Changing minds

Mental Health DayTo mark WHO World Mental Health Day, today’s post is by Emily Hewett of the OECD Health Division

Across the OECD an estimated 20% of the working-age population suffer from mental ill-health, and the social and economic impacts of this burden of illness are huge, according to the OECD’s recent publication Making Mental Health Count. Together, the direct and indirect costs of mental ill-health can exceed 4% of GDP across the OECD, driven by expenditure on medical needs and social care costs, as well as higher rates of unemployment and more absences from work. According to OECD’s Sick on the Job report, people with severe mental illness are 6 to 7 times more likely to be unemployed, while those with a mild-to-moderate illness are 2 to 3 times more likely to be unemployed.

World Mental Health Day should also be a time to look beneath these striking statistics, and think about the millions of individuals living with mental ill-health across the OECD, and worldwide.

The reality of mental ill-health is often a grim one. Mild and moderate mental illnesses such as depression or anxiety are estimated to affect around 50% of people in their lifetime. For society and economies the costs are clearly significant, but for individuals the strain can be crippling. The heavy weight of depression and anxiety can stop individuals reaching their full potential in education or at work and put huge strain on relationships with loved ones. If untreated, individuals suffering from depression or anxiety can quickly find themselves out of work and dependant on sickness or disability benefits. Sick on the Job shows that after long periods of sickness absence, individuals find it harder and harder to return to work. Furthermore, the stigma around mental illness can lead people to hide their suffering, leaving them to struggle alone.

Individuals with severe mental illnesses, like bipolar disorder or schizophrenia, experience symptoms such as hallucinations and big swings in mood, which are hard to understand and tough to control. In too many instances, treatment is restricted to ‘what’s available’, rather than the care that best suits the individual’s needs or preferences. Individuals with severe mental illness also have poorer physical health, and higher rates of cardiovascular disease, diabetes and cancer. For health systems this means higher spending on services, and for individuals having a physical and a mental illness together can mean dying up to 20 years earlier than the average for people born around the same and in similar circumstances to them.

What, then, needs to be done?

The high social and economic costs of mental ill-health demand a more robust policy response. Individuals with mental ill-health should be offered care that is timely and appropriate for their needs, which puts them at the centre of care delivery, and makes treatment choice a reality. Sick on the Job stresses the importance of making employment a core desired outcome for mental health care and the need for employment services to address widespread mental health needs among jobseekers. With appropriate training, guidance and resources, the ability of teachers and managers to provide support with mental health problems can make a huge difference to individual wellbeing, and can be decisive in whether a student or worker stays in education or work or not.

The structure of mental health services, how they are set up, funded, and delivered to the individuals who need them, needs to be strengthened. Even as national pressures, costs and priorities bear down, OECD mental health systems need enough services, enough investment, enough evidence-based care, and enough cleverly designed service delivery to make patient-centred high quality care a reality for every individual that needs it.

Making mental health a policy priority would have significant and economic benefits, but most importantly it would enhance people’s lives. We can hope that by the next World Mental Health Day we are further along the road to societies where all individuals with mental health needs get the treatment, care and support that they need.

Useful links

OECD work on mental health systems

OECD mental health and work project

Depressing depression: mental illness at work OECD Insights

Work-life imbalance OECD Insights

Dementia: a modern killer OECD Observer

High seas, ICs and health care

ICTs and Health
Click to read

“John Stone, aged 25, private marine; feels pain in the throat… difficulty of swallowing… diluted sulphuric acid used as a gargle”. The British Royal Navy medical officer who wrote that report didn’t say if the patient got better, and presumably the patient never said anything ever again, so we’ll never know if the cure worked. His colleague who treated fever cases with a tepid salt water bath did however note the salutary effects on all his patients, even though, technically speaking, they all died soon afterwards. If you’ve got an hour or two to waste (as I hadn’t when I was supposed to be writing this article) take a look at this collection of reports compiled by Royal Navy Surgeons and Assistant Surgeons from ships, hospitals, naval brigades, shore parties and on emigrant and convict ships in the period 1793 to 1880.

