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29 May 2013

Right to Health and mental health


King College London (project Emerald, "
emerging mental health systems
in low- and middle-income countries)

Wednesday 27 March 2013, I had the privilege of attending the 2nd day of a symposium “The world in denial: Global mental health matters at Royal Society of Medicine, London.

There was much I learnt, and much I was already aware of as CABI’s Global Health database has nearly 20,000 records on mental health, 25% of them focussed on developing countries. One of the eye-openers for me was an understanding of the various legal tools dealing with international recognition of the Right to Health and the problems of getting mental health included in this framework; how including it under disability has implications for access to treatment.

This is what I learnt, put simply, from talks given by Professor Norman Sartorius (President of World Psychiatric Association) and Gunilla Backman (Former health adviser SIDA & Editor, The right to health: theory and practice).

Basic Human rights: these are not defined or not universally accepted


There are 5 categories of documents related to human rights

1. Conventions:  UN or international covenants: countries sign and then must abide by them

2. Declarations:
1948 UN declaration of human rights: referred to by everyone (individuals, academics and government policymakers) BUT not obligatory AND a choice of 2 different documents for countries to choose from! [One favoured by USA, one by Russia, each with different emphasis]. Under this banner, has come human genome project, opportunities for the disabled, protection of people with mental illness AND right to treatment.

3. UN Special Rapporteur on Right to Health, annual reports:
The 1st rapporteur was appointed in 2002, changed hands in 2009, and is held by a human rights lawyer. Role: “to raise the profile of the Right to Health as a fundamental human right; to clarify what the Right to Health means; and to identify ways of operationalizing this human right”. Acknowledges that mental health is most neglected of all human rights.

4. Regional instruments:

• WHO mental health declaration for Europe (valid only in Europe)

• American convention of human rights

• Banjul African charter of human & people’s rights

Arab charter on human rights

5. Non-binding standards, guidelines & declarations: these depend on an individual’s application of them in health practice and also on medical societies.

The problem is that “most of these documents are not well-known, are vague allowing different interpretations, and are not universally implemented (even the UN ones)”. They can actually become an obstacle to care: for inclusion of mental health under the Rights Of The Disabled means that treatment requires the patient to give permission, which in some mental health illnesses is not possible. If the patient is incapable of understanding enough to give permission, then 2 doctors have to sign. This is feasible in Switzerland but not in many African countries where surgeons & ophthalmologists are thin on the ground let alone clinical psychiatrists.

Furthermore, the classification under disabled, with its implied “no recovery”, creates tension between the family and the patient. The patient will be unwilling to accept a “ no recovery” label and won’t seek help. Their desperate family will grab at any chance to access help.

In developing countries, the mentally ill are on a hiding-to-nothing, as are the medical staff who try to help. For they have to deal with:

1. Stigma: prevents help being sought & a key issue in developed countries too

2. Access: if help is sought, applying guidelines which require 2 signatories is physically impossible.

3. Lack of hospital mental health services: financial cost is prohibitive so staff & resources are not provided, the existing hospital staff burnout trying to cope, services become further reduced.

4. Government or even international programmes fail because they don’t take into account cultural factors when they develop their messages or interventions. The actual decision makers in a family are not targeted or the targets are frightened off. Result: “right to health” not implemented.

e.g. Tamil Nadu Integrated Nutrition Programme: provided health care, education and supplements to pregnant women. Failed because it was provided at the market, where pregnant women did not go: should have educated the husbands and mother-in-laws who could go to market.

e.g. Swaziland men & circumcision: (IRIN, United Nations humanitarian news site). A 15-million-dollar initiative for voluntary circumcision in Swaziland has failed, largely due to a failure to inform men adequately about the benefits and risks, and about what is done with the foreskin after removal. (See Further Reading).

5. NO sunset clause: rules & regulations are not updated regularly, or discarded when new insights make them obsolete or downright pointless.

The way forward, according to Gunilla Backman, is to make human rights law compulsory in the health school curriculum, to ensure increased interdisciplinary approach to human rights and public health, and to use the existing tools available (not create new ones!)

One of the key aims of this 2 day symposium was to raise awareness of the human rights of the mentally ill coupled with specific requirements due to the nature of the illness. Major progress in understanding mental health has not come with a realization of their human rights. “Even in resource-tight times much can be done by stakeholders working together to create an action consensus”; to develop harmonized health & mental health services for all wherever they live.

Editor’s notes

Mental health was one of the key topics at this month’s 66th World Health Assembly. For a quick summary, view this blog.

To distinguish records on mental illness from records on people with mental disability, search Global Health with this searchstring:

de:("mental health" OR "mental disorders") NOT de:"people with mental disabilities"

Further reading

Both  these references have Fulltext held in Global Health.

  • The potential of involving traditional practitioners in the scaling up of male circumcision in the context of HIV prevention in Tanzania. Kilima, S. P et al. Tanzania Journal of Health Research, 2012, 14, 1.
  • Mental health spillovers and the Millennium Development Goals: the case of perinatal depression in Khayelitsha, South Africa. Tsai, A. C.; Tomlinson, M.; Journal of Global Health, 2012, 2, 1, 010302.


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