Makeshift@TED: Grassroots Healthcare
Makeshift is reporting live from TEDGlobal 2012 with five questions for Professor Vikram Patel.
Born in India and trained in the UK in the underfunded field of mental health, Dr. Vikram Patel is no stranger to resource constraints. But when he began a two-year post in Zimbabwe, he found himself utterly unequipped. In towns with few clinics, mental health often goes overlooked. In India, for example, the psychiatrist-to-patient ratio is one-fiftieth that of the UK’s. That’s why he adopted and spread a process called “task shifting” to crowdsource healthcare from community members. Now co-director of Centre for Global Mental Health at the London School of Hygiene & Tropical Medicine, Patel explains how to save minds where there is no psychiatrist.
We’re hearing more reports of suicides from India than ever. How serious is the mental health need?
Suicide in India is extremely preventable, just as many countries have shown by public health measures. But the resource constraint in India is the same across all areas of health—the great shortage of skilled healthcare professionals. The question is how you define a professional. In the modern world, we often relate that to doctors and nurses. There are very few doctors and nurses in Africa and Asia, and they’re inequitably distributed; they mostly work in the cities. Although we’re fascinated by technology in healthcare, the single most important technology is the human being with the skill to deliver interventions.
And task shifting can overcome these constraints?
Task shifting had been developed and tested in other fields—the process of shifting tasks to less expensive people. The first step is to define which elements of your intervention could be shifted and the competencies needed. The next task is to define how to get people to acquire those skills. The third is how to maintain those skills. Technology can play a huge role in monitoring, which is also very resource intensive. You could use mobile smartphones or other Internet devices to have peer group supervision or continued professional development.
The biggest challenge in translating task shifting to mental health was the impression people have about mental health being super complex. A lot of mental healthcare doesn’t require specialized training. There are low-hanging fruit: epilepsy, which is treatable in an extremely cost-effective way, and depression, for which we have robust evidence for talking treatments and anti-depressants. A bit further up the tree are drinking problems. Further up would be psychosis and dementia, where task shifting is less likely to be effective.
What makes a good amateur health worker? What do they bring that specialists can’t?
The important qualities are that you belong to the community, are articulate (that’s not the same as being educated), have compassion and interest in social issues, and are motivated to work with people on an individual level. Community workers bring a deep-rooted understanding of their own community which physicians and nurses don’t because they get de-cultured. The 10 years of training makes them rational thinkers of science as opposed to also understanding community values and understandings of health and illness. The community worker marries this understanding with training. This makes her interventions more acceptable because there’s less of a social class differential. For example, someone with a drinking problem is more likely to accept advice from someone he can identify with, who’s shared that problem and recovered, as opposed to getting prescriptive advice from someone in a white coat.
How did you spread the process?
The key challenge is getting people in the establishment—doctors and program leaders—to accept the idea that you can take ordinary people and train them and that this is the only practical way forward. Program leaders then say, “Alright, if you’re going to come up with a cheaper model that’s immediate, then I’m going to give you a chance.” The next step is to implement robust scientific methods to evaluate; otherwise, it becomes almost a religious belief. We work with existing government and community systems by placing new community workers within functioning clinics and comparing outcomes with clinics that don’t have community workers.
Did it work?
We’ve run a number of trials for different conditions—psychosis, dementia, depression. They all show that when compared with what usual care is available in those settings, the task-shifted addition of community health workers providing psychosocial interventions—psychological treatments and social interventions—produces much better outcomes. Whether it’s clinical outcome like recovery rates or functional outcomes like disability rates or economic outcomes such as getting back to work.