couldbe treated before legislation was adopted. Suchlegislation should be timed to coincide with animprovement in care and not be rushed through.

Lastly, was there any evidence that the extendedfamily structure prevailing in most African Statesoffered an advantage in mental health care? Could itbe shown, all other things being equal, that coun-tries with an extended family structure stood a bet-ter chance of dealing with mental illness than devel-oped countries that did not have such a structure?

Uganda

Dr Kiyonga, noting the trust placed in traditionalhealers by the general population in his country,expressed interest in views on the role that tradi-tional medicine could play in mental health care.His country gave a high priority to the treatmentof mental illness as the HIV/AIDS pandemic andprotracted civil strife had increased the incidenceof such illnesses. Uganda, in common with othersub-Saharan countries, suffered from high rates ofunemployment and poverty.The public sector wastherefore seen as the key to tackling mental healthproblems and to raising public awareness so as toreduce stigmatization and to encourage the mental-ly ill to seek help. A loan recently granted by theAfrican Development Bank would be used toreform national institutions responsible for healthcare delivery and to integrate the delivery of men-tal health and general health care.The training ofhealth workers was currently being reviewed, inorder to facilitate recognition at primary healthcare level of conditions likely to affect mentalhealth and to avoid over-specialization.

United Arab Emirates

Mr Al-Madfaa, concurred with previous speakerson the importance of eliminating discriminationand stigmatization in regard to the mentally ill. Hiscountry took account of the psychiatric causes ofcertain illnesses, and was making efforts to raiseawareness of mental health issues among studentsin universities and training institutes.The need forinteraction between various ministries was recog-nized, and the ministries of health and education inhis country were working together to combat psy-chological disorders among schoolchildren. Heemphasized the importance of awareness-building,of the role of the family, of research, and of the useof the media in order to target areas for mentalhealth action more successfully.

United Kingdom of Great Britainand Northern Ireland

Ms Hutt said that the National Assembly for Waleswas aware that all the policy areas for which it wasresponsible, namely health and social services,housing, environment, economic development andeducation, were relevant to the improvement ofhealth and well-being and to tackling mental healthproblems. It had also become clear to thatAssembly in the two years of its existence that anational strategy for mental health was essential,with priority funding. Such a strategy would pro-vide for local delivery and local management ofservices through primary care and communityhealth development.

Every effort was being made in Wales to ensurethat people who had used mental health services orwere suffering from mental health problems wereinvolved in policy development, both in their localcommunities and in the National Assembly.

In developing community services, it was essentialto have plans and funds in place before closingexisting institutions. It was equally important, withone in four people likely to experience mental dis-tress at some time, either in their families or intheir communities, to ensure that the communitywas able to address their needs.


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United Republic of Tanzania

Ms Abdallah observed that some 85% of the pop-ulation of her country lived in rural areas wherethere were practically no mental health servicesapart from traditional healers. In most cases men-tal illness was associated with curses or supernatu-ral causes. Her Government had developed a men-tal health policy, but traditional practices stillneeded to be integrated into modern medicine.She requested assistance from WHO in that area.

Specific causes of mental disorders in her countryincluded the rapid breakdown of traditional psy-chological support systems and social norms,poverty and rural-urban migration in the absenceof social skills and strategies to adapt. A secondcause was the long-term presence of refugees,whose settlements were breeding grounds formental disorders. In surrounding areas there hadbeen increases in crime, resulting in insecurityamong the indigenous population. Mental healthservices thus needed to serve local populations aswell as refugees.

United States of America

Mr Thompson, responding to the second questionput by the Chairman, said that it was the responsi-bility of governments to disseminate informationon mental health as widely as possible in order tocombat the suspicion and scepticism that surround-ed the subject. In the United States, one seventh ofgross national product was spent on mental andphysical health combined, and in all countries men-tal illness was among the five leading factors con-tributing to low productivity, absenteeism and sui-cide.The United States was spending more thanUS$ 1000 million on research into mental health,as a result of which great progress was being made.

Two of the most difficult problems in the field weresuicides among young people and discriminationagainst women. More needed to be done to reachout to young people and to try, through the educa-tion system, to reduce the number of suicides andeventually to prevent them.There was no doubtthat certain mental illnesses were more prevalentamong women than men, a difference that shouldbe reflected in research and in expenditure on serv-ices. His Government intended to give mental ill-

ness a higher priority than in the past, and toensure that it was treated on a par with physical ill-ness.

