TEDGlobal 2012
Vikram Patel: Mental health for all by involving all
Vikram Patel：通过公众参与来实现所有人的精神健康
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世界上有接近4亿5千人被精神疾病所困扰。在发达国家，只有一半的患者接受了适当的治疗，在发展中国家，由于精神疾病医生的严重短缺，有接近90%的患者不能接受治疗。Vikram Patel 向我们指出了一个十分有前景的道路——培养社区成员，使得他们可以进行精神健康干预，这一举措也激励着普通人之间的相互关爱。
Vikram Patel - Mental health care advocate
Vikram Patel helps bring better mental health care to low-resource communities -- by teaching ordinary people to deliver basic psychiatric services. Full bio
Vikram Patel helps bring better mental health care to low-resource communities -- by teaching ordinary people to deliver basic psychiatric services. Full bio
Double-click the English transcript below to play the video.
00:16
I want you to imagine this for a moment.
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让我们一起来想象一下，
00:19
Two men, Rahul and Rajiv,
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有两个人，拉胡和拉吉，
00:21
living in the same neighborhood,
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住在一个小区，
00:23
from the same educational background, similar occupation,
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教育程度相同，工作也差不多。
00:27
and they both turn up at their local accident emergency
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他俩都去当地的急诊室，
00:29
complaining of acute chest pain.
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说他们有严重的胸部疼痛
00:32
Rahul is offered a cardiac procedure,
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急诊室给拉胡做了心脏检查，
00:35
but Rajiv is sent home.
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却让拉吉回家。
00:38
What might explain the difference in the experience
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是什么原因让这两个几乎一样的人
00:41
of these two nearly identical men?
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有着不同的遭遇？
00:44
Rajiv suffers from a mental illness.
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因为拉吉患有精神疾病。
00:47
The difference in the quality of medical care
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得不到同等质量的医疗服务，
00:51
received by people with mental illness is one of the reasons
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是导致精神疾病患者寿命
00:53
why they live shorter lives
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短于不罹患精神疾病的人
00:55
than people without mental illness.
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的原因之一。
00:57
Even in the best-resourced countries in the world,
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即使是在世界上资源最为丰富的国家，
01:00
this life expectancy gap is as much as 20 years.
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这一寿命差距也有20年之多。
01:04
In the developing countries of the world, this gap
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而在发展中国家，
01:06
is even larger.
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两者的寿命差距更大。
01:09
But of course, mental illnesses can kill in more direct ways
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然而，精神疾病当然也可以更直接地导致死亡。
01:12
as well. The most obvious example is suicide.
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最常见的例子就是自杀。
01:15
It might surprise some of you here, as it did me,
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也许在座的一些朋友会感到吃惊，我那时也是，
01:18
when I discovered that suicide is at the top of the list
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因为我发现，自杀在引起青年死亡的主要原因中
01:21
of the leading causes of death in young people
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排在第一位。
01:23
in all countries in the world,
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在每一个国家都是如此，
01:25
including the poorest countries of the world.
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包括世界上最贫穷的国家。
01:28
But beyond the impact of a health condition
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不过，除去健康状况对寿命的影响，
01:31
on life expectancy, we're also concerned
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我们还关心
01:33
about the quality of life lived.
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生活质量。
01:36
Now, in order for us to examine the overall impact
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现在，为了让我们准确的知道
01:38
of a health condition both on life expectancy
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健康对寿命和生活质量的全面影响
01:41
as well as on the quality of life lived, we need to use
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我们需要用到
01:44
a metric called the DALY,
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一个叫做DALY的度量单位，
01:45
which stands for a Disability-Adjusted Life Year.
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DALY是伤残调整生命年的缩写(Disability-Adjusted Life Year)。
01:50
Now when we do that, we discover some startling things
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当我们这么做时，我们发现了精神疾病的一些令人震惊的事实，
01:52
about mental illness from a global perspective.
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而这些事实是世界各国普遍存在的。
01:55
We discover that, for example, mental illnesses are
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例如，我们发现了精神疾病是
01:58
amongst the leading causes of disability around the world.
