COVID-19 Webinar 14: Mental health and poverty alleviation
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health organise a series of weekly webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair:
Julian Eaton, CBM Global and the Centre for Global Mental Health at the LSHTM
Speakers:
Dr Daniel Vigo, University of British Columbia, Harvard Medical School
Adv. Liron David, Enosh - The Israeli Mental Health Association
Pooja Pillai, Project Burans, India
Cathy Conteh, Partners in Health, Sierra Leone
Dr Fizza Yasmeen, BasicNeeds Pakistan
Key messages:
Liron David: Community support, a recovery approach and a resiliency framework are a useful combination of tools to support people with psychosocial disabilities, and maximise their independence and independent decision-making: during normal day-to-day, during crisis, and as a mechanism to get out of the crisis stronger.
Pooja Pillai: Leveraging our existing networks and the trust that we had built up as an organisation in the community has been invaluable in ensuring that we were able to continue to provide services through the COVID-19 period. Looking forward, as we come out of lockdown, there will be a large mobilisation of NGO and grassroot-level workers, who will be at the forefront of working with the communities. It will be important to message mental health as part of every community-based intervention, to get the information about mental health to wide swathes of the population.
Cathy Conteh: To ensure that our service users, many of whom are homeless people living with mental health conditions, could continue to be looked after during the lockdown, we established a network of care-givers in the community. Looking more broadly, given how people living with mental health illnesses are stigmatized, handled and neglected in the community, it is crucial to educate the wider society that mental ill health is a medical condition (and not caused through demonic-spiritual means).
Fizza Yasmeen: We believe that a person is only recovered once he or she is able to work productively in the community. It is key to combine psycho-social interventions with poverty-alleviating interventions to break the cycle of mental ill health and poverty. Fear divides, hope mobilises. We should keep hope high.
Daniel Vigo: Governments should focus on forecasting excess mortality, lost output, health system capacity, and their ability to borrow throughout the year, and ground domestically-developed public policies in this. Such an approach starts to take into account the many impacts of COVID beyond simply measuring deaths recorded as attributed to the disease.
These policies should also be cognisant of regional differences within a country and differences between the vulnerabilities of different groups. Millions will be plunged into extreme poverty as a result of COVID-19 in 2020. Poverty kills, and has a direct effect on mental health. In fact, poverty will likely first kill people with severe mental illnesses. I couldn’t stress enough how important it is for the survival of people in vulnerable positions to have a comprehensive public policy in this area.
Record of the meeting:
Julian Eaton, CBM Global and the Centre for Global Mental Health at the LSHTM:
Thank you all for dialling in. This webinar is part of a broader series on COVID-19 and mental health, where we come together as a community to hear from people who are experts in the topic, and who work in practical ways to alleviate the negative impact of mental ill health in their communities.
The topic that we will be discussing today is among the most important that we have yet talked about, and sits at the transition point between COVID-19 emergency response and longer-term recovery from COVID-19. As you know, there is a strong link between poverty and mental ill health. Indeed, there is a well-documented negative cycle, whereby poverty puts people at a greater risk of mental ill health, and mental ill health increases the risk of people falling into poverty. Over the next 45 minutes, we will hear more about this, and about some of the solutions that have been put in place to alleviate this, especially during COVID-19.
Daniel, you have done some research in this area. Would you mind sharing some of your findings?
Daniel Vigo, University of British Columbia, Harvard Medical School:
We have been doing research on the public policy approach of countries in how they deal with COVID-19. Through our work, we became concerned that there was a sense of misguided optimism in lower- and middle-income countries as to the impact of COVID-19, which could result in a catastrophic “second wave” - or an extension of the first wave - of the pandemic. Unfortunately, this has indeed happened. Latin America is now the epicentre of the crisis, with more than 50% of total deaths happening there.
Before I go further, it must be acknowledged that no one knows what the perfect combination of public health policies and economic stimulus is. However, there are wrong approaches, such as the policy paralysis that we have seen in (for example) Brazil: denial at the federal level, and a variety of policies at city and state levels. The result has been a level of excess deaths at 300% of the usual death rate, for instance in such places as Manaus [Brazil].
