A fairly recent study conducted by the World Health Organization (WHO) identified depression as the leading cause of disability. According to a report on The Independent, in 1998 WHO's estimate of mental patients in Bangladesh with a population of about 130 million had nearly 1.2 million and 12 million severe and mild mentally ill patients, respectively. A 2011 National Institute of Mental Health report found there are 14.5 million adults with mental disorders in the country.
Interestingly though, most people in Bangladesh would not consider mental health a disease. It raises hope, therefore, that the conversations about mental health, are beginning to occur in the context of general health issues as has been on the occasion of World Health Day on the 7th of April this year.
However, much of the conversation around mental health has been led mostly by civil society members and seen from a rights based perspective. And until recently, given there are daily human rights violations, arguably of higher proportions, the conversation around mental health has taken a backseat. However, regardless of whether we consider rights of the mentally ill as urgent or mental illness a disease, the harmful impact that mental illness has on the productivity of a nation is undeniable. I would quote the unemployment rate of Bangladesh here but unfortunately, the unemployment rate only takes into account those who are actively looking for jobs and not those who are too ill to look, and in turn fails to take into account those whose abilities are impaired, either physically or mentally.
A 2013 report published by the icddr,b indicates there is a 13-31 percent prevalence rate of mental illness. This means, 13-31 percent of the population, when left un-catered to, are either not engaged or partially engaged in productive employment. According to the WHO, every dollar invested in improving access to treatment leads to a return of USD 4 in better health and productivity. But how do we ensure that investment in mental health, does in fact, result in greater productivity?
An obvious method would be to build institutional capacity to strengthen both the demand and supply side factors in the labour market. If we were to consider mental illness as a problem that negates productivity of labour, we have to acknowledge that employers reluctant to hire persons with mental illnesses or accommodate their needs are posing demand side barriers, while institutions which fail to provide adequate support for sufferers of mental health issues are posing supply side barriers.
To explore the supply side barriers one must inquire what services are being offered by public institutions to counter this problem. The WHO-AIMS (World Health Organization Assessment Instrument for Mental Health Systems) report on Bangladesh, published in 2007, pointed out that approximately four percent of the training for medical doctors in Bangladesh is devoted to mental health. The number of professionals that graduated in 2006 from academic and educational institutions in psychiatry per 100,000 graduates is 0.0036 psychiatrists. Moreover, a large portion of these graduated psychiatrists emigrate out of the country. The department of psychology at the Dhaka University takes in 150 students in the first year. Assuming they all graduate and serve as mental health professionals, it is still unlikely that the number is enough to meet the demand.
The National Institute of Mental Health (NIMH) established in Dhaka started functioning in 2000 as a coordinating body which promotes public education and awareness. Farzana Alam, a student of psychology at the Dhaka University, visited NIMH as part of her placement for the Identity Inclusion project, which aims to identify the needs of people with a psychosocial disability, and break the barriers that affect their capacity to participate in the community. Alam describes her experience at the NIMH as unpleasant to say the least, where the filth, stench, and the unhygienic conditions create an environment far from suitable for healing. She reports that the psychotherapists saw multiple patients simultaneously in the same room and the service providers engaged in rude and inappropriate behaviour.
Dr Razia Sultana, an occupational therapist working at the NIMH as part of a joint project undertaken with the Centre for the Rehabilitation of the Paralysed (CRP) since September 2014, deems the facilities and services decent compared to the psychiatric wards in Pabna Mental Hospital. In fact, she believes the medical services provided at the NIMH are of reasonable standard because they have sufficient manpower. However, the psychosocial services suffer because of a shortage in manpower. The NIMH is trying to improve their rehabilitation services in order to better cater to the needs of those who are mentally challenged.
But it is not only the supply side, i.e. the lack of available services to cater to and build capacity of those who are mentally challenged, that poses a problem. On the demand side, Dr Sultana thinks the stigma associated with mental health prevents employers from recruiting those who have suffered from a mental illness even when the recovery is complete. Mental illness, much like diabetes, can be managed when adequate measures are taken. However, colleagues at work and family at home often fail to provide the kind of support system required for the patient to recover fully and engage in employment.
Shamsin Ahmed, founder of Identity Inclusion and a social inclusion activist, supports this and further adds that there is little effort on the side of employers to accommodate those who suffer from mental illness. For instance, most organisations do not have an in-house counsellor. BRAC is one of the very few organisations that do but that is a fairly recent development.
While public institutions do not have enough capacity to cater to the challenges posed by mental illness, there has been a rise in the number of non-government initiatives and youth based groups who have taken it upon themselves to break the stigma around mental health issues. Noteworthy among them are Innovation for Wellbeing, MindMatters, End Stigma Save Lives, Identity Inclusion, Sajida Foundation and ADD International at the grassroots level.
While these ongoing conversations to help break stigma and initiatives to provide both medical services and psychosocial counselling are definite positive steps, much remains unaddressed on the demand side of employers. Unless employers are decisively inclusive of those with mental illnesses, not only will this add to the burden of the person suffering and their families but slowly and steadily, this will grow into one of the heaviest burdens that the nation must then bear. Therefore, we must reflect on whether we have built enough muscle required for this heavy lifting.
Shagufe Hossain is founder and project director of Leaping Boundaries and a member of the editorial team at The Daily Star.