‘It reflects the society we live in where a young person does not feel life is worth living’

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This Working Scientist podcast series is sponsored by the University of Queensland where research is addressing some of the world’s most challenging and complex problems. Take your research further at UQ. Visit uq.edu.au

Juliana Gil: 00:25

Hello, this is How to Save Humanity in 17 Goals, a podcast brought to you by Nature Careers, in partnership with Nature Food.

I am Juliana Gil, chief editor at Nature Food. Welcome again to the series where we meet the scientists working towards the global development targets brokered by the United Nations.

In 2015, world leaders pledged to solve a range of economic, environmental and social issues. A package of 17 development goals were agreed upon.

Since then, in a huge effort, thousands of researchers all over the world have been tackling the biggest problems that the planet faces today.

In episode three, we look at Sustainable Development Goal number three: How to ensure health and well-being for all. And meet a psychiatrist who is determined to push mental health further up the agenda.

Shekhar Saxena: 01:25

So my name is Shekhar Saxena. I am a psychiatrist by training, and have involvement in public mental health. Currently, I teach at Harvard Chan School of Public Health, at Harvard University.

Earlier, I worked at the World Health Organization for several years, and I was directing the department of mental health and substance abuse.

The Sustainable Development Goals of the United Nations was actually a landmark achievement and an agreement of all countries, which was very much more advanced than the previous Millennium Development Goals. And I would refer to two reasons why I say it was a major change.

One is that SDGs apply to all countries, rather than only to the so-called developing countries.

And the second areas is that SDGs included, were many more than MDGs. So it was more comprehensive. And it was applicable to all countries.

And I’m very happy to say that SDG 3, which is about health and wellbeing, is a very progressive agreement of the countries. They really said that health is important for their development.

And the goal is healthy life and wellbeing, which will have a high degree for all the citizens.

So it was a landmark declaration by the counties. Human is just a conduit. It’s the countries that decided to do that.

And I'm also happy to see that mental health was explicitly included within SDG 3.

And it was an integral part of health. So yes, it was definitely a very progressive declaration and mental health attained a level of attention that perhaps was not there earlier.

I began my professional career as a psychiatrist, treating people who came to me one after another, 100 after another 100.

And that was very much in clinical practice where SDGs, which were not there at that time, were quite irrelevant. However, my profession transited to public mental health, where it was not about clinical practice. It was about population mental health.

And that's where the principles of health for all, and also community participation, and prevention and promotion became more important than just the treatment.

That was a nexus stage where I started working for WHO. The SDG era, which started in 2015, is a further transition where mental health is not only a part of health, but it's a part of development.

And that's what my work involves now. To see to it that mental health is given enough attention within the health agenda, but it is also given importance in the sustainable development agenda.

I should just say that having done clinical practice for two decades actually helped me a lot in my further work as a policy person.

Because when I look at policies now, when I advise about mental health policies to countries, I have those people in mind who I treated. The policy is to actually help real people in real places, and not on an abstract. Policy is a document that is written on paper, but it's supposed to help real people.

And that's what is lost many times. And I consciously try to keep that in mind, to see what could be the impact of the policies on people who I saw in Delhi, or I saw in Nigeria, in Lagos, or anywhere else, including in New York, actually.

And the policies need to be such that they help the people who are most in need, at the maximum. And that is what is important. The principle of equity, the principle of policy, serving everybody, and policy serving the largest number of people, rather than, very well, a small number of people.

The understanding of mental health has improved a lot. The awareness about mental health problems within the citizens has also improved a lot. The very frequent references to mental health in the media, in the conventional as well as social media, has increased enormously.

Now, we cannot go through a day without reading something about mental health in the media that we read. So understanding has increased, research has increased, awareness has increased.

What has actually not increased is the amount of resources that we spend on mental health. I should also say that COVID pandemic, which obviously killed a lot of people and affected a very large proportion of population in the world, was actually a net gain for mental health because it increased the awareness.

Of course, mental health problems increased. Quite substantially, actually. But the awareness and attention also increased a lot.

However, there is still a lack of human as well as financial resources that are devoted to mental health. You might be surprised to learn that, on an average, countries spend less than 2% of their health budget on mental health, when the burden is something like 10%. So there is a large gap between what is needed, and what is available for mental health.

So that is the number one problem for mental health in the world today. We lack trained people who can provide care. We lack policies which are conducive to better mental health for the population. And we need the financial resources to make that happen.

Having said that, and also having said that mental institution has actually improved not as much as the day and the progress is far too slow.

Let's take a couple of examples to illustrate. Suicide is one of the final and perhaps the most tragic outcome of mental health issues and conditions, not necessarily of mental disorders, but obviously of distress, which people face. And that is still a very large problem.

However, it is a public health problem. In the world currently, it's nearly 800,000 people who die because of suicide every year. And every death is far too many.

So this is a big problem. Although I should say that the overall suicide rate in the world has actually come down just a little bit.

