This week I have enjoyed participating in several livestreamed sessions of the 50th annual meeting of the World Economic Forum (WEF) under the theme “Stakeholders for a Cohesive and Sustainable World.”  One of the 7 diverse topic areas being addressed during the Meeting is “Healthy Futures”, which I found to be not only highly relevant to the overall theme of the 2020 meeting, but highly evocative of Thomas Mann’s masterpiece “The Magic Mountain” which takes place before World War I in a tuberculosis sanatorium in Davos, the Swiss Alps town, where the WEF meeting is held yearly.

I say this because a healthy population, both physically and mentally, should be seen as a key goal of a country’s development, as it is an essential building block for productive, inclusive, resilient, and happy societies. But, as in Mann’s novel, this social outcome requires “community” action, with active stakeholder participation, to deal with ill health and its multiple determinants and manifestations.

I was quite pleased to watch Bollywood actor Deepika Padukone receive the WEF’s Crystal Award 2020 for her work in raising mental health awareness in India.  On receiving the award and later in a one-on-one session with Tedros Adhanom Ghebreyesus, the WHO Director General, she reinforced the need to shine a collective light on the still widespread silence, stigma, and discrimination that surrounds mental and substance use disorders globally.  She also conveyed hope and offered an example for other political, private sector, and cultural leaders to follow and engage in this issue:  "Depression is a common yet serious illness. It is important to understand that anxiety and depression are like any other illness and treatable. It was experience with this illness that encouraged me to set up Live Love Laugh," she said while talking about the Foundation she has set up for this cause.

The session “Protecting Mental Health in Youth” offered diverse perspectives on the challenges and options to scale up approaches to dealing with mental illnesses among children, adolescents, and young adults aged 14-25 years.  The special focus on this group is warranted because nearly 75% of mental health conditions begin before age 25, and suicide is a leading cause of death among youth, particularly among young women aged 19-24 years in some countries, with research showing that early intervention is the best means of prevention.  Also, as argued by Patrick McGorry, a noted psychiatrist from Australia known for his development of the early intervention services for emerging mental disorders in young people, the experience in his country shows that an initial focus on mental health in youth helps bring the issue to the wider political arena since it can galvanize the attention of parents and families, who are concerned about the wellbeing of their children; organized community and interest groups; voters; and governments.  People living with mental health problems have a major role to play in speaking out, sharing their stories, and articulating their rights and demands, in the same manner as the movement of HIV-positive people did a couple of decades ago to demand access to life-saving drugs.

The activation of a wider “conversation”, anchored in empathetic listening, is critical to overcome a range of social barriers, from the taboo of mental illnesses, the stigmatization of individuals who are affected by these disorders, the fear of discrimination among their families, to widespread beliefs that these conditions are not “real” health problems, or  are problems brought on by one’s own choices or “social deviant” behavior in the case of substance use disorders.    Indeed, as illustrated from the lived experience of  Amornthep Sachamuneewongse, a WEF Global Shaper Bangkok  who participated in the panel, in many countries mentally ill individuals “live in places where people really do not understand what mental illness is, where there is no one to talk about it, or where one cannot express much, and (ultimately) attempts suicide” to overcome loneliness, stress, grief, depression, and anxiety. 

Because the brain is extremely sensitive to environmental factors, particularly in the first two decades of life, and because most mental health problems begin before young adulthood, the need to act early to prevent their onset was stressed by panelists, who argue for ensuring nurturing and safe environments for children and adolescents to thrive in schools, at home, and in communities.  Henrietta H. Fore, the Executive Director of UNICEF, eloquently noted that as conflict exposes populations to violence and high levels of stress, bottom-up, multisectoral approaches are required in humanitarian and development programs to address the needs of displaced population groups and refugees.  Indeed,  investment in education, social protection, and employment training would ameliorate social exclusion and build social resilience by serving the unique needs of vulnerable groups, such as children and young people who have been exposed to rape and other forms of violence, who have served as child soldiers, or who have witnessed the killing of close family members.  As she argued, affected children and youth need to feel safe, have someone who they can trust and talk to, and have access to the positive socialization that schools and other social support programs can provide to help “bring them back.” 

Panelists also highlighted that private firms and enterprises have a vested interest in having mentally healthy workers, not only for “bottom line considerations”, but more importantly to increase productivity and competitiveness —a “top line” consideration. As mental illnesses account for a large share of absenteeism and presenteeism (a situation in which an employee is present for duty but is not fully capable of performing workplace tasks due to an illness or other condition) in the workplace, companies reduce economic losses and increase productivity and competitiveness by promoting the physical and mental wellbeing of employees, and in some cases their families.

Although global healthcare spending has increased dramatically over the past decade, greatly helping to expand access to health services, a significant supply-side barrier across the world is the lack of mental health parity in the provision and financing of health services.  To deal with this situation, as voiced by different panelists, mental health needs should be viewed in the same vein as physical health needs and be recognized as a basic human right.  Moving from advocacy to implementation, this would require a wider acceptance of the idea that mental health disorders are conditions of the brain that should not be treated differently than other chronic health conditions, such as heart disease or cancer. Nor, in fact, are they truly separable: If untreated, mental disorders can negatively affect management of such co-occurring diseases as tuberculosis and HIV, diabetes, hypertension, cardiovascular disease, and cancer. 

As I have argued before, the realization of universal health coverage commitments by countries should include strategies and plans for the medium term to integrate mental health care into health services delivery platforms that focus on the whole patient rather than an aggregation of diseases.  This, in turn, requires a definition of what mental health conditions to prioritize, as they range from autism and intellectual disability in childhood, to anxiety and depression, bipolar disorders, schizophrenia, to alcohol and substance use disorders in adulthood, and to dementia in old age; how to select a menu of evidence-based, cost-effective treatments to be offered for sets of conditions by service providers at different levels of care (as is commonly done for physical  health conditions); and how these services will be funded and reimbursed without perpetuating discrimination. Key barriers to overcome include lack of trained personnel for the provision of psychosocial support; limited availability of generic drugs in public facilities of peri-urban and rural areas; and under health insurance arrangements, pre-existing clauses that do not cover a medical condition that started before a person's health insurance benefits went into effect, as well as high deductibles, copayments, and lifetime limitations in coverage, that increase the risk of catastrophic health expenditures and impoverishment among vulnerable population groups.

As Jeremy Farrar, the Director of Wellcome Trust, observed, while it is common for WEF participants to elaborate on problems and propose solutions, what is needed for moving the “Healthy Futures” agenda, particularly multisectoral and multidisciplinary action to address mental and substance use disorders among youth, is to track commitments and make public and private stakeholders accountable for their realization.  Only if the talk is translated into a walk for action and measurable impact will we be able to ensure the availability of required investments for supporting scaled up interventions globally.  If this is done, as Fatima Azzahra El Azzouzi, the moderator of the session, noted, we can aspire to achieve an “emotional and mentally cohesive and sustainable future”.