For the casual reader like me, the most interesting aspects are stuff like being attacked by a walrus, stealing a skull, being struck by lightning, or accidentally circumcising yourself when playing a joke on your shipmates (anything for a laugh). For the less frivolous, the records are a mine of information on a whole range of medical topics. Mortality for instance: half the deaths on warships were from disease, ten times the proportion killed in battle. Or medical methods and technologies. Apart from the descriptions of acid gargles or blowing tobacco smoke into a drowned sailor’s lungs to revive him (it worked), the reports list more mundane treatments. “Amputation” appears a lot. In fact, on a quick reading it seems to be the main surgical activity on the ships, and other sources describe how during a naval battles, the surgeon’s assistants (“loblolly men”) could fill tubs with severed limbs.

Many of those who survived the surgery died later from infections, and this was the case for civilian patients operated on shore as well. That would change by the end of the period covered by these reports, with the Victorian “surgical revolution”, brought about by the introduction of anaesthesia in the 1840s, antisepsis in the 1860s and x-rays in the 1890s. We often talk about “medical science”, but what happened over that half century had nothing much to do with science. It was a technological and organisational revolution that would mark medical care well into our times.

In this article, Jim Connor reminds us that knowledge of chemical or physiological principles had little to do with the advent of anaesthesia or explaining how it works. There was little scientific basis for antisepsis when Lister introduced it. And Roentgen was pioneering radiology before any theoretical explanation for x-rays was available. Technology was not the servant of science, or of the market. As Connor argues, there was no call for these innovations from practitioners, and many patients were even reluctant to undergo anaesthesia for fear of what the doctors might do when they were unconscious.

The revolution came from the interactions of science, technology and medicine among each other and with economic and social trends. If the state and business get involved in such a process, the result is what John Pickstone calls “technoscience”, where scientific knowledge and its applications become marketable commodities. The result in the 19th century was to change the position of the surgeon from an independent artisan, owning his own tools and premises and seeking out clients, to essentially an employee of a large organisation that centralised demand and supplied the equipment, bought from an increasingly powerful group of outside suppliers.

This fundamentally changed health care as a calling and as a business. Today, another revolution is underway, driven by ICTs, or what we might call tele-technoscience, and responding to what a new OECD report identifies as “social and demographic changes, the rise in chronic diseases, and the need to improve the efficiency and quality of healthcare delivery”. ICTs and the Health Sector: Towards Smarter Health and Wellness Models looks at how mobile devices, the Internet and ICT in general can be used to support self-management, behavioural modification (not as sinister as it sounds) and “participatory healthcare”, and allow health care systems to learn.

The streams of data flowing from medical devices and research programmes are the raw materials the new systems will be built on. But data as such are of relatively little value if they can’t be processed, turned into useful information and shared. Those old naval records contained masses of data on cases, living conditions, even climate and geography, as well as potentially life-saving information on best (and worst) practices. But this information couldn’t be shared significantly using the technologies available at the time.  The OECD report talks about a similar situation with today’s technology and analytical tools, arguing that they can’t effectively manage or even capture the many data streams available and turn them into useful information.

The Victorian revolution produced the hospital-centred, doctor-oriented system we know today. The ICT revolution could produce a system that is based on the patients, their family and community, with more emphasis on evidence-based approaches and personalised care, and a less prominent role for the clinician’s training and experience in diagnosis and treatment. These will remain important though, as will the practitioners’ attitude to their job. Bruno Pappalardo, the specialist in charge of the Royal navy collection, told The Independent newspaper that despite the harsh environment the naval medical officers worked in, “their compassion shines through – they did their utmost to care for people.”

Useful links

OECD work on health policies and systems

When you are old and grey and full of sleep

A good life in old ageThe hardest job I ever had was as a nursing assistant in a psychiatric hospital. On a typical shift, five or six of us would look after 60 patients or more. This was the usual staff:patient ratio throughout the establishment, except in the section for the “criminally insane”. In such conditions, the care philosophy was brutally simple. As a colleague explained on my first day, “If they move, we give them drugs. If they don’t move, we give them electric shocks”.