When thinking about their approach to COVID-19, policy-makers should focus on four metrics, measured over the course of the full year:
All cause excess deaths. This is key to understanding the full impact of COVID-19. For instance, in some places (e.g. Nicaragua), the true COVID-19 death toll is being hidden through various mechanisms; but through this metric it can be understood
Lost economic output
Systems capacity to respond to the health crisis
Country capacity to borrow against its future
Julian:
The impact of COVID-19 has been harshest on the poorest and most marginalised communities: they have suffered a higher death rate, and have a lower likelihood of bouncing back.
Liron, could you tell us about your work with vulnerable people in Israel?
Liron David, Enosh - The Israeli Mental Health Association:
Enosh – The Israeli Mental Health Association is a national NGO in Israel providing community-based mental health services. Our services are funded by the government according to the mental health rehabilitation law.
We provide rehabilitation services based on the recovery approach in areas of supportive housing, employment & vocational training, social centres and support for families. We also provide psychological support centres for youth.
Many of the people with severe mental illness in Israel are living in poverty and rely on governmental support. They are faced with institutional, public and self-stigma that worsens the cycle of poverty.
COVID-19 had a great impact on our service users. People who held jobs in the free labor market were being fired and lost their income, people in independent living settings and people who were coming to our social centers suddenly lost their routine.
The crisis made us go “back to basics” in our services to see that the basic needs of people who are quarantined or in isolation were being addressed. In addition, we immediately moved our services online, and were fortunate to get a donation of cell phones and data for our service users, which was a crucial accessibility tool for them to continue getting the support they need. (We were also aware of leaving no one behind and provided face to face services when needed.) We continued in our role helping people navigate the system and access their rights using community resources and connections.
Our resiliency programs that we developed in the past few years, and being flexible in how we work, helped us and our service users get through the crisis. The recovery approach we routinely use helped people move towards independence even in the face of uncertainty, and go back to the new normal earlier.
A key point to recognise is that the access gap to services that exist in times of peace is deeper in times of crisis, such as COVID-19. We are working on addressing this gap, but the government should also do more planning and support in this area.
For more information, please see this link, a video of our director of housing services, and the MHIN blog.
Julian:
Pooja, can you tell us about your experience of working with highly marginalised communities in India? How were you able to build on the relationships you had pre-COVID-19, to support your COVID-19 work?
Pooja Pillai, Project Burans, India:
Project Burans works mainly in Uttarakhand State in the north of India, with highly marginalised communities. The challenges that our service users faced were already large pre-pandemic, and COVID-19 really amplified them. For instance, because many of our service users are daily wage labourers, food insecurity really shot up.
The first thing we did was try to tap into the networks that we already had built over the past five or so years, such as with religious leaders and groups. One example that comes to mind is working with a Gurdwara, which is a Sikh temple. They have a practice of serving food on a daily basis. While they were doing this already, we worked with them to ensure that the food got to the right people.
Similarly, when distributing dry rations and essentials, we needed to leverage police and community leaders. Luckily, we had built up networks with them over the past five years, and developed a level of trust in us as an organisation. It is worth noting that this all took place in quite a politically charged environment, where there was a lot of mistrust. So having the pre-existing relationships in the community was invaluable for helping us navigate this environment.
Relationships in the community also allowed us to perform needs assessments through our network of volunteers, who are our eyes and ears on the ground. They can tell us exactly what the most relevant needs of the communities are at a given time. These relationships are also crucial going forward, as we don’t necessarily know what the next need is going to be, or when the next “zone” will go into lockdown.
Looking forward, a major challenge will be how to package mental health within the whole package of daily needs of a community.
Julian:
In many countries, relationships that were built by organisations through previous crises have served them really well during the current pandemic. Sierra Leone has gone through a number of crises in the past years. Cathy, how have you been able to engage with marginalised groups through your work in Sierra Leone?
