Vikram Patel, Pershing Square Professor of Global Health at Harvard Medical School and a Steering Committee member at LMSAI, at a TED conference.
Vikram Patel has spent much of his life questioning norms. As a young medical student doing rounds in India, he recalls following the attending doctors from bed to bed, asking what care they were planning for the patients with incurable illnesses, in particular for neurological conditions, as he was fascinated by the brain. For the precocious Patel, the doctors’ responses of “nothing”–that they had untreatable conditions–was not enough. “I was increasingly disillusioned with our medical specialties that were primarily focused on disease or diagnosis. There was this overriding idea that medicine was primarily about curing people rather than supporting people with long-term conditions.”
Although disillusioned, he was still determined to make a difference. He quit his passion for neurology and, much to the displeasure of his mother, pursued training in psychiatry, a field he thought better suited his interest in blending medicine with person-centered care grounded in a social-determinants perspective. It was a bold move to enter a field that was full of stigma and with care that was subpar at best. “At that time, the overwhelming majority of mental health professionals in India lived and worked in just a few urban areas. And almost all in-patient care was in asylums that had been built during the British era,” says Patel, now the Pershing Square Professor of Global Health at Harvard Medical School and a Steering Committee member at the Mittal Institute.
The situation did not deter the doctor-in-training; instead, he set out to change it. He would spend the next several decades questioning the current delivery models, asking why more people couldn’t have access and when they got access, how they could receive evidence-based care that maximized their chances of recovery.
Today, Patel is recognized as one of the world’s foremost leaders championing new models of mental health delivery. He co-leads Harvard Medical School’s Mental Health for All lab as well as the GlobalMentalHealth@Harvard initiative. He has received many awards for his pioneering work and was recognized by TIME magazine as one of the 100 most influential people in the world.
But getting to this stage required enormous determination.
Vikram Patel was recognized by TIME magazine as one of the 100 most influential people in the world. Screenshot from TIME website.
Raising Awareness, Changing the Stigma
When Patel started out, mental health was a marginalized specialty of medicine. One of his early challenges, in the mid-1990s, was to change people’s attitudes, especially those of policy makers, who were focused on tackling myriad development and health challenges, such as poverty alleviation or infectious diseases. Mental health was often seen as a trivial or irrelevant issue. Patel wanted to show that mental health conditions were often intricately intertwined with other health and development priorities and needed to be integrated into programs addressing them.
He needed to arm himself with stories and data, so he headed out into the field to capture the experiences of people living with mental health conditions. His initial forays into what would ultimately lead to his key contributions to global health were living in Zimbabwe for two years in the mid-1990s, providing clinical care in the teaching hospital in Harare and researching mental health problems in traditional healer and primary health care settings. He moved to Goa, India, in 1996 where he co-founded a non-profit organization, Sangath, with which he continued to study the social origins and consequences of mental health problems and design innovative approaches for their prevention and care by leveraging community resources.
“The field of mental health was seen as a peripheral subject in the health field by virtually everyone at that time, and I believe that one of my key contributions back then was to contribute to the evidence that demonstrated that mental illness, even though mostly invisible, for example with no physical signs or laboratory tests, was a real, universal form of human suffering associated with enormous personal consequences.”
As Patel began to make mental health more visible, he also felt the need to challenge the stigma. For him, the stigma was less about mental illness itself than it was about the way society treated people with mental illness across the centuries. He believed that if people better understood mental health problems–if they could see it in their communities and see that there were humane, community-based strategies to support recovery rather than the incarceration, sedation and violence that was the hallmark of care in both traditional and psychiatric facilities–then people’s beliefs and attitudes would change, too. That’s when he started testing the idea of community-based mental health care using local human resources.
“The moment you build community-based care systems that don’t label people with fearsome diagnoses, respect their dignity and autonomy, do not incarcerate and sedate them against their will, and offer care which they value and is evidence-based, you will find the stigma will go away.”
“The moment you build community-based care systems that don’t label people with fearsome diagnoses, respect their dignity and autonomy, do not incarcerate and sedate them against their will, and offer care which they value and is evidence-based, you will find the stigma will go away.”
Championing Community-based Mental Health Care
Where Patel set out to go with his ideas, there were few psychiatrists or psychologists accessible to the vast majority of people in need of mental health care. In India’s villages and for its poor everywhere, the need was great but the options for help were few and far between.
Patel didn’t need to reinvent the wheel: psychosocial interventions were already well-established; he just needed to adapt these to suit the context and to identify a community-based workforce to deliver them. Many mental health conditions–from autism and emotional disorders in adolescents to depression and substance-use problems–didn’t require a highly trained mental health professional; rather, he wanted to show how community members and front-line providers already working in routine care sectors could be trained to deliver proven, psychosocial interventions.
That’s what triggered my move into demonstrating how we could actually leverage widely available, low-cost community resources. In effect, I turned the assumption on its head by saying, ‘let’s not ask what we don’t have; let’s ask what we can do with what we do have.’”
“The prevailing assumption was that you needed mental health specialists to deal with these problems and, because there weren’t enough specialists in most populations around the world, there was precious little we could do to alleviate suffering. That’s what triggered my move into demonstrating how we could actually leverage widely available, low-cost community resources. In effect, I turned the assumption on its head by saying, ‘let’s not ask what we don’t have; let’s ask what we can do with what we do have.’”
