Mental Health Amid Rising Global Fragility, Conflict and Violence
As discussed today in the 2022 World Bank Group (WBG)-International Monetary Fund (IMF) Spring Meetings flagship event "On the Frontlines of Rising Fragility”, over the last two years, the world has seen a series of massive setbacks to stability in regions across the world. As noted, this disturbing trend points to an urgent need for the international community to come together and develop new and innovative approaches to deal with and help people cope with some of the dire consequences of the most significant public health and economic crisis in almost a century.
Indeed, as David Malpass, the President of the WBG, has observed, “recent trends are disheartening and tragic.” More so if we realize that, as he noted, “Conflict, fragility, and violence cut across all income groups and the poor are the most affected. They add to the damage caused by COVID-19 and now by the war in Ukraine.”
One area that merits particular attention is the severe toll on the mental health and well-being of populations living in situations of fragility, conflict, and violence.
Mental Health Toll of COVID-19
Even before the emergence of the COVID-19 pandemic, mental disorders were among the leading causes of health burden globally. As we progress into the third year of the COVID-19 pandemic, a disproportionate increase in the global burden of depressive and anxiety disorders has been reported, particularly impacting the mental health of women and children worldwide. According to a recent analysis published in The Lancet, among women, there were almost 52 million additional cases of anxiety disorders and more than 35 million additional major depressive disorders (MDD) in 2020, compared to 2019, as they were more likely impacted by the social and economic consequences of the pandemic (e.g., challenges like school closures and illness disproportionately required women to fill the role of caretaker). Likewise, younger people were more affected by major depressive disorder and anxiety disorders than older age groups, with additional prevalence of these disorders peaking among those aged 20-24 years. More ominous, according to the Global Burden of Disease 2019, self-inflicted injuries are the main cause of death worldwide in adolescent girls, and suicide is the leading cause of death for girls and women between 15 and 19 globally.
Mental Health Impact of Population-wide Shocks
Fragility and conflict pose daunting challenges in an increasing number of places around the world, frequently spilling across borders, causing people to become refugees or internally displaced. More than 84 million people were estimated to be forcibly displaced by mid-2021—before the war in Ukraine caused the fastest-growing refugee crisis in Europe since the end of World War II. Around 76 percent of refugees are displaced for more than five years, and the vast majority of the world's refugees and internally displaced people live in developing countries.
Different studies show that population shocks, or unexpected or unpredictable events that disrupt the environmental, health, economic, or social circumstances within a population, contribute to increase the prevalence of depressive and anxiety disorders. Indeed, conflict and other factors such as poverty, unemployment, death of loved ones, physical illness, conflict, forcible displacement, refugee status, social dislocation, and crime and violence, impact the mental well-being of people, causing mental health disorders mostly in vulnerable groups. Country data from Afghanistan, for example, showed that half of the Afghan population aged 15 years or older was affected by at least one of these mental disorders: depression, anxiety and post-traumatic stress disorder.
Among the consequences of war, the impact on the mental health of the civilian population is one of the most significant. Armed conflict and violence disrupt social support structures and exposes civilian populations to high levels of stress. The experience in countries such as Colombia indicate that exposure to violence in general and to armed conflict in particular, over several decades, has been consistently associated with an increased prevalence of mental illness (e.g., depression, somatization disorder and alcohol abuse).
The 2015 Global Burden of Disease study found a positive association between conflict and depression and anxiety disorders. While most of those exposed to emergencies suffer some form of psychological distress, accumulated evidence shows that 15-20 percent of crisis-affected populations develop mild-to moderate mental disorders such as depression, anxiety, and post-traumatic stress disorders (PTSD). And, 3-4% develop severe mental disorders, such as psychosis or debilitating depression and anxiety, which affect their ability to function and survive. If not effectively addressed, the long-term mental health and psychosocial well-being of the exposed population may be affected.
The above study also found that between 2010 and 2015, mortality due to war (collective violence and legal intervention) increased, rising to 171,300 in 2015. More than 40·6 percent of these deaths occurred in Syria and Yemen. According to the study, these numbers of war fatalities, remain much lower than those recorded in 1993 and 1994, when more than 626,000 lives were lost to the Rwandan genocide, the Iraq civil war, the armed conflict in Bosnia and Herzegovina, and other occurrences of collective violence.
What to Do?
In conflict or post-conflict situations like those currently faced in the Middle East, in some African countries, among refugees flowing into European Union countries, particularly now from Ukraine, or the internally displaced population due to conflict in other countries, one of the priorities is to develop programs to protect and improve people’s mental health and psychosocial well-being. In these situations, much-needed mental health care can be incorporated as part of humanitarian and development responses. Since affected populations are at an increased risk of mental disorders and psychological distress, inaction can severely overwhelm the local capacity to respond, particularly in settings where social networks and roles have been altered, and the health and social services infrastructure was already weak or rendered dysfunctional by crisis situations.
A robust body of evidence exists to guide efforts to integrate mental health services in crisis response programs and address common skepticism at national and international levels about the feasibility of doing it effectively. Organizations such as the World Health Organization (WHO), the United Nations Refugee Agency (UNHCR), Partners in Health (PIH), International Medical Corps (IMC), Grand Challenges Canada, and the Mental Health Innovations Network have accumulated vast amounts of evidence about what to do in conflict and post-conflict settings. The 2016 Disease Control and Priorities report on Mental, Neurological, and Substance Use Disorders, which draws on the knowledge of institutions and experts from around the world, also provides a “gold standard” assessment and evidence on burden, interventions, policies and platforms, and economic evaluation.