Cathy Conteh, Partners in Health, Sierra Leone:
Sierra Leone has gone through a number of traumatic experiences. Let me give you an example of the sort of things we are doing in this environment. We were working with a 50 year old woman, who saw her children killed in front of her during the Rebel War. As a result of this trauma, she left her family. However, due to the intervention of the Partners in Health mental health team, she has been able to return home.
Partners in Health has been recognised especially for the work we have been doing to support homeless patients.
We go to the community, identify potential homeless mental health patients, treat them in clinics, provide them with some financial support, help them with clothing and food. During the period of COVID-19, we also identified care-givers in the community for these patients, who can help the patients locally with food, and keep an eye out for them.
In addition, we are providing mental health education in the community. Unfortunately, it is the case that many people think mental ill health is somehow spiritual or demonic. So it is important to work with people in the communities to ensure they know that these are medical conditions, and that they can affect anyone in the community. Through this, we are able to identify additional potential patients, and provide them with support and help them access services.
Julian:
Fizza, we have been hearing about the importance of fulfilling basic, day-to-day needs, especially in the time of crisis. How has your organisation engaged with this where you work in Karachi?
Dr Fizza Yasmeen, BasicNeeds Pakistan:
BasicNeeds Pakistan has been working on the mental health needs of marginalised communities for the last 9 years. We have adopted the 5-step model of BasicNeeds international, including capacity building, whereby we train community health workers, teachers, and religious leaders in mental health. We also support community health services, through patients identification, to medical treatment, counselling, psychoeducation and rehabilitation, and entrepreneurship.
The last stage is very important for us. If a patient doesn’t work, we do not think of them as recovered. We only think of them as recovered once they are able to play a productive role in society. By this means, we aim to break the vicious cycle between poverty and mental ill health, that is otherwise just like a “revolving door”.
For example, for women with mental ill health in marginalised communities, we have established six vocational centres, where we train them in finances and entrepreneurship. After this training, they form support groups, and are given a loan, recoverable after 9 months, to start their own business.
Julian:
How have you adjusted your services due to COVID-19?
Fizza:
For example, we normally have capacity for 70 women in one of our centres, they come in two shifts (morning and evening). During COVID-19, we have reduced that number to 6 per shift. In fact, we closed only for 15 days, and then started up again, having implemented the appropriate SOPs, as our service users were facing financial difficulties.
Julian:
Liron, as you mentioned, people were already experiencing access gaps pre-COVID-19. How have you addressed this during the outbreak, given the larger gaps that appear during crises?
Liron:
In the first stage of the crisis, we focused on understanding the situation: how many staff were available, how many service users required our support, who was in lockdown, who needed medication.
We then tried to move as much as possible online, helped by the donations of the phones and data that I mentioned. COVID-19, in fact, created a sort of opportunity for us in this. Previously, our work was very localised to our branches. However, moving online meant that we were able to create a new sphere of national-level activity, across larger groups of people. The move online also enabled us to access the more remote and peripheral areas of the country more easily.
Lastly, we worked on recovery planning for the future, to understand how resources can be allocated within the community, to ensure continuity of support going forward.
Julian:
As we know, poverty is driven by structural inequity. As we turn to think about building a post-COVID-19 future, how can we ensure that people who don’t normally have a voice are able to express what they need from that future?
Pooja:
The low socio-economic status of our service users means that they are typically uncomfortable speaking publicly - many people we are working with have not even gone to school. To overcome this, since 2017, we have set up an “experts by experience” group, and included people with lived experience in this. We have also included them in the Project Burans advisory group. We try our best to co-produce tools with them, such as our pictorial recovery tool that we co-developed with the “experts by experience” group. Any interventions that we designed over the years have also had input from this group. Indeed, this group is the middle ground where the research view of mental health comes to terms with the view of real needs in the communities we serve.
It is also worth mentioning that many of our staff are people living with a psycho-social disability, or are care-givers of people living with a psycho-social disability.
Julian:
Daniel, on a policy level, are there any key messages to give to governments in countries about how to ensure that the link between mental health and poverty can be addressed?
