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https://www.theguardian.

com/society/2019/apr/30/busting-the-myth-that-depression-doesnt-affect-people-
in-poor-countries

Busting the myth that depression


doesn't affect people in poor countries
For decades, many psychiatrists believed depression was a uniquely western
phenomenon. But in the last few years, a new movement has turned this thinking
on its head. By Tina Rosenberg

Main image: Illustration: Ersoy Emin/Phil Patridge/Getty/Guardian Design

When Vikram Patel first began to study mental health, he believed depression only
existed in rich nations. But today, he is the single most influential figure in the
growing global movement to treat mental illness in poor countries, especially the
most common disorder, depression.

Busting the myth that depression doesn't affect


people in poor countries – podcast
In 1993, Patel, who was born in Mumbai, finished his training as a psychiatrist in
London and moved with his wife to Harare, the capital of Zimbabwe, to begin a
two-year research fellowship at the national university. His purpose was to find
evidence for the view, then widespread among psychiatrists, that what looked like
depression in poor countries was actually a response to deprivation and injustice –
conditions stemming from colonisation. The remedy in such cases, he believed,
was not psychotherapy, but social justice.

Patel began his work by holding focus-group interviews with traditional healers
and others who cared for patients with mental illness, and then by
interviewing patients. He asked them what mental illness was, what caused it, and
how to treat it. The most common illness had a name: kufungisisa, a word in
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Shona, the local language, which means excessive worry about a problem. Many of
the healers said kufungisisa was not an illness, but a reaction to the stresses of life,
such as poverty or illness. Aha! Patel thought. It was as he expected: in Zimbabwe,
mental suffering was being caused by social injustice.

But when Patel asked patients how kufungisisa felt, the answers were familiar. No
matter what they called it, no matter what they held to be the reason or the cure,
they cited hopelessness, exhaustion, inability to confront their problems and a lack
of interest in life – classic signs of depression. “They were identifying the same
symptoms as people I would treat in a clinic in south London,” Patel said.

Far from exposing depression as a uniquely western phenomenon, Patel’s research


in Zimbabwe led him to conclude that depression is a fundamental human
experience. “The basic nature of emotional pain is no different than physical pain,”
he said. “The way they seek help may be different, but human beings feel it in the
same way.”

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While Patel was in Zimbabwe, the World Bank in Washington was conducting a
landmark project that would transform global health. For the first time, data was
being used to make decisions about preventing and treating illnesses around the
world. In order to know how best to allocate international aid, bank officials
decided they needed to know what humans suffer from. What kills us? Sickens us?
Causes us to live less than fully? Analysing data that had been gathered from
around the world three years earlier, researchers published a study called The
Global Burden of Disease, 1990. (Such mapping now happens continuously,
involving thousands of researchers.)

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The results shocked doctors and policymakers. Earlier such projects had tracked
only deaths, not disease. While mental illness is a factor in many deaths, it is
almost never listed on death certificates, so it barely even registered in previous
reports. Now, for the first time, researchers went beyond deaths to examine the
global causes of illness and disability. They found that the single largest cause of
disability worldwide was mental disorders – largely, the common illnesses of
depression and anxiety. They caused a seventh of all the disability in the world. In
the poorest countries as well as the richest, and at every socioeconomic level in
between, mental disorders were the greatest thief of productive life.

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Therapy on a bench: the grandmas beating mental illness in Harare

The consequences of this were catastrophic. Patients in south London had a shot at
seeing any number of psychologists or psychiatrists. But the treatment typically
given to sufferers of depression in wealthier countries was completely out of reach
for hundreds of millions of people who needed it. Poor countries spent virtually no
money on mental health.

“I was astonished to find that there were just 10 psychiatrists in Zimbabwe,” said
Patel, who is now Pershing Square professor of global health at Harvard Medical
school. “Eight of them were in Harare. And of the 10, eight were foreigners like
me.” Those psychiatrists spent their time treating the few patients wealthy enough
to pay. The situation was similar in other poor countries. In 2005, the World
Health Organization reported that a number of countries – including Afghanistan,
Rwanda, Chad, Eritrea and Liberia – had just one or two psychiatrists in the whole
country.

Training the tens of thousands of traditional mental health professionals that


countries such as Afghanistan and Zimbabwe needed was impossible, Patel feared.
But there was a more radical solution.

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For most of the 20th century, the view that “mental health” was exclusively a
problem of the wealthier west was widely held by doctors, mental health
professionals and cultural theorists. JC Carothers, a psychiatrist and consultant to
the WHO, represented one typical branch of this belief. In 1953, he published an
influential paper on the “African mind”, in which he argued that the continent’s
inhabitants lacked the psychological development and sense of personal
responsibility necessary to experience depression.