Uruguay

Dr Touyá said that a process of de-institutionaliza-tion of mental health care had begun in 1986, withmuch of the responsibility passing to the communi-ty.That had resulted in fewer and shorter hospitalstays, thereby improving patients’ quality of life intheir family environment. Psychiatric care couldnot fail to improve with increasing knowledgeabout brain function. Nevertheless, the risks formental disorders were increased in a civilizationthat pushed people increasingly towards self-destruction.The most positive approaches wereprevention and protection, to which end WHOshould firmly support countries that set examplesof strong family bonds, which were known toreduce poverty and violence.The media should beused to raise awareness.

Venezuela

Dr Urbaneja Durant reported her country’s expe-rience in carrying out extensive political and insti-tutional changes that had enabled progress byensuring that universal rights such as the right tohealth were met.That right must include the rightto mental health, and health must be seen as anintegral part of well-being and development.Obstacles to those goals were often related topoverty and inequality.Venezuela had worked outthree strategies to try to overcome those obstacles:incorporating guarantees for rights in the country’sconstitution; ensuring application of the constitu-tional provisions through governmental policies;and health system reform.

Venezuela’s constitution enshrined health as a basicright, without any discrimination on grounds suchas mental ability or gender. It included respect fordiversity and differences between individuals,which demanded a major change in attitudes.

Promoting health was essential for guaranteeingoverall rights.That meant intersectoral approaches,improved access to more effective and appropriateservices, tackling discrimination, and provision of


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decent living conditions for health. Gender differ-ences were recognized, for instance in access tohealth services, discrimination and quality of life.The National Women’s Institute had designed spe-cific policies and strategies together with nationalplans in that regard. A council for the protection ofchildren and young people had been established toensure shelter, proper nutrition and feeding, andaccess to education, especially for street children.For disabled people there was a national commit-tee for disabled persons and legislation forimproved protection was being enacted. Stepswere being taken to improve the living conditionsfor indigenous people whose rights were guaran-teed in the constitution. Laws were in place toguarantee individual rights in times of emergencyand disasters.

Her country had changed its model of health care,emphasizing health, rather than disease, as thestarting point. Prevention and health promotionformed critical strategic elements for health careworkers; they needed to understand that in inte-grated health care, health must be promoted inplaces regularly frequented by people, such asschools, sports venues, and outpatient clinics. Inparallel, the profile of a health worker was beingchanged in favour of that integrated health careapproach.That would help to remove the stigmasthat blocked access to the mental health care whichpeople needed; otherwise mental health problemsand stigmatization would be exacerbated.

Specifically with regard to psychiatric care, she wasconvinced of the need to care for both acute andchronic cases, with involvement not only ofpatients but also of their families and communities.That would ensure proper treatment, both in hos-pitals and in communities, with rapid reintegrationinto society.

Viet Nam

Professor Pham Manh Hung informed the meet-ing that, like many developing countries,Viet Namhad seen an increase in the incidence of mental andbrain disorders.The Government was dedicated topoverty reduction and had made considerableprogress in the past five years. Priority had beengiven to programmes with a strong commitmentto the provision of equitable health care services

for the poor, including priority allocation ofexpenditure for health in poor areas. Health work-ers in the mental health field were encouraged byadditional allowances equivalent to 20% of theirsalaries, a seven-hour working day and early retire-ment.

Improvements had also been made in hospital care,and the number of mental health departments incities and provinces had been increased, as had thenumber of psychiatrists. More recently, mentalhealth care had been integrated into the generalhealth service, with emphasis on community-basedservices. Most districts currently had a mentalhealth consultancy, responsible for the care and fol-low-up of patients.

Community awareness of mental health problemshad increased. Nevertheless, and despite the con-siderable progress made in providing mental healthcare, poor people continued to suffer. Limited gov-ernment expenditure on health and the lack ofwell-trained psychiatrists on the one hand, andpoverty, social discrimination and prejudice, a lackof information and superstition on the other, weremajor obstacles to the provision of mental healthcare and information on preventive treatment.

To counteract that situation, the Government hadapproved a five-year plan for development of thehealth sector with the aims, inter alia, of expand-ing health care centres to a further 50 communes,expanding community-based mental health servic-es to other provinces, providing community-basedmanagement and improving cure and rehabilitationrates. A notable result was that 50% of the coun-try’s community health centres now had at leastone medical doctor.