The evidence is clear. As summarized in a WBG paper, effective scaled-up responses to improve the mental health and psychosocial wellbeing of conflict-affected populations require careful adaptation to specific contexts of multi-layered systems of services and supports (e.g., provision of basic needs and essential services such as food, shelter, water, sanitation, and basic health care; action to strengthen community and family supports; emotional and practical support through individual, family or group interventions; and community-based primary care health systems). This allows a focus on affected individuals as a whole, addressing both their physical and mental health needs, while reducing the risk of stigma and discrimination among families and communities. This is important since mental disorders are highly co-morbid with other priority conditions (e.g., maternal and child health conditions, HIV/AIDS, and non-communicable diseases such as cancer and diabetes).
To inform the design of context-specific interventions in emergency settings, the mapping of the problem is of paramount importance, including assessment of mental health and psychosocial information about the affected population, covering both those with disorders induced by the crisis, and those with preexisting disorders. Such assessments can also clarify what is the current availability of mental health services in affected settings.
As illustrated by PIH experience in countries such as Haiti, Rwanda, Peru, and Liberia, many effective, evidence-based interventions are available and can be grouped into an essential package of interventions along a mental health value chain at community and facility levels, that includes prevention (e.g., community stigma reduction); case finding (e.g., psychological assessment, diagnosis); treatment (e.g., counselling, psychosocial interventions such as cognitive behavioral therapy, and treatment with essential medicines such as antidepressant and antipsychotic medications); follow-up (e.g., monitoring of symptoms); and reintegration (e.g., social and economic interventions).
Is this Approach Cost-Effective?
A WHO-led study prepared for the WBG/WHO global mental health event at the 2016 WBG/IMF Spring Meetings showed that the estimated cost of treatment interventions at the community level for moderate to severe cases of depression, including basic psychosocial treatment for mild cases and either basic or more intensive psychosocial treatment plus antidepressant drug for moderate to severe cases, is quite low: the average annual cost during 15 years of scaled-up investment is $.08 per person in low-income countries, $0.34 in lower middle-income countries, $1.12 in upper middle-income countries, and $3.89 in high-income countries. Per person costs for treatment of anxiety disorders are nearly half that of depression. In terms of the economic returns on investment, benefit-to-cost ratios for scaled-up depression treatment across country income groupings were in the range of 2.3 to 2.6. For anxiety disorders, the ratios were slightly higher, with a range 2.7–3.0.
We must be clear, however, that the provision of mental health and psychosocial support services at the community level cannot be seen only as a vertical or free-standing intervention offered in a health facility. Rather, it needs to be part of broad integrated platforms—population, community and health care—that provide basic services and security, promote community and family support through participatory approaches, and strengthen coping mechanisms not only to improve people’s daily functioning and wellbeing, and protect the most vulnerable (e.g., women and children, adolescents, elderly, and those with severe mental illness) from further adversity, but also to empower the affected people to take charge of their lives as valuable members of society.
How to Finance these Programs?
We must be wary of siloed approaches to increased mental health funding. Rather, governments and the international community can mobilize new resources and leverage existing funding streams by integrating mental health interventions into existing service delivery platforms across sectors. For example, funding from the International Development Association (IDA) – the WB’s fund for the poorest, and other multilateral and bilateral sources could be tapped, particularly under the WBG’s Strategy for Fragility, Conflict, and Violence (FCV) that has helped the WBG move the needle on its support to FCV-affected countries. Over the last five years, the WBG has tripled its financial support to countries struggling with FCV, with over $30 billion in commitments these last two years.
Another source is the WBG’s $26 billion COVID-19 Global Health Emergency Response Program (including vaccines/vaccination support), which is already funding under national programs, psychosocial interventions to help people deal with negative psychological effects associated with stressors such as lockdowns, self-isolation and quarantines, infection fears, inadequate information, job and financial losses, and stigma and discrimination. Other existing funding streams for maternal and child health, such as those under the Global Financing Facility (GFF) in support of Every Woman, Every Child, can be leveraged to deal with maternal depression, especially postnatal, and the associated stunting in children.
A collaborative response is required to tackle mental health as a development challenge. Such a response needs to involve multidisciplinary approaches that integrate health services at the community level, in schools, and in the workplace to explicitly address the mental health and psychosocial needs, including alcohol and other drug use problems, of displaced people and host communities. It would also include innovative social protection and employment schemes that facilitate the reintegration of affected persons into social and economic activities, such as done under Canada’s RISE Asset Development, which provides seed capital and lends at low-interest rates to people with a history of mental health and addiction challenges.
It is time to stop treating mental and substance use disorders differently than other health conditions. After all, these disorders are of the brain, an equally important organ in the human body as the heart, liver, or the lungs. A firm commitment is therefore needed from national and international actors to champion mental health parity in the provision of health and social services, as part of dedicated development support and assistance programs. We must help displaced people and refugees overcome their vulnerabilities, build mental resilience, and take full advantage of poverty reduction programs, economic opportunities, and legal protection, particularly to deal with widespread stigma and discrimination.
I am optimistic that recent attention to this issue will lead to increased commitments, funding, and implementation of required multi-sectoral action to address the needs of displaced people and refugees.
In moving forward, let’s not forget the words of António Guterres, the Secretary General of the United Nations, who observed before, that “while every refugee’s story is different and their anguish personal, they all share a common thread of uncommon courage – the courage not only to survive, but to persevere and rebuild their shattered lives.” If this is done, as Toluwalola Kasali, a IFC colleague from Nigeria noted, we will be helping the affected people regain “the ability to dream, desire and work for a future, one very different from their present circumstances.”
Source of Image:
Shutterstock Item ID: 1683613129 (author paid subscription)
"People displaced by the war in Syria."
Contributors: Mohammad Bash