The hospital had been built as a lunatic asylum in the 19th century, on a moor that was miles from the nearest village. It looked exactly as you’d expect: a grim fortress with bars on the windows and locks on the doors. Our job wasn’t really to look after our patients, we looked at them to make sure there was the same number at the end of the day as at the start.

Except in the geriatric ward where I worked for a few months. Many of the patients were bedridden, and the nurses took great pride in the fact that not one of them ever got a bed sore. We even healed some horrific wounds that had become gangrenous. Some of the people I met there made me realise that in calling their institutions “asylums”, the Victorians were stressing something positive. An asylum is a place of refuge, maybe a last resort, and some of our men (the regular staff always called them “our men”, never our patients, inmates, cases, clients…) had nowhere else to go.

One man had lived on the road for nearly 30 years, making sure he got sent to prison for the winter until finally a magistrate told him he was too feeble to look after himself. The only place that would take him was the psychiatric hospital. Another man was paralysed by Parkinson’s disease and his wife couldn’t cope. A third had spent his whole life locked up after being abandoned as a baby because he had Down syndrome.

The majority of the men had a combination of psychiatric and other conditions – Alzheimer’s, alcoholism, schizophrenia, various degrees of paralysis, and so on. What they had in common was the need for the long-term care the hospital provided. It’s a need that’s going to grow, with the number of people aged over 80 in OECD countries doubling between now and 2050. The share of the over-80s will rise from 3.9% of the population now to 9.1% in 2050, and from 4.7% to 11.3% in the EU-27.

The OECD and the European Commission have just produced a report on monitoring and improving quality in long-term care. If you’re worried about growing old, A Good Life in Old Age? will do nothing to reassure you. “…at least one in two people admitted to hospital from a care home setting are at risk of malnutrition… at least 30% of older people in acute hospitals and 40% of older people in care homes meet the clinical criteria for a diagnosis of depression… There is no sign of a consistent decline in the incidence of physical restraint use… two-thirds of LTC [long-term care] users in institutions were exposed to one or more medication errors… one old person dies due to a fall every five hours… Pressure ulcers are known to affect a large number of LTC recipients in nursing homes…”.

So, what can be done, other than head north to cast yourself adrift on an ice floe before global warming melts them all? A Good Life in Old Age? suggests a combination of regulation; standardization and monitoring; and incentives for providers and choice for consumers. However, most countries do not collect information on quality systematically, and if they do, their efforts are limited to information on aspects such as staffing and the care environment, what the report calls “inputs” rather than the outcomes for the person’s health and well-being.

The OECD and EU are right about the importance of attitudes and behaviours in the quality of care, even if they use the hideous expression “leveraging consumer choice and centeredness” to say so. Apart from depression, I never came across any of the issues listed above, because the people I worked with were “consumer centred” even if the consumers in question had no choice.

That experience convinced me that it’s possible to provide quality care even in a highly unfavourable setting. The OECD-EU report suggests that there are plenty of solutions to help do so now and in the future.

Useful links  

OECD work on long-term care

OECD work on health

Want a better life? Put your mind to it.

Everybody thinks on occasion about how life might be improved.  But working towards that better life means solving a certain number of knotty problems.   What do you think should be tackled first? Complex answers to this simple poll are much appreciated- just put them in the comments section.  Now, put your minds to it!

Spend less, stay healthy

Fans of TV medical shows know the procedure: In a chaotic emergency room, Dr. McDreamy examines a feverish patient, furrows his brow, shouts out a diagnosis and – before you know it – a dozen or so suspiciously attractive doctors and nurses are running around, subjecting the poor patient to a bamboozling array of medical tests and scans. All very impressive.

But, in the real world, it’s also all rather expensive – and getting more so by the year. In OECD countries, for instance, the amount governments spend per person on healthcare has risen by more than 70% in real terms since the early 1990s. That spending has brought big benefits, not the least of which is that people are living longer: Over the past two decades, life expectancy – a widely used indicator for national health levels – has been rising by about a year every four years.