Yemen

Dr Al-Munibari agreed with earlier speakers thatwarfare and violence were among the major causesof mental illness. He also pointed out that smokinghad a deleterious effect on mental health, andemphasized the importance of sporting activities inovercoming mental health problems. It was essen-tial that the subject of mental health should remainon the agenda of future round tables.


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Yugoslavia

Dr Kovac said that in the past 10 years the popula-tion of his country had experienced the traumas ofwar, sanctions, and consequent impoverishment.That had occurred at both family and communitylevels, and materially as well as spiritually, throughthe collapse of traditional social and cultural val-ues, and the loss of hope. Mental health wasimpaired as never before.The incidence of classicalmental disorders had increased, as had conditionssuch as post-traumatic stress syndrome, anxiety,neurosis, substance misuse and marked depressionswith psychosomatic symptoms.Those were reac-tive pathologies to which people were not suscep-tible in normal conditions.The consequences wereincreased social pathologies, evidenced as greaterdelinquency, crime and violence.The presence oflarge numbers of refugees, with associated mentaldisorders, posed an additional problem. Children,many orphaned or living in collective centres, con-stituted the most vulnerable population. Some hadexperienced traumas at an early age.

The past 12 months had seen considerableimprovement in mental health.The Ministry ofHealth and Social Policy was finalizing a multidisci-plinary project to reduce and eliminate sufferingand to facilitate treatment.The support of WHO inthose efforts would be welcomed.

Zambia

Mr Mumba observed that mental health problemscontinued to have a considerable negative impacton his country’s health status.While Zambia haddone a great deal to upgrade the quality of mentalhealth care in recent years, there had been a signif-icant erosion of the human resource base, in par-ticular, front-line mental health workers. Healthinfrastructures and equipment were in a deplorablestate, and essential psychotropic drugs were onlyintermittently available. Zambia had established apost of mental health specialist, and some progresshad been made. A mental health situation analysishad been undertaken; a draft bill had been submit-ted to the Ministry of Legal Affairs; mental healthhad been integrated into the essential health carepackage at community level, with the possibility of

referrals; and mental health had been accorded itsplace among public health priorities.

Zambia’s participation in international forums andprojects had led to the establishment of key linkswith a broad spectrum of mental health experts. Asa member of the International Consortium forMental Health Policy and Services of the GlobalForum for Health Research, Zambia was pursuingways of securing WHO support, and was partici-pating in the WHO/UNDCP Global Initiative onPrimary Prevention of Substance Abuse. At thelocal level, partnerships had been established withcommunities, giving them a central role in realiz-ing improvements in mental health care. HisGovernment was committed to developing a men-tal health policy, providing human resources formental health, reviewing relevant legislation andupgrading health infrastructure and equipment.New international networks would also be devel-oped that would benefit the local mental healthprogramme. Zambia viewed the stigmatization andmarginalization of people with mental health prob-lems as an inappropriate legacy from the past.Mental health services were a crucial componentof primary health care that would enable people towork productively and fruitfully.The inclusion ofmental health in WHO’s public health agendaunderscored the commitment of governments tothe development and improvement of nationalmental health services in line with relevant resolu-tions adopted by the World Health Assembly, theWHO Regional Committee for Africa, the UnitedNations General Assembly and UNDCP.

Zimbabwe

Dr Stamps said that, after achieving independence,his country had totally recast its Mental HealthAct, so that it was currently dedicated to the needsof the patient rather than to the needs of societyfor protection.The Government had formulated itspolicy on mental illness, on the basis that psychi-atric events were never due to a deliberate act onthe part of the patient, so that all treatment,including the provision of drugs, was free.Therewas, however, a severe staffing problem. Nurseswere being trained but, on qualifying, often wentto more attractive posts abroad.The lack of trainedstaff meant that passive disorders were diagnosed along time after the first symptoms appeared.


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He drew attention to the increasing use of drugs intreating mental disorders, including the adminis-tration of stimulants and sedatives to children agedbetween two and four years.

The use of psychedelic substances to ensnareyouth, for the purpose of commercial gain, was amatter of great concern. Although the worst prob-lem was that of alcohol, dangerous drugs werereadily available to young patrons of night clubs.The involvement of community leaders had beenvery effective in confronting such trends. Heappealed to all to work together to bring about amore spiritual approach to living, in order toreduce temporary or permanent mental disability.


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