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引起生活不能自理的主要原因。
02:03
Depression, for example, is the third-leading cause
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比如，抑郁正是第三大原因，
02:06
of disability, alongside conditions such as
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除此之外，还有
02:09
diarrhea and pneumonia in children.
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腹泻和儿童肺炎。
02:12
When you put all the mental illnesses together,
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当把所有精神疾病看成一个整体，
02:14
they account for roughly 15 percent
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全球15%的疾病负担
02:16
of the total global burden of disease.
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是由他们造成的。
02:19
Indeed, mental illnesses are also very damaging
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事实上，精神疾病对人们的身体将抗具有很大的破坏性，
02:24
to people's lives, but beyond just the burden of disease,
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除了疾病负担，
02:29
let us consider the absolute numbers.
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让我们全面的了解一下精神疾病的破坏性。
02:32
The World Health Organization estimates
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世界卫生组织统计到
02:34
that there are nearly four to five hundred million people
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全世界有
02:37
living on our tiny planet
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接近四亿到五亿的人
02:39
who are affected by a mental illness.
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受到精神疾病的影响。
02:41
Now some of you here
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你们中有一些人
02:43
look a bit astonished by that number,
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对这个数字赶到震惊，
02:45
but consider for a moment the incredible diversity
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但是，仔细想一下，精神疾病有数以万计的种类，
02:48
of mental illnesses, from autism and intellectual disability
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从儿童时的自闭症、智障
02:51
in childhood, through to depression and anxiety,
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到成年的抑郁、焦虑、
02:54
substance misuse and psychosis in adulthood,
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滥用药物和精神病，
02:56
all the way through to dementia in old age,
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再到老年的痴呆，
02:58
and I'm pretty sure that each and every one us
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我敢肯定的说，今天在座的每一个人
03:01
present here today can think of at least one person,
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都能想到至少一个人，
03:04
at least one person, who's affected by mental illness
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在我们最熟悉的人中，至少有一个人
03:07
in our most intimate social networks.
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受到精神疾病的影响。
03:12
I see some nodding heads there.
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我看到一些人在点头。
03:15
But beyond the staggering numbers,
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除了这些令人震惊的数字，
03:18
what's truly important from a global health point of view,
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从全球健康的角度来看，
03:21
what's truly worrying from a global health point of view,
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真正重要和真正令人担忧的是，
03:23
is that the vast majority of these affected individuals
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在受影响的这些人中有很大一部分
03:27
do not receive the care
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没有接受治疗
03:29
that we know can transform their lives, and remember,
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然而，这些治疗确实可以改变他们的生活，请注意，
03:31
we do have robust evidence that a range of interventions,
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我们有充分的证据表明，
03:34
medicines, psychological interventions,
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一些干预、药物治疗、心理辅导和社会干预
03:37
and social interventions, can make a vast difference.
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确实对精神疾病的治疗有很大的作用。
03:40
And yet, even in the best-resourced countries,
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但是，即使在资源丰富的国家
03:42
for example here in Europe, roughly 50 percent
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例如欧洲也有大约50%的人
03:45
of affected people don't receive these interventions.
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不能接受治疗。
03:48
In the sorts of countries I work in,
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在我工作的一些国家，
03:51
that so-called treatment gap
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甚至有90%的人
03:53
approaches an astonishing 90 percent.
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不能接受治疗。
03:58
It isn't surprising, then, that if you should speak
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因此，当你与
04:01
to anyone affected by a mental illness,
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患有精神疾病的人交谈时，
04:03
the chances are that you will hear stories
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你一般总是能听到他们说起
04:06
of hidden suffering, shame and discrimination
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几乎在他们所有的生活领域，
04:10
in nearly every sector of their lives.
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他们都会有隐藏的痛苦、羞耻和被歧视的感觉。
04:13
But perhaps most heartbreaking of all
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但是，或许在他们的描述中，
04:16
are the stories of the abuse
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最令人痛心的就是
04:19
of even the most basic human rights,
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对最基本的人权的践踏，
04:21
such as the young woman shown in this image here
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就像这张照片中的女子
04:24
that are played out every day,
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这样的事情每天都会发生，
04:26
sadly, even in the very institutions that were built to care
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悲哀的是，即使是在本应该治疗人们精神疾病的
04:30
for people with mental illnesses, the mental hospitals.