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Even by the late 1990s, versions of this thinking survived. There was a heated
debate going on in the US about whether the triggers for depression in wealthier
countries could possibly have the same effect among the world’s poor, recalled
Melanie Abas, a reader in global mental health at the Institute of Psychiatry,
Psychology & Neuroscience at King’s College London. Abas characterised the
sceptics’ position as: “If your baby died and you had seven already, you didn’t
experience it in the same way.”

Curiously, many people with leftist views arrived at the same dismissal of the need
for mental health care, although via different routes. Critics of colonialism argued
that calling what looked like depression an illness needing treatment was an act of
western cultural hegemony: it medicalised experiences that were not considered
illnesses and were dealt with perfectly well by the local culture. Others believed
that the more communal nature of society and the stronger family ties in poor
countries inoculated people against depression, which was linked to the loneliness,
stress and materialistic culture of western life. Still others acknowledged the
existence of depression, but argued that treating it was a luxury: surely people with
no food or shelter have more important things to worry about. The implication of
all of these views was that people in poor countries didn’t need the sort of
counselling often prescribed for sufferers of depression in the west.

Dr Vikram Patel in New Delhi. Photograph: Mint/Hindustan Times via Getty


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We now know that they need it desperately. Abas has spent much of her career in
Zimbabwe; in the 1990s, she treated patients at Harare Psychiatric hospital and,
even before Patel did, documented extensive depression. Some of her research
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looked at the relationship between depression and life’s tragedies. She found that
severe events, such as the death of a child, were as likely to cause depression in a
poor woman in Harare as they were in an affluent Londoner. “But women in
Zimbabwe faced many more such events in a year,” Abas said.

Before working in Zimbabwe, Patel had believed that depression was simply an
appropriate response to adversity. Your husband drinks and beats you. Your crop
failed. Your family is homeless. Your children are hungry. Of course you are sad.
You and your family need treatment for alcoholism, fertiliser subsidies, stable
employment. What does psychotherapy have to do with it?

Sadness is an appropriate response to adversity. But depression is not the same.


(While the poor are more likely to be depressed, the vast majority of the poor are
not, so poverty alone does not lead to depression.) Depression is a fog of negative
thoughts that debilitate and paralyse the sufferer so she cannot respond to terrible
events. “The question is how quickly you are able to get past distressing emotions
so they don’t themselves acquire an independent effect on your life, and become a
problem in themselves,” Patel said. “If your negative thoughts are coming in the
way of solving a problem, if your sleeplessness affects work – that is compounding
whatever triggered it.”

The disability caused by depression is actually much wider-ranging than the data
from World Bank’s 1993 report suggested, because the numbers only measured
depression’s direct effect on health. But depression also takes a huge indirect
toll. It makes other diseases much worse. People who are depressed are more likely
to get other illnesses, and less likely to be treated successfully. Depressed patients,
for example, do not take their HIV medicine, and are less able to support their
families or take care of others: babies of depressed mothers often aren’t well
nurtured and fail to thrive.

Far from a luxury, treating depression is often a necessary first step towards
solving other problems. Addressing poverty sometimes brings about a small
improvement in people’s mental health, said Kari Frame, the programme director
at Strong Minds, an organisation that helps depressed women in Uganda treat
their illness by forming self-help groups. But addressing mental health very often
leads to a big decrease in poverty.

In 2007, Patel and several other experts published a series of articles on global
mental health that inaugurated a profound change in approaches to treatment
worlwide. The series, in the prominent British medical journal The Lancet, warned
that mental health disorders are neglected and stigmatised, and pointed to the
critical shortage in mental health care. This was – and still is – true in rich
countries: more than half of Americans who need treatment don’t get it, for
example. But in poor countries, virtually no one was getting the care they needed.

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In low- and low-middle-income countries, budgets for mental health treatment
were less than 3% of an already meagre health provision. Most of that went to
institutions housing people with severe mental illnesses such as schizophrenia.
Such institutions were almost always understaffed, manned by poorly trained
workers and dedicated to containing rather than treating their patients, using
methods that often amounted to torture. Depressionand anxiety got no treatment
at all.

The Lancet articles proposed a massive expansion of mental health treatment


worldwide. Richard Horton, the Lancet’s editor, urged people to join a new social
movement to provide effective care for the world’s neediest populations. “The time
to act is now,” the authors wrote.