Increased healthcare spending isn’t the only reason for that – factors like diet and poverty also play a big role in determining life expectancy. For example, Japan spends less than the OECD average on healthcare and has just 2.2 practising physicians for every 1,000 people – well below the OECD average of 3.2 per 1,000. Nevertheless, it has the highest life expectancy in the OECD area – just under 83 years – and very low rates of infant mortality, due in part to the fact that it’s a wealthy country with a relatively healthy diet.

Still, the increased spending on healthcare since the 1990s has undoubtedly helped to improve health standards in OECD countries. But there’s a downside: spending probably can’t go on rising at its current rate. In 1995, it accounted for $12 out of every $100 spent by OECD governments. Twelve years later, that had risen to $15 out of every $100. In the wake of the financial crisis, when many governments are tightening their budgets, health spending may well come under the scalpel.

But that might hurt less than you’d expect. Why? Simply because governments don’t always get great value for money in healthcare – many could spend less and still get the same results. A report released by the OECD this week suggests that efficiencies could lead to substantial savings in health spending: Without reducing health outcomes, Ireland could make savings on healthcare equivalent to almost 5% of GDP by 2017, the OECD calculates, with Greece and the United Kingdom not far behind on almost 4%.

But even if countries don’t reduce spending, they could still gain substantial health benefits from spending more efficiently, says the OECD. For example, if all countries equalled the performance of the most efficient spenders, life expectancy at birth could be increased by another two years across the OECD area.

Staying with health, the OECD has also been looking recently at sickness and disability benefits, which is another major budget area for governments – it accounts for about 10% of public social spending in OECD countries. Before the recession struck, more people in OECD countries were receiving disability benefits than unemployment benefits – just over 30 million compared with just under 28 million.

A disproportionate number of people with disabilities in OECD countries live in poverty – around 22% compared with about 14% of non-disabled people. Helping them to go out to work could lower that number, but in many cases there are real obstacles to doing that: people with disabilities may have relatively lower levels of education and may face prejudice when applying for jobs. The OECD report suggests addressing these barriers by a partial shift from “passive” to  “active” spending. That means that, instead of simply making payments to people with disabilities, more should be spent on things like providing them with training and offering subsidies to employers to hire  them.

Useful links

Health Care Systems: Efficiency and Policy Settings at OECD iLibrary

Find out more and briefing note on this report

Sickness, Disability and Work: Breaking the Barriers at OECD iLibrary

OECD work on health

Data and statistics on health from the OECD

OECD work on sickness and disability

What’s wrong?

This doesn't come cheap, you know

How many diseases are there? An expert would probably look for the answer in ICD-10, the WHO’s catalogue of over 12,000 calamities that could hit you.

The eponymous hero of Jules Romains’ play Knock, or the Triumph of Medicine would probably have replied that there as many as you can convince people to have. According to him, a healthy person is merely a sick one who doesn’t know it yet.

The ICD can give you that impression too. Some of the characteristics of F60.5 (anankastic personality disorder if you must know) sound more like my job description, and in fact few of my colleagues would escape intact from even a superficial check against sections F60-69, Disorders of Adult Personality and Behaviour. Who hasn’t worked with/for “There may be excessive self-importance, and there is often excessive self-reference”?

According to a special issue of PLoS Medicine, the expansion in the number of diseases these past years is not due to the population becoming sicker or diagnostics getting better. The real reason is “disease mongering” – interested parties creating an all-in-one package of a new treatment and a new condition it can treat, or a new use for an old treatment whose patent is about to expire.

This may play a role in increasing health costs, but the main reasons are that patients expect more from health care systems and that the type of conditions the systems have to treat are changing.

Scanners and other modern imaging techniques are expensive, but are now commonplace, as are sophisticated testing techniques. Many diseases that would once have killed the sufferer can now be treated, but the treatment may last for years. The population is ageing, and more people are living to an age when costly care is needed on a daily basis.

These are postive developments, and investment in health pays dividends. For example, up to 40% of the increase in life expectancy since the early 1990s could be due to increased health spending.

