Controversial UN Special Session on Children

The World Federation for Mental Health sent four representatives to the Special Session of the General Assembly on Children which was held on 8-10 May at UN Headquarters in New York. They were President Elect Patt Franciosi, Main Representative Nancy Wallace, the Federation’s Representative to UNICEF, Carol Kessler, and a WFMH member, Richard Donahue. Another WFMH Representative, Ricki Kantrowitz, attended the NGO events associated with the Special Session.

This major meeting included high-level government representation (together with 240 children in the official delegations), and 1,700 NGO representatives. The official government conference involved many private meetings and intense final negotiations among coalition groupings. The NGO delegates held many meetings of their own and came together in advocacy groups to press specific issues such as the right to education, and opposition to child labor, the sexual exploitation of children, and the recruitment of children in armies. Young people were very visible in presenting their views.

The Special Session was the culmination of a long process of prior negotiations among governments, and had been postponed from September 2001. The much anticipated event proved in the end to be generally disappointing, as the governments engaged in last-minute negotiations in which the Western powers took the outcome document in unexpected directions.

The reproductive rights of young people (and the question of abortion) became a central issue, polarizing the Session between those who favored empowering adolescent women through education and reproductive health services and those took a conservative view focused on medical care during pregnancy. The United States took a strong conservative stand against the inclusion of abortion in reproductive care, while the European Union finally reduced its backing for reproductive services in exchange for a somewhat limited reference to the abolition of the death penalty for adolescents who have committed crimes.

Gro Harlem Brundtland, Director General of the World Health Organization (right)
and Patt Franciosi, President Elect of WFMH, at the WHO photo call in the lobby of the UN Headquarters
following Dr. Brundtland's address on "The Last Mile to End Polio" at the Special Session on Children.

The final document does not refer to reproductive health services for adolescents, but calls for “ready and affordable access to essential obstetric care…post-partum care and family planning in order to, inter alia, promote safe motherhood.” Critics considered the final document was a substantial step backwards from the UN Conference on Women in Beijing in 1995 and the follow-up conference “Beijing plus 5” in 2000.

Government negotiations on child labor also led to compromises, which resulted in failure to adopt the standards promoted by the International Labor Organization. In the weakened final text, there was no mention of a minimum age for child workers. It referred to “the worst forms of child labor” (that is, trafficking in children and the recruitment of child soldiers) rather than children who are pushed into the workforce by poverty, and have no chance of full-time education. A proposal to compile new data on child labor was dropped. Even provisions related to humanitarian aid for children in displaced families and in armed conflicts were dropped.

Many NGOs were disappointed that the outcome document of the conference did not give a central place to the Convention on the Rights of the Child, the most widely ratified UN Convention (though not signed by the United States). It has been used by many countries to strengthen children’s rights at the national level, and has valuable provisions for collecting information. This year’s WFMH World Mental Health Day planning kit highlighted the importance of the Convention, and a number of other issues on the Special Session’s agenda.

[Source: “On the Record for Children” was a useful resource for this report. It is the newsletter of the NGO Committee for UNICEF, a network of 125 NGOs that work closely with UNICEF. Past issues can be found at the NGO Committee’s website: www.ngosatunicef.org]

News from the Regions

Europe
Mental Health Europe has participated in a study on “Disability and Social Exclusion in the European Union – time for change, tools for change.” Seven organizations worked together to collect information on the causes of social exclusion among disabled people, covering such matters as extra costs of disability, lack of access to a social environment, unemployment, and the lack of specialized services. MHE contributed information on specific difficulties faced by people with mental health problems. The research was carried out in 2001 and an evaluation meeting to close the project was held on 1-2 March 2002. The final report is now available. Contact the MHE Secretariat at info@mhe-sme.org, or fax: 32 2 280 1604.

Western Pacific
Taiwan Board member Chueh Chang, president of the Mental Health Association in Taiwan, has started a weekly hour-long educational radio program on mental health topics which is heard throughout the island. She examines a different issue over four programs each month. The first three programs examine the topic from the viewpoint of public perception, followed by contributions from people who have experienced the problem and their families, and then from teams of professionals working in mental health. The fourth program invites the public to call in for an open discussion.