So there is some progress that is taking place. But in many countries, suicide rate is high and is increasing. Let’s take the example of two large countries. One is India, where the official rate, official number of people who die because of suicide is about 170,000 per year, which is anyway large. But a fairly substantial number of suicides are not reported because of the stigma and because of the legal issues and other issues. So the unofficial numbers are perhaps much larger than that.

And actually, it has been said that India has about one third of all completed suicides in the world, which is so large and is increasing.

What is even more troubling is that some of the most vulnerable groups in India have shown the largest increase in the suicide rate, which of course, includes the poor, but also suicides among women, and amongst young people are increasing a lot.

And that is something which is extremely tragic in a country like India, which is, which is developing, actually developing as opposed to many other countries who are not developing.

This is a very sad loss of human resources, who could actually assist the economy. And that brings me to SDGs. Because suicide is a phenomenon that is directly affected by the social and community environment where we live.

So, things like poverty, lack of education, lack of job opportunities, discriminations of all kinds, and deprivations of all kinds directly affect people who are prone to die because of suicide.

And we need policies that actually can provide the kind of environment where people live, which will be helpful to decrease the number of suicide. For example, suicide amongst young students have shown a marked increase because of the excessive competitiveness that is part of their life.

They have to struggle through the school education, they have to appear in the competitive examinations, then they have to struggle for a job. And many young people decide that dying is easier than struggling through for many years, which is very sad.

It reflects the society that we live in where a young person does not feel that life is worth living. It’s a sad reflection on the kind of environment that we’re providing to our young people. But that’s what is happening.

Take another example of USA, where again the suicide rate is larger than the global average. And in fact is increasing from about 10 per 100,000 per year in the year 2000. In 2022, the rate is 14.

So there is a substantial 40% increase in the rate of suicides. And it’s again increased in young people who find themselves jobless, or without any opportunities.

And there has been substantial amount of talk on what are the reasons for doing that, including lack of a direction in their life and lack of opportunities when they should be doing survey. Getting educated, getting a job raising a family. That’s where people decide to die.

So these are two countries which are very large, which have a higher rate of suicide than global average, and is an increasing rate. Which to me, directly connects it to the social and economic determinants of mental health, and of wellbeing. So these are issues that that are extremely important for global mental mental health currently.

Shekhar Saxena: 13:50

Mental health is the final outcome of many factors that are operating. There are of course biological factors.

It has to do something with the kind of brain that we have the kind of structure and function of our, of our higher brain functions, which is the, and to some extent, genetic predisposition. But those are relatively smaller.

Mental health is much more an outcome of the environment that we live in, and the kind of stresses that are operative on us, and the personality and the resilience that we gather over a period of time, and the maturity that we acquire over the years.

Mental health is important for all people at every stage of their life, so starting from their birth in fact, even before birth, there are factors that affect us.

And the factors that are affecting mental health are much more important during early childhood, compared to the later adult life. Because the formative years of life are the ones where some of these factors can have a very large impact later in life.

Many of these factors are social and economic. The kind of environment that we live in and the kind of family the kind of community, the kind of macroeconomic environment that we live in. And it has a direct relationship with sustainable development that have been decided by the United Nations as goals.

Shekhar Saxena: 15:40

Early childhood is a period where the privations of all kinds of, for example extreme poverty or lack of adequate nutrition, or lack of adequate social stimulation can have a direct impact on children's development.

And that will lead to lesser mental health in the future, as well as certain mental health conditions. For example, depression, or anxiety, or sometimes the substance abuse problems that are there.

The second issue, which is again quite important is violence. Violence against children of all kinds, physical as well as sexual, and also against other vulnerable groups. Like girls who are especially prone to violence, as well as adolescents, who can be suffering from bullying, including cyberbullying, which is now quite a common occurrence, can have a lasting impact on your mental health.

And these factors can be definitely taken care of, by educate policies, but also by protective mechanisms, which are put by the family as well as community.

And that’s where the maximum cost effectiveness can be gained by the kind of policies and the kind of structures that we put in place. Unfortunately, there is inadequate realization of some of these very important factors.

And so we fail to protect our children and adolescents from suffering the harms of some of these factors. And in providing the kind of protection that is needed, especially for those children who are more vulnerable to that.

So for example, children coming from poor socioeconomic status, children who have difficulty in staying, joining and staying in school. The children at home who might be isolated, children who come from difficult families, and so on.

So these are the kinds of policies that can actually affect the mental health of the future generations in a much better way.

It is important to recall that 50% of all mental health conditions arise before the age of 15, and 75%, before the age of 24. So young people who have the vulnerability to have a mental health condition and sometimes, (not always, but sometimes), these conditions have an effect all throughout the life.

And so protection of mental health and prevention of mental disorders by socioeconomic policies and community-led initiatives is paramount for public mental health.