Psychiatrists and psychologists were costly to train and pay. And how would poor
countries keep them? Medical professionals often studied at their government’s
expense – and then emigrated, to practise in North America or Europe.

The Lancet writers noted that one of the most important trends in global health
was shifting tasks from professionals to lay people. Community health workers,
who offer basic health information and services in the communities where they
live, were not new – China’s “barefoot doctors” programme of the late 1960s was
one example – but they had fallen out of favour. In the early 2000s, however, there
was a resurgence of interest. Developing countries were training and paying (albeit
poorly) millions of community health workers to teach nutrition, weigh babies,
treat pneumonia and organise campaigns to clean up standing water.

Lay health workers didn’t deal with depression, but there was no reason they
couldn’t, Patel and his colleagues argued. For all the suffering it causes, it turns out
that diagnosing and treating many episodes of depression is actually not that
complex.

To see the role that a lay person could play in addressing depression, I visited
Santa Cruz high school in the Indian state of Goa. In September 2016, Mamta
Verma set up a table and two plastic chairs in a crammed storeroom, and installed
herself there on Monday and Wednesday mornings. For the first time, the school
could offer its students counselling.

Verma exudes gentleness and warmth. She had studied psychology in college, and
was getting her master’s degree through distance learning. But she was not a
psychologist yet – and that was the whole point. If she were, she wouldn’t be
working in a storeroom at a high school. She was testing a new programme created
by Sangath, a Goa-based organisation founded by Patel and six colleagues in 1996.

Sangath – the name means “together” in Konkani, the official language of Goa –
designs and studies ways to make mental health care as cheap and accessible as
possible. When a programme works, Sangath then chips away at it to see how
much it can shed without sacrificing results. If eight weeks of counselling bring
success, how about six weeks? Could group therapy leaders get two weeks’ training

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instead of four? If someone with a high school education is leading the group, what
about a community health worker with less education – or none? If the patient is a
child, can his parents learn to deliver the therapy?

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While I sat in her storeroom, a steady stream of students visited Verma to talk
about parents who fight, classmates who bully, anger management, boy trouble,
their weight, their skin, their concentration, their difficulties in Hindi or maths.
Verma uses a workbook featuring Priyanka and Ajay, two fictional teenagers with
typical teenage issues. Verma asked students to analyse what Priyanka and Ajay
were facing and come up with solutions for them to try. Then the students applied
these techniques to their own problems. This method is called problem-solving
therapy.

Sangath is by far the most influential research organisation on mental health care
in poor countries. It has 300 employees and fellows, and has published dozens of
studies, many of which describe real breakthroughs in care. People visit from
around the world to learn Sangath’s strategies for preventing or treating conditions
such as postnatal depression, problem drinking, schizophrenia, depression in the
elderly, stress in people with HIV and their caregivers, and teen depression and
behaviour problems. All of these strategies involve lay therapists like Verma, and
many use a version of the sort of problem-solving therapy she applies.

One example is Sangath’s health activity programme. The organisation trained lay
people to give around eight weekly sessions of counselling to patients suffering
from severe depression. The focus is helping patients stop doing things that make
them feel bad – staying in bed, neglecting personal hygiene – and start doing
healthy activities, such as talking to friends, engaging in hobbies or taking a walk.
Counsellors also ask patients to brainstorm possible solutions to their problems,
pick the best one and try it. It seems absurdly simple, but three months later, the
patients who had been through just that brief programme were 64% more likely to
be in remission than those that hadn’t.

Abas, the Institute for Psychiatry reader, said that although Sangath has been
seminal, its approach to depression focuses too narrowly on single episodes.
“Depression for most people is really a chronic illness,” she said. “I don’t think
they’ve done enough to emphasise that. It’s important to get treatment when
you’re really low, but if this relapses, what next?”

For most patients in wealthy countries, what’s next – or often what’s first – is an
antidepressant. Abas points out that medicines are curiously absent from the
global mental health movement. “It’s become very fashionable to talk about talk
therapy,” she said. “A lot of people do really well with it. But some are too unwell to
even start. If you are very depressed and your brain is shutting down, are you even
able to talk?”

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In the 12 years since Patel and his colleagues published their groundbreaking
series of articles, global mental health has become a movement. When they were
drafted in 2000, the UN’s millennium development goals for 2015 made no
mention of mental health. Now, “mental health care for all” is a pillar of the UN
sustainable development goals for 2030. Dozens of low-cost mental health care
projects have sprung up around the world. Various networks, including the Mental
Health Innovation Network, help them share information and ideas.