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医院中也存在这种现象。
04:34
It's this injustice that has really driven my mission
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这是这一点让我感觉到我应该
04:37
to try to do a little bit to transform the lives
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试着做一点努力来改变
04:39
of people affected by mental illness, and a particularly
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遭受精神疾病折磨的人们的生活，
04:42
critical action that I focused on is to bridge the gulf
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我做的一个主要的工作就是在
04:46
between the knowledge we have that can transform lives,
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我们所拥有的改变生活、有效治疗的知识与
04:49
the knowledge of effective treatments, and how we actually
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把知识运用到日常生活中之间
04:51
use that knowledge in the everyday world.
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搭建一所桥梁。
04:55
And an especially important challenge that I've had to face
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我所要面对的一个重要挑战就是
04:58
is the great shortage of mental health professionals,
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极度缺乏像精神病专家和心理学专家这类的
05:01
such as psychiatrists and psychologists,
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精神健康专家，
05:02
particularly in the developing world.
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而这一现在在发展中国家尤为严重。
05:05
Now I trained in medicine in India, and after that
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现在，我在印度学习了医学，
05:08
I chose psychiatry as my specialty, much to the dismay
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我选择了精神病治疗作为的专业，
05:11
of my mother and all my family members who
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这让我妈妈和我的亲戚觉得很失望，
05:13
kind of thought neurosurgery would be
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因为在她们严重神经外科医生才
05:15
a more respectable option for their brilliant son.
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配得上他们聪明的儿子。
05:18
Any case, I went on, I soldiered on with psychiatry,
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我始终坚持着做精神病治疗不论遇到什么病例，
05:21
and found myself training in Britain in some of
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并且我让自己在英国一些最好的医院得到了锻炼。
05:23
the best hospitals in this country. I was very privileged.
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我十分的幸运。
05:26
I worked in a team of incredibly talented, compassionate,
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我与一些十分有天赋、有工作热情的人一起工作，
05:29
but most importantly, highly trained, specialized
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但是最重要的是，他们也是接受了严格训练的、
05:32
mental health professionals.
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专业的精神疾病专家。
05:35
Soon after my training, I found myself working
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在我学习完不久，我首先在津巴布韦工作，
05:37
first in Zimbabwe and then in India, and I was confronted
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之后到了印度，
05:39
by an altogether new reality.
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我又需要面对一个新的事实。
05:42
This was a reality of a world in which there were almost no
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我需要面对的是，有一些地方
05:45
mental health professionals at all.
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根本就没有精神病专家。
05:48
In Zimbabwe, for example, there were just about
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例如，在津巴布韦，只有大约十来个精神病医生，
05:50
a dozen psychiatrists, most of whom lived and worked
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并且他们中的大部分居住在哈拉雷（津巴布韦首都），
05:53
in Harare city, leaving only a couple
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使得只有几个精神病医生
05:55
to address the mental health care needs
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负责生活在乡下的9百万人的
05:57
of nine million people living in the countryside.
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精神健康。
06:01
In India, I found the situation was not a lot better.
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印度的情况不比津巴布韦好到哪里去。
06:05
To give you a perspective, if I had to translate
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具体地说，如果我把
06:07
the proportion of psychiatrists in the population
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英国精神病医生的人口比例
06:09
that one might see in Britain to India,
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应用到印度
06:12
one might expect roughly 150,000 psychiatrists in India.
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印度大约需要15万精神病医生。
06:17
In reality, take a guess.
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然而事实又是怎样呢？
06:20
The actual number is about 3,000,
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实际上，印度只有3千精神病医生，
06:23
about two percent of that number.