That doesn’t mean that the 9% of GDP an average OECD country devotes to health is all money well spent. Health ministers meeting at the OECD this week will be looking at how to get the best value for money, and ensure that the progress we’ve seen in treating those 12,000 diseases continues. They’ll also be looking at prevention, how to stop us getting them in the first place.

Useful links

OECD work on health

The MRI brain scan is courtesy of Dwayne Reed

Putting women and children first

My mum's Norwegian! Photo courtesy of C. Olsen

You’ll feel rage but not despair, and be astonished but not surprised on reading State of the World’s Mothers 2010, the latest annual report from NGO Save the Children, with its country rankings of the health, education and economic situation of mothers, women and children, and the stories behind the statistics.

Rage at figures like these: every year 8.8 million children die before reaching age 5 and 343,000 women lose their lives due to pregnancy or childbirth complications. Practically all of these deaths occur in the developing world, where 50 million women give birth at home each year with no professional help.

Rage at families denying women and children care, even when it is available. Often, it’s because men don’t want another man to examine a female patient. Often it’s due to ignorance. An Egyptian woman tells how her mother-in-law refused to let her go to hospital because severe bleeding after childbirth was “normal”.  

Egypt is one of several countries where the birth of a child isn’t celebrated immediately. Ceremonies like  Egypt’s el sebou’, practiced by Muslims and Christians alike, recognise a grim truth: many babies do not live very long.  The first four weeks of life are the most dangerous, accounting for 41% of infant deaths.

Despite the depressing situation (57 countries have “critical shortages” of health workers, 36 of them in Africa) there’s optimism too. What astonished me is the way terms and ideas I’ve encountered so often that they’ve become meaningless suddenly become real again. Here for instance: “Increased investments in girls’ education are essential… to empower future mothers to be stronger and wiser advocates for their own health and the health of their children.”

Concretely, this is because educated girls tend to marry later and have fewer, healthier and better-nourished children. Mothers with little or no education are much less likely to receive skilled support during pregnancy and childbirth, and both they and their babies are at higher risk of death. They are also more likely to respect harmful traditional practices such as delaying breastfeeding for up to 24 hours after giving birth.

Relatively minor investments pay huge dividends – “leverage” as we’d say here at the OECD. In Bangladesh for instance, female community health workers with limited formal education and only 6 weeks of hands-on training contributed to a 34% reduction in newborn mortality. Women with a few years of formal schooling can master the skills needed to diagnose and treat common early childhood illnesses, mobilise demand for vaccinations, and promote improved nutrition, safe motherhood and essential newborn care.

Some of the techniques are incredibly simple, low tech and low cost, or even no-cost, as when mothers of underweight, preterm babies are taught “kangaroo care”. The mothers serve as human incubators, keeping their babies next to their skin for warmth, and encouraging them to breastfeed frequently. A review of 15 studies in developing countries found kangaroo care was more effective than incubator care, cutting newborn deaths by 51% for preterm babies who were stable. Up to half a million newborns could be saved each year if kangaroo care were used everywhere.

Finally, as you’d expect, the Scandinavian countries top the rankings, along with Australia and New Zealand.  At the other end of the scale, every mother in Afghanistan is likely to lose at least one child.

Useful links

The OECD Education Directorate conference on the economic crisis and early childhood education and care is here.

The Lancet monitors progress between 1990 and 2010 on maternal, newborn and child survival in light of the Millennium Development Goals.

The OECD Family Database provides data on “family outcomes and family policies” with over 50 indicators for all OECD countries on everything from breastfeeding to participation in elections. 

Doing Better for Children looks at the state of child wellbeing in OECD countries.

Gender Aid at a Glance provides statistics on Official Development Assistance focused on gender equality and women’s empowerment 

Work on gender at the OECD Development Centre

educationtoday OECD’s “education lighthouse for the way out of the crisis”.

Wikigender is designed to help participants “share and exchange information and best practices on gender equality”

The article on kangaroo care is published in the April 2010 issue of the International Journal of Epidemiology. This issue is on “Development and use of the Lives Saved Tool (LiST): a model to estimate the impact of scaling up proven interventions on maternal, neonatal and child mortality”.