The Mental Health Association held a policy conference organized by Dr. Chang in conjunction with its annual meeting in April. More than 200 consumers, family members, physicians and other professionals attended a program on improving government policies which affect people with mental illnesses. Afterwards they divided into discussion groups to consider national health insurance; the financing, quality and evaluation of services; legislation; and the reduction of discrimination and stigma.

NGO World Forum and UN Second World Assembly on Ageing

Madrid, April 2002

Board member Agustin Ozamiz attended the NGO World Forum on Ageing on 6-9 April 2002 and the UN Second World Assembly on Ageing on 8-12 April on behalf of WFMH. A resident of Biskaia, Spain, he is the chief of the insurance division in the Health Department of the Basque Region. The following comments are extracted from a longer report he sent to the Federation:

The two overlapping meetings in Madrid emphasized the world’s changing demographic situation. For the first time in history we can look forward to more people over the age of 60 than people under the age of 15 years. By the year 2050 one out of five persons will be over 60. The increase in the numbers of older people will be even higher in Asia than in Western countries.

The UN Second World Assembly on Ageing, opened by Kofi Annan on 8 April, concentrated on public policy towards such matters as employment, widespread gaps in social security, and the need for a flexible retirement age. The President of the International Labour Organization and the European Union’s Commissioner for Social Affairs both spoke about work-related issues.

The President of WHO, Dr. Gro Harlem Brundtland, gave a comprehensive speech to the World Assembly about the problems of poverty in developing countries and its impact on the health of the elderly. She said that WHO was adopting a new policy to encourage “active ageing,” that is, the process of optimizing opportunities of health, participation and security in order to enhance the quality of life of elderly people.

NGO Forum
Women are a high proportion of the older population, and the problems of an ageing group have many gender aspects. The NGO Forum gave considerable attention to the situation of poor, illiterate and socially deprived older women in developing countries. Violence against elderly women was identified as one of the most important problems. Women’s lack of social status and influence handicaps them in efforts at self-help.

In poor societies the safety-net of social security and public health care may be very weak or almost non-existent. This was a particular focus of concern at the NGO Forum, where it was said that in South America 50% of old people are poor (15% of them extremely poor), and only 30% have access to care and social insurance. These rates are highest in rural areas. In rural Mexico, for example, only 10% of women have the right to social insurance and health care.

Prevention of Health Problems
There was some interest in prevention at the meeting. The director of WHO’s program on ageing, Alexandre Kalache, said the idea was to promote health through “healthy customs, environmental and social conditions, and economic resources.” Another WHO speaker said that improving living standards and economic development were keys to prevention.

WFMH put forward the view that quality of life is even more important than adding years to life. Knowing that mental health issues often have an impact on the lives of the elderly, and are often neglected, the Federation suggested the development of promotion and prevention strategies focused on mental health (see box). This is a complicated area, often affected by other health problems, but one which certainly deserves inclusion in the overall approach to ageing.

Objectives of Proposed Promotion/Prevention Strategies for Coping with Anxiety and Depression in Elderly People

1. To gather relevant information concerning a) the impact of anxiety and depression and related disorders on the public health status of citizens, and b) mental health promotion, prevention, early detection and early management of these problems;
2. To identify and evaluate strategies, programs and models of best practice from different countries;
3. To develop Regional strategies for mental health promotion and prevention…based on the information acquired from different countries and from other sources;
4. To develop and carry out an integrated strategy for communication and dissemination of the aims, mechanisms and outcomes, using appropriate media most likely to a) raise awareness among relevant professionals, policy makers and the general public; and b) encourage effective policy development and implementation within States.

The expected results of the program would be a strategy to combat anxiety, depression and related disorders in older people; reports describing the burden on public health; a directory of best practices and selected model programs; and broad dissemination and implementation of the results.

Mental health was discussed at length. Following WHO’s emphasis on the subject throughout 2001, it is now the focus of a five-year Global Action Program to encourage member states to enhance their capacity building for mental health policy, service development, information gathering, advocacy and research.

WHO’s Secretariat provided an excellent report, “Mental Health, Responding to the Call for Action,” as a background paper for the Assembly. Representatives from 46 member states commented on it. WFMH President Pirkko Lahti had intended to participate in the Assembly and to speak on this item, but she was unable to attend because of illness.