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只是15万的百分之2。
06:25
It became quickly apparent to me that I couldn't follow
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我很快的意识到，在像印度或津巴布韦这些国家，我不能
06:28
the sorts of mental health care models that I had been trained in,
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我不能再遵循我所学的那种精神病治疗模式了，
06:31
one that relied heavily on specialized, expensive
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因为那种模式的精神病治疗，
06:34
mental health professionals to provide mental health care
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只能在一个人有能力获得专业的、昂贵的精神病专家的治疗
06:36
in countries like India and Zimbabwe.
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的情况下才能成功。
06:39
I had to think out of the box about some other model
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我必须打破思维定势，
06:41
of care.
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寻找其他方式。
06:43
It was then that I came across these books,
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那时，我接触了这些书，
06:46
and in these books I discovered the idea of task shifting
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在这些书中我发现了
06:49
in global health.
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全球健康任务转变这一观点。
06:51
The idea is actually quite simple. The idea is,
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这一想法十分的简单。就是，
06:54
when you're short of specialized health care professionals,
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当你缺少专业的健康专家时，
06:57
use whoever is available in the community,
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可以找社区中有空闲时间的人
07:00
train them to provide a range of health care interventions,
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教给他们一些保健干预的知识，
07:03
and in these books I read inspiring examples,
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这些书中就有一些鼓舞我的例子。
07:06
for example of how ordinary people had been trained
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例如，书中有写到怎样使普通人学会
07:09
to deliver babies,
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接生、诊断并治疗早期肺炎，
07:10
diagnose and treat early pneumonia, to great effect.
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这些都十分的有效。
07:13
And it struck me that if you could train ordinary people
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于是，我想到，如果我们可以训练普通人去
07:16
to deliver such complex health care interventions,
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完成这些复杂的保健干预，
07:18
then perhaps they could also do the same
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或许他们也能进行
07:21
with mental health care.
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精神疾病治疗。
07:23
Well today, I'm very pleased to report to you
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今天，我十分高兴的告诉你们
07:25
that there have been many experiments in task shifting
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在过去十年，发展中国家有许多
07:29
in mental health care across the developing world
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精神疾病治疗任务转移的实验，
07:31
over the past decade, and I want to share with you
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我想和你们分享3个特殊的实验
07:33
the findings of three particular such experiments,
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的成果，
07:36
all three of which focused on depression,
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这三个实验都是关于最普遍
07:38
the most common of all mental illnesses.
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的精神疾病——抑郁症。
07:41
In rural Uganda, Paul Bolton and his colleagues,
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在乌干达的郊区，Paul Bolton 和他的同事
07:44
using villagers, demonstrated that they could deliver
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对该村村民进行实验，发现他们可以
07:48
interpersonal psychotherapy for depression
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进行抑郁症的人际关系精神疗法，
07:50
and, using a randomized control design,
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Paul 和他的同事进行了一些随机控制实验，
07:53
showed that 90 percent of the people receiving
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他们发现接受这种干预的90%的人恢复健康，
07:55
this intervention recovered as compared
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而与之相比在对照组，只有
07:57
to roughly 40 percent in the comparison villages.
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大约40%的人恢复了健康。
08:01
Similarly, using a randomized control trial in rural Pakistan,
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类似的，Atif Rahman和他的同时在
08:05
Atif Rahman and his colleagues showed
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巴基斯坦的郊区也进行了随机控制实验，
08:07
that lady health visitors, who are community maternal
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该实验表明在巴基斯坦保健系统
08:10
health workers in Pakistan's health care system,
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的社区女工作者
08:13
could deliver cognitive behavior therapy for mothers
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在对患有抑郁的母亲进行认知行为治疗时
08:15
who were depressed, again showing dramatic differences
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也同样在康复比例上取得了显著的提高。
08:17
in the recovery rates. Roughly 75 percent of mothers
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大约75%的母亲获得了康复，而
08:20
recovered as compared to about 45 percent
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对照组中只有45%
08:23
in the comparison villages.