Through his non-profit Sangath, which launched 25 years ago in Goa and now operates through three hubs in India (in Goa, New Delhi and Bhopal), Patel began setting up a program to design, deliver and evaluate psychosocial interventions to be delivered in routine settings, such as primary care and school, through community providers, including lay persons. It’s for these types of innovations that Sangath has been recognized as a pioneering organization in mental health care solutions for India and other countries and even won the MacArthur Foundation’s International Prize for Institutions and the WHO Public Health Champion of India prize.
Now with a body of evidence, in 2003, Patel wrote, “Where There is No Psychiatrist,” to serve as a manual for front-line workers. The book has been translated into 15 languages and a much-revised second edition was published in 2018. Through a series of scientific studies, including some of the largest clinical trials evaluating such innovative delivery strategies, he demonstrated how the mental health crisis of care might be solved.
“If you asked me about my biggest success, it would have to be the development of a methodology that can design psychosocial interventions that are acceptable and feasible, applying them to prevent and care for a range of mental health conditions and demonstrating either that they were effective in prevention or in helping people recover or reduce their disability and improve their quality of life.”
Patel’s mission is now to translate the evidence he has generated to scale to benefit populations in both India and the US, the two countries he calls home. With a team of colleagues from Harvard Medical School and Sangath, and partners around the world, he has led the Empower program, which is harnessing digital technologies to build the workforce of front-line providers by giving them the tools to learn, master and deliver evidence-based psychosocial interventions. Empower’s first offerings are to scale up the “Healthy Activity Program,” a six-session treatment for depression in select populations in India and the US. Other treatments in the pipeline include targeting emotional disorders in school-going adolescents and young children with autism as well as developing a well-being curriculum for any person to learn how to support others in their communities.
“This is not a replacement for the specialized mental health care system; what we’re doing is expanding the footprint and reach of the existing mental health care system deep into the community to reduce the large disparities in access to quality care.”
Ultimately, all these interventions and ideas are part of what Patel sees as a continuum of care. “This is not a replacement for the specialized mental health care system; what we’re doing is expanding the footprint and reach of the existing mental health care system deep into the community to reduce the large disparities in access to quality care.”
A Crusade for Universal Health Coverage
Patel is conscious that the crisis of care for mental health problems is often a symptom of a broken health care system. Looking at the whole system is what Patel has turned his attention to these days with an ambitious project convened by the Mittal Institute. The Lancet Citizens’ Commission aims to reimagine India’s health system and provide a roadmap toward universal health coverage in India, informed by the experiences of diverse stakeholders, in particular the actors and beneficiaries of the health care system. For Patel, the mission and principles of universal coverage go hand-in-hand with his quest for mental health for all.
“The principle of universal health coverage, no matter what disease or health issue you’re concerned with–whether it’s HIV or maternal health or mental health, the foundation of an equitable and efficient health care system is primary care,” explains Patel. ”We define primary care, not as a building where people sit and patients come; rather, primary care is a concept focused on bringing healthcare closest to where people are”–a concept remarkably aligned with his vision of mental health care.
“I know that mental health coverage will not scale unless we also invest in universal health coverage, because the word ‘universal’ actually means more than just universal in terms of people; it also means universal in terms of the kinds of health problems people experience, so it’s all health problems for all people delivered in an integrated and person-centered way.”
“I know that mental health coverage will not scale unless we also invest in universal health coverage, because the word ‘universal’ actually means more than just universal in terms of people; it also means universal in terms of the kinds of health problems people experience, so it’s all health problems for all people delivered in an integrated and person-centered way.”
The Commission is now in its second year and is undertaking multiple studies to inform its recommendations, including the largest survey of India’s residents to assess their attitudes, preferences and aspirations for health care.
The discussion of universal health coverage is one that Patel knows resonates across borders. As someone who splits his time between India and the U.S, he sees many ways for his two home countries to learn from each other.
“For me, to be doing something audacious like building a community-based, non-specialist workforce to deliver interventions for mental health problems in two totally different countries, allows me to build learning networks that aren’t just local but global,” says Patel. “What happens in India can help and inform what happens in the U.S and vice versa, and I think that kind of learning collaborative is what really excites me about the future.”
Read more about the Lancet Citizens’ Commission for Reimagining Health Care in India.
Read more about Sangath.
Read more about Project Empower.
This article was written by Carlin Carr, Communications Manager at the Lakshmi Mittal and Family South Asia Institute.
References:
- Patel V, Chisholm D, Parikh R, Charlson FJ, Degenhardt L, Dua T, et al. Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities, 3rd edition. Lancet. 2016;387(10028):1672-85.
- Herrman H, Patel V, Kieling C, Berk M, Buchweitz C, Cuijpers P, et al. Time for united action on depression: a Lancet-World Psychiatric Association Commission. Lancet. 2022.
- Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018;392(10157):1553-98.
- Patel V, Mazumdar-Shaw K, Kang G, Das P, Khanna T. Reimagining India’s health system: a Lancet Citizens’ Commission. Lancet. 2021;397(10283):1427-30.