In her absence, WFMH’s Permanent Representative in Geneva, Dr. Stanislas Flache, spoke on behalf of the Federation (no other NGO was granted the floor in the debate). He congratulated WHO on the progress achieved in mental health programs last year, and drew attention to important aspects of the Secretariat report – the large numbers of people experiencing mental disorders, the staggering costs involved, the impact of depression as a leading cost of disability, the availability of treatment, and the need for a dual perspective of promotion and prevention. He emphasized WFMH’s support for action through primary health care, with equitable treatment for the poor, and expressed its enthusiastic endorsement of the new five-year Global Action Program.

Later the Assembly gave consensus approval to a Belgian draft resolution (WHA55.10) on “Mental health: responding to the call for action.” This urged member states to support the Global Action Program for Mental Health, and “to increase investments in mental health both within countries and in bilateral and multilateral cooperation, as an integral component of the well-being of populations.”

A new report, “Promoting Mental Health Around the World,” brings together information from nineteen countries where members of the WFMH International Committee of Women Leaders for Mental Health are involved in diverse campaigns and activities. It highlights the value of their contributions, not only in promoting issues and participating in the annual WFMH World Mental Health Day campaign, but in some cases influencing their national governments’ health planning.

The Committee was founded in 1992 to support World Mental Health Day, and the Carter Center agreed to host it. Former United States First Lady Rosalynn Carter serves as the honorary chair, and has been active in encouraging women leaders throughout the world to expand their support for mental health causes. Membership consists of women heads of state, the spouses of heads of state, and members of royal households, who as prominent citizens can draw attention to the special causes they choose to support.

Gregory L. Fricchione, Director of the Carter Center Mental Health Program, notes that the common themes in the new report include moving mental health into the community, with special attention to women’s mental health and human rights issues. Attention has also been drawn to problems of service delivery in all countries.

The nineteen country reports include considerable background information as well as details of women leaders’ activities. Prime Minister Helen Clark of New Zealand has helped to make providing strong community-based mental health services one of the government’s major health priorities. In Finland, where the government has given much attention to mental health in recent years, President Tarja Halonen is an active supporter of national programs. In the Republic of Honduras Former First Lady Mary de Flores has taken an interest in preventing violence against women. First Lady Ruth Cardoso of Brazil also supports this issue, which has been given considerable attention by the Ministry of Health. In Belize, First Lady Joan Musa helped to found the Mental Health Association and was instrumental in obtaining funding from the Japanese government to build an acute care psychiatric unit. In the Pacific island of Palau, First Lady Debbie Remengesau supports the work of the Mental Health Council, and attends its special events with her husband. In the Caribbean island of St. Lucia, Governor General Pearlette Louisy became patron of the Mental Health Association when it was founded in October 2000, has stayed involved in its work, and comes to speak at its fund-raising drives.

Though most reports focus on recent progress, a few are very frank about describing shortcomings in their national programs. First Lady Nanuli Shevardnadze of Georgia listed the efforts of the NGO “Georgian Women for Peace” to support some psychiatric care institutions with very basic supplies at a time of acute economic crisis. This section states that “people with mental illnesses are one of the most vulnerable social strata of Georgia” and “the majority of them are found without a ‘means for survival.’”

Copies of the “Promoting Mental Health Around The World” can be obtained from:
The Carter Center
Mental Health Program
One Copenhill
453 Freedom Parkway
Atlanta, Georgia 30307
USA
Tel: 404 420 4165
Fax: 404 420 5158
Email: ccmhp@emory.edu

The Federation’s project to place a mental health specialist in the World Bank’s health planning staff came to an end in March, 2002, at the expiration of the three-year grant from the MacArthur Foundation. Fortunately, the US National Institute of Mental Health (NIMH) and the Center for Mental Health Services (CMHS) under the Health and Human Services (HHS) Administration of the US Government became interested in the project and have taken over its funding.

Florence Baingana, the psychiatrist from Uganda’s Ministry of Health who has held the post since 2000, will continue at the Bank as a Senior Health Specialist (Mental Health) on a new one-year appointment. This may possibly be renewed for a further two years.

Deborah Maguire, the Federation’s Director of Administration, was able to make arrangements with the MacArthur Foundation to extend the grant to the end of April to facilitate the transition to the new funding plan.

The Federation is delighted that support has been found to carry this initiative forward. The placement of a mental health professional at the Bank helped to expand the expertise of its health planning group, and contributed to better contacts between the Bank and the World Health Organization, and between the Bank and its client countries.

