Dr. Dévora Kestel
Sub-regional Advisor for the English-speaking Caribbean
Mental Health, Substance Abuse, and Rehabilitation Unit
Pan American Health Organization (PAHO)
"As community-based mental health capacity increases in the Region, countries of the Americas are also reducing admissions to psychiatric hospitals"
The Pan American Health Organization is working with Member States to strengthen its community-based mental health capacity so that these services are fully integrated within the customary range of services at country-level primary healthcare systems.
Mental health reform is making progress throughout the Americas, albeit modernization is taking years, even decades, to fully reach health systems.
Just as it happens in other regions of the world, mental health hospitals (or asylums for the mentally ill as some of them are commonly known still) function in many instances with procedures in place that neither serve the health needs of persons with mental illnesses nor fully guarantee the human rights of patients. In fact, violations to the basic human rights of patients have been frequently reported and probed by international watchdog groups.
Many general hospitals, clinics and health centers in cities and towns in Latin America and the Caribbean, however, are increasingly incorporating much needed mental health capacity, services and new expertise into primary care systems in countries all throughout the Americas. Efforts towards this end are moving forward in an exemplary manner in specific locations. Traction for progress is been generated by healthcare workers commitment, sense of purpose and duty, and the political will of those capable to make changes at large. But despite progress, the Pan American Health Organization (PAHO) and its Member States recognize that there is still a long road ahead for the Mental Health sector in the Region.
Highlighted strategies include those centered on promoting the social inclusion of mental health services clients and also those that aim at greatly enhancing patient quality attention and care. The new services and attitudes are being developed within Member States thanks in part to the ongoing technical cooperation and the expertise provided by PAHO. Efforts are also directed in response to the stigma and discrimination still present in the society as a whole towards those suffering from mental illnesses and disorders. Many countries are also seeing a consistent proliferation of family support entities increasingly engaging as partners in the process of reform for which they are being created in the first place.
Decentralization of psychiatric health care services, together with concrete actions to avoid inexplicably long hospitalizations or questionable methodologies, are already seen as critically necessary steps to guarantee the right to health for all people suffering at some point in their lives with symptoms of mental illness.
"A serious challenge in the Caribbean region is the lack of human resources in the health sector and particularly in mental health. This situation should promote more 'creativity' among the existing staff and other stakeholders, in order to be able to offer the required support to the people according with their needs. In this regard it is paramount the involvement of actors other than the traditional ones. Not just psychiatrists, nurses or psychologists can provide answer to such a big number of people that according with global data may need support. There is a need for the involvement of others such as general practitioners, general nurses, and social services personnel and the civil society as a whole also. Users/consumers themselves and their relatives are playing a key role in many countries not only in terms of advocacy but also in providing assistance, support and care to those who need it. Our role is also to promote their involvement and to facilitate the provision of training or other technical tools that will make their job easier," Dr. Dévora Kestel said.
Many experts in the field of mental health such as Dr. Kestel are leading the way forward in the Americas. Because of an early internship opportunity two decades ago, she saw full well how life was lived inside and out a mental hospital located in the Buenos Aires province, Argentina.
Dr. Kestel observed the organizational dynamics and conducts within the walls of a hospital environment that from that point forward became a familiar part of her professional context internationally. These early experiences started to shape in her a wholehearted interest to contribute to the advancement of technical cooperation activities as well as the drafting and development of policy, national and international strategies and assistance in mental health programs.
For a number of years, Dr. Kestel worked in the context of the European region. It was there that she met and learnt from other professionals and experts that for quite sometime were also working to affect change with substantive advancements in psychiatry as a whole. In retrospect, Dr. Kestel vividly remembers many images of what she saw back in Argentina two decades ago during her internship.
"Many of the things that I saw there shocked me", she says. "For instance, the case of a patient that had been institutionalized most of his life, with no freedom whatsoever and in precarious conditions." This person, she adds, had not committed any crime. He merely was an employee of a type-writing machine factory. And one day he suffered a psychotic episode. That day, Dr. Kestel continues, was the beginning of not just a customary visit to the doctor for an evaluation or two weeks or even three months of recommended hospital stay. It was, rather, the beginning of a psychiatric institutionalization that lasted for the following 48 years: forced and uninterrupted.
Today Dr. Kestel serves as the Sub-regional Advisor for the English Caribbean within the Pan American Health Organization (PAHO) Mental Health, Substance Abuse and Rehabilitation Unit. "It is true that early in my career it took me sometime to differentiate between theory and practice. At the beginning we are all attached to theory", she says. "But very soon I started to ask myself the hard questions. You study a great bunch of theories that try to explain what mental illness is and how to treat it. But żhow can you explain these theories in a context of seclusion, isolation and yes, also of mistreatment and human rights violations, where people ceased from being subjects as they are turned into objects?
In the Italian city of Trieste, where Dr. Kestel worked for many years, she met a number of European pioneers for change in mental health. Their ideas and concepts were already been enthusiastically endorsed by important and influential international entities.
"What we are trying to do here in Latin America and the English Caribbean is to redouble our efforts to facilitate assistance and technical cooperation to PAHO Member States so that we can all be united in effectively promote mental health developments with services integrated within the primary care level," Dr. Kestel says. "Thanks to these processes, countries in the Americas are visibly and clearly strengthening their capacity to assist people in the community, reducing thereof the rate and or need for admissions to psychiatric hospitals."
PAHO Sub-regional Advisor explains that an important measure being adopted is a proven instrument (WHO Assessment Instrument for Mental Health Systems) which helps the performance of a comprehensive evaluation of mental health systems in each country which, in turn, allows identifying existing gaps and resources available and/or needed. This, Dr. Kestel underscores, facilitates the development of much more effective and rational plans for action in the short and medium term.
Programs and strategies are also being coordinated in countries of the Americas that are entirely focused on the institutionalized so that on a case by case bases, many of these clearly unnecessarily hospitalized patients could continue receiving care and expert attention thanks to the new integrated services that are being created in the community.
"It is also a matter of working to improve living conditions of those living in hospitals", she says categorically. "We must assure that their human rights are respected and we have to think on possible, viable alternatives for those that will definitely need to be there for a long time, until other solutions are identified, with proper attention to manage their daily life."
Many miles far away from Argentina, in Europe, other doctors were also verbalizing decades ago similar thoughts as those of indignation expressed by Dr. Kestel as she remembers the experiences during her internship. Such was the case of controversial figures at the time like the famed Italian psychiatrist Dr. Franco Basaglia (1924-1980).
His work made him a well known advocate of mental health patients. He often referred to patients as a double victim of both society and the customary health practices of the time", says one of those biographical quotations.
On a recent trip to Belize to follow up on progress being made by that country with regards to mental health capacity and reform, Dr. Kestel indicated that an opportunity has clearly open up in Belize and surely in the Caribbean as a whole to further the advancement of the ongoing reform.