Daniel:
My main concern, even in LMICs that have put purposeful policies in place, is that there is a laser-sharp focus in limiting deaths directly from the virus. While these policies may have been successful in achieving this aim, the other side of that coin has been that the wealth of these countries has been destroyed, almost overnight.
For example, in Argentina, Pakistan, and India the epidemiological curve is very similar: deaths are steadily going up. And this trend is likely to continue, based on what we’ve seen in other countries. Yet, every day that people aren’t able to work or interact with each other, wealth is being destroyed.
Argentina is a good example here. It is an apparent poster-boy of public health policy, because it has achieved what HICs have wanted to achieve in terms of a low number of deaths per day. What people forget, however, is that Argentina has zero ability currently to borrow from its future to pay for people to stay at home. So, in the largest province of Buenos Aires, we have wealth being destroyed, people in lockdown in a quarantine enforced by the police - and it is a ticking time-bomb.
Therefore, any public policy that doesn’t consider excess mortality, lost output, ability to borrow from the future, and health system capacity on a 12-month time horizon (and not on a daily time-horizon, as is the focus for many countries) is likely to fail.
Julian:
Trust is crucial in times like these. When people are given health messages by others whom they trust, they are more likely to respond positively to these messages. By contrast, international messaging is not readily accepted, and the internet breeds a lot of very strange messages and paranoid ideas. How do you ensure that your service users can access good health advice?
Fizza:
We focus on early detection and prevention of mental illness. To do this, we are promoting mental health first aid training to ensure that people are aware of their mental health problems, and seek help. Pakistan is a low-resource setting, so we need to focus on early prevention and detection rather than expensive treatment.
Julian:
The people needed to support mental health are not necessarily just mental health professionals. Often, frontline workers who are not mental health professionals can have the largest impact on their communities, once they have a sound grounding in basic mental health skills.
Fizza:
Yes, and in addition to the mental health interventions, it is also key to integrate community-based poverty alleviation projects into the services for people with poor mental health.
Julian:
In the long-term, there will be important efforts, programmes, and government policies focused on poverty alleviation, and it will be key to ensure that people with psycho-social disabilities are not left behind. It is a very common experience in many parts of the world, although such programmes are meant to support the poorest, that people with mental health conditions are unfortunately left behind.
I now invite the panelists to leave our viewers with a final key message on poverty and mental health.
Liron:
Community support, recovery approach and resiliency framework are a useful combination of tools to support people with psychosocial disabilities, and maximise their independence and independent decision-making: during normal day-to-day, during crisis, and as a mechanism to get out of the crisis stronger.
Pooja:
Coming out of lockdown, there will be a large mobilisation of NGO and grassroot-level workers, who will be at the forefront of working with the communities. It will be important to message mental health as part of every community-based intervention, to get the information about mental health to wide swathes of the population. This is especially key in settings where mental ill health is at times attributed to magical-religious causes.
Cathy:
Mental ill health should be seen as a priority condition. Furthermore, seeing how people living with mental health illnesses are stigmatized, handled and neglected in the community, it is crucial to educate the wider society that mental ill health is a medical condition (and not caused through demonic-spiritual means). To do this, we seek to extend the range of actors we work with, and include - for instance - traditional healers and spiritual leaders among our stakeholders. Even as we speak, pastors and traditional healers are coming to our clinic to learn about mental health.
Fizza:
Fear divides, hope mobilises. We should keep hope high, and follow the model of MSC - masks, social distance, and cleaning of hands. If health workers and staff follow this model, they can work in the community and provide services.
Daniel:
Focus on forecasting excess mortality and lost output throughout the year, and ground domestically-developed public policies in this. These policies should also be cognisant of regional differences within a country and differences between the vulnerabilities of different groups. Millions will be plunged into extreme poverty as a result of COVID-19 in 2020. Poverty kills, and has a direct effect on mental health. In fact, poverty will likely first kill people with severe mental illnesses. I couldn’t stress enough how important it is for the survival of people in vulnerable positions to have a comprehensive public policy in this area.
Julian:
Thank you all for your contributions. I hope everyone watching this will be able to join next week’s webinar as well, on supporting patients and care-givers.
