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Interview: Prof.  Martin Gittelman USA
Let us have Public Health Olympics World Cup to see
which country protects lives of its people with mental illness
French have been leaders in Mental Health Care who also
conceived the idea of community care
United States has 50,000 mentally ill patients in hospitals
while another 200,000 are in prisons and jails

By our special correspondent

We have campaigns to save the trees and save the environment. We now need a campaign to save people. This is ethical and this is their human right which should not be denied. We desperately need to save lives of people with mental illness in developing as well as developed countries. In United Kingdom people die prematurely of schizophrenia. Diagnosis of schizophrenia in England means premature death not because of illness but of other morbidities like cardiovascular problems, respiratory problems and so on.  These are all preventable we only need to pay more attention. May be we need a Public Health Olympics. People in UK, USA and Europe are very much interested in Football and World Cup. We need to organize a World Cup to see which country protects the lives of people with mental illness.  President John Kennedy had said that “the way you measure a country is not how big its army is and how much money it has but how it feeds its own people, its children and its disabled”. These views were expressed by Prof. Martin Gittelman a noted psychiatrist from United States who is also a former President of World Association for Psychosocial Rehabilitation.

He was visiting UK to participate in Midland Psychiatric Research Group conference as well as meeting of World Association for Psychosocial Rehabilitation held at Coventry from June 8-10, 2006.  In an exclusive interview with Pulse International Prof. Gittelman discussed at length the situation of mentally ill people in both rich and poor countries, the pioneering efforts of the French in mental healthcare and community care besides development of mental health services in United States.

Speaking about the prevalence of mental illness, Prof. Gittleman said that it is estimated to be 1% of the population. Hence we have roughly six billion two hundred million people in the world with mental disorders. This includes about 25-40 million people with serious mental illness. Of those who are living in Europe, they are lucky because they get treatment for physical and mental illness... However, those who are in a poor country like Pakistan, Tanzania, countries in South Americas, they have big problems.

The situation in poor countries Prof. Gittelman said is grim. If the world population according to World Bank lives on less than two dollars a day, 1.2 million people in the world are living on less than one dollar a day. My boss sent me to Africa  when I was in training to Mali. This country was and is very poor. Mali is three times the size of France. At that time there was one psychiatrist in the country. He worked in a hospital. People used to come from hundreds of miles away, travel with ill relatives to see him. He would write the same prescription for them. The medication was very expensive. People living there are as poor as dirt. I am a New Yorker so when I went there I was a little worried. I learnt that these people were very hospitable and wonderful. They invite you to their homes, offer you food but in that country they could not afford thirty dollars a month for medication. It was so expensive. These countries survive on cotton, but due to support prices, American cotton is cheaper in Africa than Malian cotton. You go to Guatemala; American corn is cheaper than Guatemala corn. People buy American corn in Guatemala. The land is not good either. So people are just surviving from day to day. If you have mental illness and you cannot work, it’s difficult for you to survive. Go to a poor country like Jamaica where there are no nurses as nurses are recruited to come to England and United States what we call the brain drain. It is cheaper for United States to get Jamaican Nurses than to train local nurses. The government can also pay them less when they come. The streets are filled with psychotics and they are starving. We tried to set up a programme for them in the Churches to give them at least food, three times a week. If you could not come up with simple basic food, then once a week. The nurse would come though  there were very few nurses and it was very difficult to get a patient, so when people come for food,  we will also give them medicines as in Jamaica drugs are available through government to keep people alive and surviving. But in poor countries if you become homeless, you cannot survive though you can survive homeless in England and America provided you can stay warm but the food problem is there. We have seen healthy people in Philippines scavenging from garbage. If you are poor, mentally ill, you are not as competent, you cannot find out where there is food.