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But an archipelago of small programmes is far from a global solution. China and
India are trying to expand mental health care in rural areas, but it will be a long
time coming. More than a decade after the articles that changed the debate on
global mental health, there has been no real growth in access to treatment, in poor
countries’ spending on mental health care, or in mental health care funding from
wealthy countries.

There is one place, however, where mental health care has become a routine part of
medical care, and that is Harare, Zimbabwe. The nation that proved to Patel that
depression was universal has come up with a form of psychotherapy accessible to
all – one that is effective, easy to duplicate and cheap.

When Patel taught psychiatry at Harare Central hospital in the early 1990s, Dixon
Chibanda was one of his students. After graduation, the other five psychiatry
students in Chibanda’s class all left Zimbabwe for richer countries. Chibanda
stayed. He treated private patients to make money, but also worked in the
psychiatric hospital, where much of his work consisted of prescribing medicine and
trying to make sure people took it. “I got into psychiatry to connect with people
and nurture the human spirit,” he told me. “But I was beginning to feel
increasingly disconnected from the people I was trying to help.”

One night in 2005, Chibanda got a call from a doctor in Mutare, a city south-east of
Harare. One of Chibanda’s former patients, a 24-year-old named Erica, had tried
to kill herself with rat poison. Chibanda asked the doctor to tell Erica’s mother to
bring her to see him as soon as possible. He heard nothing for three weeks, then
one day the mother called to tell him that Erica had hanged herself from a mango
tree in the family garden.

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Dr Dixon Chibanda, who started the friendship bench in 2007 in Mbare.
Photograph: Cynthia R Matonhodze

“Why didn’t you bring her to see me as we planned?” Chibanda asked.

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“We didn’t have bus fare,” the mother said.

“I started to realise that psychiatry in an institution is not the way to go,” Chibanda
recalled. “We have to take it to the community.”

He conducted a survey in 12 clinics around Harare, and found that the clinic with
the highest rate of depression was in the slum of Mbare, where one in three people
was affected. In 2006, he told the city health department he wanted to start a
mental health programme there.

Neither the department nor the clinic staff were enthusiastic. “The clinic told me
the nurses were too busy,” Chibanda said. “And there was no space for me to work
inside the building.” So he set up a bench in the yard.

Grudgingly, the clinic lent Chibanda the services of its “Grannies” – middle-aged
or older women with little education, who earn a small stipend doing community
health work. The Grannies were given two weeks to learn what depression is, how
to diagnose it using a simple questionnaire adapted for Zimbabwe by Patel, and
how to do a form of problem-solving therapy modelled on an approach Abas had
used in Harare in the early 90s.

To be able to treat large numbers of depressed or anxious people, any solution has
to be cheap and easy to spread. It can’t depend on having an office or trained
professionals. The goal, said Abas, was to teach people who are already working
with the community how to treat depression. Grannies on a bench turned out to be
perfect.

By 2015, every health clinic in Harare had a group of sturdy red wood benches in
its yard, known as friendship benches, and grannies in brown uniforms who sat on
them talking to patients each morning. The grannies use standard problem-solving
therapy, but put it into terms people can relate to. They use Shona phrases for
opening up the mind and strengthening the spirit. If patients want to pray with
their granny, they pray. “We try to avoid dismissing what people believe in,”
Chibanda said. “We say, pray, but in a way that encourages problem-solving: ‘God,
help this person to identify which problem to focus on.’”

Israel Makwara, Harare’s chief health promotion officer, told me that the grannies
made every other health programme in Harare go better. The clinics’ HIV
programmes were one example. “If somebody’s frame of mind is now solid, they
are likely to adhere to their medications,” Makwara said. “They’ll do a whole lot
better than someone who has given up the will to live.”

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At the Hatcliffe Polyclinic, in the north of Harare, very few people come to the
clinic for mental health care, but the protocol is to offer everyone a questionnaire
to screen them for depression. If they score high, they get an appointment on the
friendship bench in the front yard.

In Zimbabwe, elders are used to simply dispensing advice, said Vongai


Muchengeti, a granny at the Hatcliffe clinic. But encouraging patients to come up
with their own solutions is an important part of the therapy; it teaches patients to
think more critically, assess alternatives and gain confidence.

“How do you think you can resolve this?” Muchengeti kept asking one patient.

“I’ve come here for you to tell me how,” the patient replied. “You’re supposed to
help me.”

“This is how I’m helping you,” Muchengeti said.