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恢复了健康。
08:25
And in my own trial in Goa, in India, we again showed
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我在印度果阿的实验再一次证明
08:28
that lay counselors drawn from local communities
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从当地社区中寻找的普通人
08:31
could be trained to deliver psychosocial interventions
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在经过培训后可以对抑郁、焦虑进行心理干涉，
08:33
for depression, anxiety, leading to 70 percent
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这些健康顾问可以让70%的人恢复健康，
08:36
recovery rates as compared to 50 percent
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而即使在主要的健康中心，
08:38
in the comparison primary health centers.
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这一数据也只能达到50%。
08:41
Now, if I had to draw together all these different
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现在，总观这些关于任务转换的不同实验，
08:43
experiments in task shifting, and there have of course
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当然还有其他的实验，
08:46
been many other examples, and try and identify
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当我试着寻找
08:48
what are the key lessons we can learn that makes
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成功的任务转换的
08:50
for a successful task shifting operation,
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关键所在时，
08:53
I have coined this particular acronym, SUNDAR.
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我将其总结为这样一个缩略语：SUNDAR。
08:57
What SUNDAR stands for, in Hindi, is "attractive."
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SUNDAR是什么意思呢？在印度语中是“诱人的意思”。
09:01
It seems to me that there are five key lessons
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在我看来，对于一个有效的任务转换，
09:03
that I've shown on this slide that are critically important
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有五个关键之处，
09:06
for effective task shifting.
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请看幻灯片。
09:08
The first is that we need to simplify the message
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第一，我们需要简化信息，
09:11
that we're using, stripping away all the jargon
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将医学中的专业术语
09:14
that medicine has invented around itself.
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剔除。
09:17
We need to unpack complex health care interventions
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我们需要将复杂的，未经加工的保健干预
09:20
into smaller components that can be more easily
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变成短小的内容，只有这样我们才能简单的将其
09:22
transferred to less-trained individuals.
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教授给缺乏专业训练的人员。
09:25
We need to deliver health care, not in large institutions,
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我们提供的健康治疗，并不是在一些大型的机构中提供，
09:27
but close to people's homes, and we need to deliver
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而是在人们家附近提供，并且
09:30
health care using whoever is available and affordable
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我们用的是当地社区有空闲时间且有能力
09:32
in our local communities.
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的人。
09:35
And importantly, we need to reallocate the few specialists
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重要的是，我们要将有时间的仅有的几个专家
09:38
who are available to perform roles
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也重新划定角色，
09:40
such as capacity-building and supervision.
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例如，让他们做一些能力培养和监督的工作。
09:43
Now for me, task shifting is an idea
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对我来说，任务转换是一个
09:45
with truly global significance,
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在全球都有重要性的想法，
09:48
because even though it has arisen out of the
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即使，这一想法是在发展中国家
09:51
situation of the lack of resources that you find
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这些缺乏资源的条件下产生的，
09:54
in developing countries, I think it has a lot of significance
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它对资源充足的国家同样有
09:57
for better-resourced countries as well. Why is that?
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许多重要意义。为什么是这样呢？
10:00
Well, in part, because health care in the developed world,
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一部分的原因是发达国家和发展中国家
10:04
the health care costs in the [developed] world,
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疾病治疗的费用差距
10:06
are rapidly spiraling out of control, and a huge chunk
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正在呈现螺旋式的发展，而这一趋势已经控制不了了，
10:09
of those costs are human resource costs.
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其中，人力资源的耗费占很大一部分。
10:12
But equally important is because health care has become
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还有一个同样重要的原因就是，随着健康治疗
10:15
so incredibly professionalized that it's become very remote
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变得越来越专业，
10:19
and removed from local communities.
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它与当地社区的距离也就越来越远。
10:21
For me, what's truly sundar about the idea of task shifting,
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对我来说，任务转变这一思想真正吸引人的地方
10:25
though, isn't that it simply makes health care
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不是它可以使更多的人接受
10:27
more accessible and affordable but that
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健康治疗，而是
10:30
it is also fundamentally empowering.