I know that we need treatment, but we need much more promotion, protection of mental health and prevention of many disorders, which are the hallmark of public mental health policies,

The problems because of mental health in societies around the world, are likely to continue to increase not only in terms of numbers of people who will be affected by mental ill health, but the overall status for mental health and wellbeing which are going down.

There are many reasons for that. That kind of prediction, a very unfortunate prediction. One is the demographic change because societies are getting older.

And we do know that older people have a higher chance of getting into mental health condition, including depression, as well as dementia, which directly affects affects the mental health of people.

But another reason is that large socioeconomic and other changes, including the recent recently-recognized climate change and environmental issues are also affecting a lot.

As if they were not enough problems we have one more to deal with.

Climate change is directly affecting the mental health of people. There has been various ways in which this is happening. One is that climate change is affecting the numbers of disasters and natural calamities that are coming up. And we do know that people who are affected by natural disasters, but also by conflicts and wars, are at a much higher risk of mental health problems compared to the other people. And so the proportion of people affected will continue to increase.

In the world today, with the number of conflicts and wars that are happening, as well as the increased frequency of natural disasters like floods and droughts and earthquakes and other disasters that are happening, including storms and hurricanes, much larger proportion of people are getting affected, and that's likely to increase, which means a net increase in the mental health problems.

Global mental health has seen a number of policy initiatives in international area, as well as in many large countries, and these are all positive.

For example, as we discussed earlier, the United Nations included mental health andwell being in its Sustainable Development Goals in 2015. The WHO has a mental health action plan that was passed by the World Health Assembly in 2013, and has now been extended to 2030.

These are very progressive declarations by the countries to say that mental health is important, but also to actually clearly and explicitly state what they have agreed to do for mental health in the coming decade or more.

And these are very, very positive things. Another thing which has happened is that many countries have revised their mental health policies and laws, which are more in keeping with the research findings currently, as well as the human rights issues that are coming up much more in this area. So all of that is very positive.

Many countries have made new mental health policies which are very progressive and are rights-based, rather than the earlier policies which were much more charity-based. That mental health people require help, so let’s give that. But now it is that mental health is a right. So let people let’s honour people’s rights for their health, as well as mental health.

Another good policy, which has been accepted by the United Nations, but also by the WHO, is the policy of universal health coverage, which means everybody should have the access to health and health services, as per their needs.

And it is their right, without incurring the kind of catastrophic health expenses that are very common. And when we use the word health, we include mental health obviously.

So this is, again, very progressive, although I must say that many of these international policies and agreements are far from being implemented within countries.

And here, I mean, rich countries as well as poor. Many of the rich countries have actually not accepted the principle of universal health coverage, and are providing excellent health care for a few. But are ignoring the health needs of a large number of people who live in those countries.

And obviously, in low and middle income countries, this target is far from being achieved. However, it is good to have at least international policies that are progressive and hopefully gradually the countries will adopt and implement many of these policies. And good progress is being made in many countries.

Take the example of India, which has explicitly included mental health within their health policies. And in fact, at a local level, there are health facilities which are keeping mental health as one of the health services that need to be provided. Now that's something which is good, but of course, the implementation requires much more effort, than is being done.

Take the example of a country like South Africa, where mental health has been integrated within overall health care, but also within maternal child healthcare, which has worked wonders for some of the people who need help. In spite of poor resources they are making making good progress.

Of course, there are rich countries which are making very good policies and implementing them. Take the example of Australia or Canada or some of the Nordic countries, which are doing very well. But many of the low and middle income countries are also making very good progress in their policies.

And when I mention policies, I mean, not only healthcare policies, but overall health and social economic policies, which as we discussed earlier, have a very large role on improvement and promotion of mental health rather than the treatment of mental disorders.

The United Nations Sustainable Development Goals was a promise as they agreed upon it. It was an inspiration. Are we, when we are midway on the SDGs, are we anywhere near achieving them?

I should say that in the area of health, much progress have taken place in some areas, but the progress in many other areas is is very much lacking. And it ism it’s very doubtful whether we will in the next, how many six years that are left, we'll make enough progress to achieve those goals.

However, I should say in the area of mental health, the progress is really commendable. And we need to increase the resources that need to be available. We need to have better policies, better coverage of of mental disorders, for treatment and care and more human-rights based policies.

And if countries make more efforts, then we can certainly make much more progress on that. If you're asking me a question, whether the SDG goal number three for health and wellbeing, way actually be achieved by the majority of countries, the answer is no.

But whether improvement is taking place and will take place towards this goals, the answer is yes. But I would also add that we need to speed up our progress if we are anywhere if we are to achieve the targets anywhere near the goals that we agreed upon.

Juliana Gil: 27:50

Thanks for listening to this series How to Save Humanity 17 Goals. Join us again next week when we look at Sustainable Development Goal number four: how to ensure quality education for all. See you then.

Sponsor message: 28:19

This Working Scientist podcast series is sponsored by the University of Queensland, where research is addressing some of the world's most challenging and complex problems.

Take your research further at UQ. Visit uq.edu.au