When asked about the development of mental health services in United States Prof. Gittelman traced its historical background and said that in 1950s the government in collaboration with American Psychiatric Association and other mental health groups organized an Action for Mental Health and Mental Illnesses. This was composed of leaders in the field of mental healthcare. The objective of this group was to analyze the situation for the mentally ill and make recommendations as to what was needed. After study they recommended that we should have community mental health centers. These would function to take care of the complex needs of people with mental illness because with the advent of psychotropic medication it was no longer necessary to keep people for long periods in mental hospitals. In1963 a law was finally passed under the Presidency of John Kennedy which was called Community Mental Health Centers Act. It was decided to construct one thousand mental health centers similar to what was already being done in countries like France which has always been a leader in mental healthcare. They were the people who invented asylum at the time of French Revolution. The idea was that people with mental illness needed to be protected because otherwise they would be homeless and die. The French organized and finally after many years, passed the law in 1838 which required every province in France to construct an asylum. They did that and constructed asylum throughout France. The last asylum was built in 1946. After 1945 when the War ended, many of the psychiatrists who had been prisoners in German prison and concentration camps also suffered. It was then that these psychiatrists realized that even before the advent of medication which was again a French invention, there was a need other than locking up people in hospitals which meant community care. So after the War they began to do something which was called sectorization. The idea was that instead of chief of a ward which had beds in a hospital, the chief will be taking care of not only the ward but a department in a general hospital for mental patients. Not only that they will also reconstruct buildings in geographic area that could provide treatment for people who did not need to be put into a hospital. Even the team service in that geographic area would provide services to all the people who need psychiatric care like people with serious mental illnesses and not for routine problems of daily life. The design of community mental health centre was similar to French model without being connected although some people knew about it. But when we started building them in America there was no connection between mental hospitals and community mental health centers. So people were discharged from hospital and given a piece of paper. Sometimes they were able to find a community mental healthcare center but for the most part they did not. Community mental healthcare centers were constructed all over the country. They began to learn how to treat mentally ill because lot of people did not knew how to treat mental illness. They were using heavy medications and all kinds of stuff. By 1978 it was clear that certain changes were needed. Hence, President Jimmy Carter called a White House conference and also set up a joint commission, Mental Health and Mental Illnesses. I served on that Commission. The idea was to improve connection between the mental hospitals and community mental health centers. In those days these community health centers were not treating the mentally ill. They were treating people who came in with mild depression, problems with their employers and problems of daily life. Only 14% of their contact was with seriously mentally ill people. The law was crafted called Mental Health Systems Act `1979 which was passed by Congress after big battles. Then came the elections of 1979 and the new President Ronald Reagan rescinded the Mental Health Systems Act which stopped money coming to community mental health centers. Hence they either closed or became private. Service was available to those who could pay. We began to see homelessness grow in America. I was supervising some residents in training. One resident said to me, “How you get a patient to talk about their childhood. I have a patient who won’t do that.” I enquired from him what she wanted to talk about. Then it became known that she had a fantasy about her landlord. The fantasy was that the landlord wanted her to move out of the house. We investigated further and we talked about that with her. It turned out that she had been receiving money from the government because she was disabled. She had schizophrenia and she was cut off from payments because it was not permanent since schizophrenia is not a constant disease like diabetes and asthma. There were periods when there are acute episodes. You become sick from time to time.  We began to see that the social security system had rejected all people with mental illnesses because they were not permanently disabled to save the money. We began to see thousands of people losing their apartments, thrown on the streets, becoming homeless particularly those with mental illnesses. This was the first time we saw this in 1980. Some one had done a study which was published in Psychiatric Services January 2000. The study was done on deaf and he found that once hospitals began closing, social security was removed, the death rate among people with mental illness tripled. So closing of hospitals and ending of social security for people with mental illness, had an adverse effect. In 1956 we in United States had 550,000 people with mental illness in mental hospitals. We began to de-institutionalize and we now have less than 50,000 in hospitals but we have large number who are homeless. We have two hundred thousand people who are mentally ill in prison and jails. It is not only that if you are mentally ill you are at risk of homelessness, but if you belong to a minority, you have mental illness, you are dark or black, Hispanic, you are in a worst situation. So it is a point system. With this point system if you are living in a cold climate, you can freeze to death. In summer times there is no place to go to the toilets. We have people living in the subway. So the situation is dramatic and problematic in United States, the richest country in the world.

Responding to another question Prof. Martin Gittelman said that it was not at all bad for people to emigrate from poor countries to developed countries particularly if they are trained.  My grand father was born in Arabian empire. He was educated and trained and then he came to America because life here was better. What we need is to fix the system so if a hospital recruits some body say a nurse from Philippines, they pay for it. They should not be paying to the recruiting agencies but to the Government who should have a tax which can be used to increase the salaries of the nursing teachers in Philippines. So they will have more nurses. There is nothing wrong in Philippines nursing going to other countries but let the IMF and World Bank give money to improve the nursing schools so that they can double their output. We need those nurses. We need more of these trained healthcare professionals all over the world.  They can leave the country but we need to do something appropriate for those countries. Similarly if doctors leave Pakistan, we need to increase the number of medical schools in Pakistan, train more doctors as we get lot of bright people in Pakistan. Institutions like World Bank should give funding to government to enable it to increase salaries of the doctors in Pakistan so that the difference in their remuneration is decreased. People do wish to stay in their own country too. The difference in salary of doctors in UK and Pakistan should not be so great. People would like to stay in their own country if they can make a decent living.

Another problem is HIV/AIDS. In some countries doctors are making more money treating HIV/AIDS than treating mental illness. We need to work with our HIV/AIDS colleagues, OXFAM and all other groups which are treating AIDS and tell them look fox, come on people are dying of HIV/AIDS. Let us help developing countries, given them more money and medicines. Let us not only treat HIV/AIDS but do what United Nations used to say for many years but no more “Health of All.” We do not hear it any more. We only hear HIV/AIDS. People do not realize that you do not die of HIV/ AIDS immediately. Most people do not have any symptoms for eight ten years and then they develop some immune problem. Even then you do not die of HIV/AIDS but of other diseases. People with schizophrenia are facing exactly the same situation. They do not die of schizophrenia but their resistance to other diseases is reduced and they tend to smoke. Even if you do not have money, you continue smoking because you become addicted. They are more susceptible to Hepatitis, tuberculosis, asthma, cancer and cardiovascular disease. All this needs to be to be taken care off.