The ideas the patients do come up with – I could look for work, I could talk to my
husband – might seem obvious, but they’re not to people with depression. “You
have HIV, your teenage daughter is pregnant, your husband is abusive, you’re
about to be evicted,” said Ruth Verhey, a German-born clinical psychologist who
runs the programme with Chibanda. “That buildup leads to a sense of
helplessness.”

The grannies help people overcome that. At the end of 2016, Chibanda published
the results of a randomised control study in which he assigned 573 patients either
to a bench or to a better version of usual care, including antidepressants when
necessary. After six months, 50% of patients in the non-bench group were still
depressed, while only 14% of friendship bench patients were.

Today, Zimbabwe has friendship benches at 72 health clinics in three cities. Verhey
estimated that about 40,000 patients have been treated in the last two or three
years, most of them women. Chibanda has also launched benches in rural areas,
and one for adolescents, which will be staffed by their peers. The model is also
being adapted in other places, from Malawi and Zanzibar to New York.

Verhey said people write from all over the world. “We get so many people saying: ‘I
want to do this with my NGO, with my church group,’” she said. “My standard
reply is that we like to work inside the health system. That way you have
accessibility and sustainability.”

For all its profile, however, the programme has next to no money. Neither
Chibanda nor Verhey are paid. The programme has funding for specific research
projects – including, recently, a much-needed study of how grannies were actually
delivering therapy. But there are no funds to spread the programme.

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Even before the friendship bench programme was fully underway, Chibanda knew
it also had to offer some solutions to patients’ most important problem: desperate
poverty. He consulted an expert on how women in slums or villages could make
money: his own grandmother, who lived in Mbare, where the programme began.
She said many women make money by crocheting sleeping mats – could they
crochet other things?

Verhey began collecting plastic destined for landfills, such as grocery bags and old
videotapes, that could be shredded or unspooled and turned into yarn. Women
visiting the benches used the yarn to crochet bags, purses, laptop cases and other
items. They then sold the bags in local markets, while Verhey sold some in
Zimbabwe’s high-end tourists shops and to other parents at Harare’s international
school. A bag could sell for as much as $10 – more than three times the average
daily income in Zimbabwe.

The crocheting project had a second purpose: treatment on the bench usually lasts
for about six sessions. But the need for solidarity and companionship does not go
away. Meeting to turn in their bags and get new materials gave women a reason to
congregate. The programme created a support system for the women, called Circle
Kubatana Tose, which means “hold hands together”. There was a circle in nearly
every clinic.

I went to one circle in a small red building on the campus of the psychiatric unit at
Harare Central hospital. Women came in with their latest crochet work and there
was soon a heap of brightly coloured bags on the floor. They prayed, drummed,
sang and shared their news. Their problems – domestic violence, alcoholic
partners, HIV, hunger – were common in their neighbourhoods. But because of
stigma, they were rarely discussed outside the circle. Neighbourhood life can be
supportive and warm, rich with human connection. But it can also be dominated
by gossip and judgment.

Grannies in Harare, waiting for visitors to their friendship bench. Photograph:


Cynthia R Matonhodze

A woman named Tackla told me that when she was diagnosed with HIV, she was
desperate to talk about it. “But I was frightened to talk to people because they
might laugh at me,” she said. “And if you talk to a neighbour, they could tell
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everybody. So I kept it to myself.” The circle was the only place she could talk
freely, she said. In her circle, she was the first to volunteer that she was infected.
“When I did, another woman said she was, too. We talk to each other,” she said.
“We are friends.”

The collapse of Zimbabwe’s economy is accelerating, and Verhey’s bag programme


collapsed a year ago for lack of buyers. But the circles refused to fail. Women still
gather at their health clinic or village well and sit and talk in a group they trust,
and while they talk, they still crochet, or make shoes from rubber tyres.

Vikram Patel had gone to Zimbabwe in 1993 seeking to show that depression was a
social and political condition, and that no clinical intervention was necessary. He
convinced himself of the opposite: psychotherapy or medicine were all that was
needed to cure it.

Now he has come halfway back around: you need both. About 80% of depressed
people everywhere, Patel said, need only what he called a “hope intervention” –
someone to guide them through self-help. That could be as little as a single session
of counselling with a lay health worker. But it is also necessary to sit and talk to
trusted friends in a circle. It is necessary to take a crochet hook and fashion old
videotape into something that can allow you to feed your children.

“We have to redefine what is a psychological intervention, recognising that for


many people, their psychological well-being is embedded in their social world,”
Patel said. “It would be almost unreal for a psychological worker in India to say to
a woman whose husband beats her: ‘That is not my concern. I’m only concerned
with your negative thoughts.’”

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