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它的最基本的激励作用。
10:32
It empowers ordinary people to be more effective
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它激励普通人在治疗
10:36
in caring for the health of others in their community,
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本社区患者时变得更加有效，
10:39
and in doing so, to become better guardians
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同时，他们也成了患者们更好的
10:40
of their own health. Indeed, for me, task shifting
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健康卫士。事实上，对我来说，任务转变是
10:44
is the ultimate example of the democratization
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医疗知识民主化的最终范例，
10:46
of medical knowledge, and therefore, medical power.
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因此他也是医学力量民主化的最终范例。
10:52
Just over 30 years ago, the nations of the world assembled
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仅在30年前，世界各国聚集在
10:55
at Alma-Ata and made this iconic declaration.
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阿拉木图发表了如图这个图标式宣言。
10:58
Well, I think all of you can guess
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我认为，你们都能想到
11:00
that 12 years on, we're still nowhere near that goal.
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12年后，我们离那个目标还是很遥远。
11:03
Still, today, armed with that knowledge
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然而，今天，我们有条件
11:06
that ordinary people in the community
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在充足的监督和支持下，
11:09
can be trained and, with sufficient supervision and support,
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使得社区中的普通人通过接受训练
11:12
can deliver a range of health care interventions effectively,
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可以进行一系列有效的健康干预，
11:15
perhaps that promise is within reach now.
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或许那个承诺已在我们的能力范围之内。
11:19
Indeed, to implement the slogan of Health for All,
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事实上，为了贯彻实现所有人健康这一口号，
11:23
we will need to involve all
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我们需要所有人
11:24
in that particular journey,
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对此的参与，
11:26
and in the case of mental health, in particular we would
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在精神健康方面，我们格外
11:29
need to involve people who are affected by mental illness
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需要患有精神疾病的患者和
11:32
and their caregivers.
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他们的护理者的参与。
11:33
It is for this reason that, some years ago,
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几年前，正是因为这个原因，
11:36
the Movement for Global Mental Health was founded
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全球精神卫生运动成立了，
11:38
as a sort of a virtual platform upon which professionals
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作为一个虚拟平台，
11:42
like myself and people affected by mental illness
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许多像我一样的专家和被精神疾病困扰着的人们
11:45
could stand together, shoulder-to-shoulder,
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团结起来，肩并着肩，
11:47
and advocate for the rights of people with mental illness
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倡导精神疾病患者获得
11:50
to receive the care that we know can transform their lives,
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可以改变他们生活的治疗的权利，
11:53
and to live a life with dignity.
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让他们活的有尊严。
11:56
And in closing, when you have a moment of peace or quiet
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最后，我希望当你们空闲时或
12:00
in these very busy few days or perhaps afterwards,
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在这不忙的几天或者以后的任何时候，
12:02
spare a thought for that person you thought about
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你们可以替你们认识的
12:05
who has a mental illness, or persons that you thought about
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患有精神疾病的
12:08
who have mental illness,
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人或人们想想，
12:09
and dare to care for them. Thank you. (Applause)
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并尽可能的照顾他们。谢谢。（鼓掌）
12:13
(Applause)
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（鼓掌）
ABOUT THE SPEAKER
Vikram Patel - Mental health care advocateVikram Patel helps bring better mental health care to low-resource communities -- by teaching ordinary people to deliver basic psychiatric services.
Why you should listen
In towns and villages that have few clinics, doctors and nurses, one particular need often gets overlooked: mental health. When there is no psychiatrist, how do people get care when they need it? Vikram Patel studies how to treat conditions like depression and schizophrenia in low-resource communities, and he's come up with a powerful model: training the community to help.
Based in Goa for much of the year, Patel is part of a policy group that's developing India's first national mental health policy; he's the co-founder of Sangath, a local NGO dedicated to mental health and family wellbeing. In London, he co-directs the Centre for Global Mental Health at the London School of Hygiene & Tropical Medicine. And he led the efforts to set up the Movement for Global Mental Health, a network that supports mental health care as a basic human right.
From Sangath's mission statement: "At the heart of our vision lies the ‘treatment gap’ for mental disorders; the gap between the number of people with a mental disorder and the number who receive care for their mental disorders."
Vikram Patel | Speaker | TED.com