Dr. Baingana brought special knowledge of conditions in Africa and the problems of providing mental health services in low-income countries under stress. She also made noteworthy contributions to the Bank’s analytic work in the area of mental health, as well as in operational work in Lesotho, Burundi and the West Bank and Gaza.

Florence is sure that the collaboration with the World Federation for Mental Health will continue.

Zane Wilson, a consumer advocate from South Africa who has established a large support network there, visited the WFMH Secretariat to discuss her work and learn more about the Federation. The staff asked her questions about the development of her organization in South Africa. She described methods of outreach to remote, poor communities, and the overwhelming impact of HIV/AIDS, which intersects with all other health problems in the country.

Q. How did the Depression and Anxiety Support Group get started?

A. I suffered from debilitating panic disorder for many years. As I recovered I saw the need for consumer advocates. The Depression and Anxiety Support Group was founded in 1994 and now has a general manager and three paid staff in Johannesburg, 20 volunteers, and has established 100 support groups around South Africa. I am unpaid, and pay my own costs unless sponsored.

Q. Do you work across the whole country?

A. No – to some extent our funding specifies the areas we work in. About half of our work is in urban areas, and half in rural areas, some of which are very remote. I’d have to say the need in public health and in rural settings is especially serious. There are only about 320 practicing psychiatrists for the entire country, which is a ratio, roughly, of 150,000 persons per psychiatrist. But some 200 of the psychiatrists work in the private sector, where the ratio is about 33,000 persons per psychiatrist. With only 120 psychiatrists working in the state sector, the ratio there is about 440,000 people per state psychiatrist. There are very few psychologists working in rural areas, and psychiatric nurses are stretched beyond belief.

Q. In this situation, how do you go about developing rural outreach?

A. We visit the selected location with a standard three-day outreach effort to get a local program set up. We’ve decided to do it this way because reaching some of these distant villages is quite time-consuming in itself. Two of our staff members will go out to the village with a psychiatrist, who is with them only for the first day. His goal is to talk to all the general physicians working in the area, to educate them about mental illness and to discuss the problems they see in their practices.

On the second day, we target the community leaders – church leaders, police, nurses, teachers, youth groups, etc – with the aim of finding two people who will work as volunteers to start a support group and keep it going. On the third day we invite interested volunteers to a meeting, and provide them with a start-up pack and as much helpful information as we can. At 1 pm we do a teachers’ meeting specifically to discuss ways to identify teenagers who might be thinking of suicide. And that evening, we have the first meeting at a local church, school or hospital hall with those seeking to join the support group.

Q. How do you make contact with people who might want to join?

A. We place notices in hospitals, schools, clinics, community centers. We will ask the local radio station in advance to broadcast information. Sometimes local organizers go through townships in a car broadcasting a message from a megaphone – it’s not what we would do in other areas, but in rural areas it seems to work.

Q. Who comes to these meetings?

A. The initial number could be 6 or 160. It depends on the size of the community and the degree of stigma locally. A group could include people with HIV/AIDS, cancer, or even heart problems - we don’t turn anyone away, because we know that many physical illnesses can involve mental health problems as well. Wherever possible, we try to provide contacts to other organizations that can focus on specific problems – for example, there is an excellent outreach organization for schizophrenia.

Q. What is the goal of the meetings?

A. It's simply to sustain a presence in a rural area to provide information, and a place where people who feel depressed or anxious can go. We want to create awareness that there is help available, and illnesses are treatable. A lot of people don’t realize that. The local volunteer coordinators decide how often to hold meetings, perhaps once every two weeks. Sometimes the meeting is held in English, but often it is conducted in the main local language, and quite often the leader speaks several African languages. We stay in touch with the local organizer by phone, put him or her in touch with the nearest mental health service, and provide a supply of materials (brochures, pamphlets, audiotapes, videos).

Q. How serious is stigma and discrimination against the mentally ill?

A. It’s a problem, but I would say it has been slightly decreasing over the past eight years. Unfortunately, the stigma has been transferred to AIDS – it is much worse for those who have AIDS.

Q. In what ways does HIV/AIDS impact the mental health field?

A. It is pervasive. And the social effects are immense, far beyond those who have the illness. The number of children left without parents is just one example. People with HIV/AIDS often experience emotional problems, rejection by family members and friends, fear, shame, guilt and isolation. Often this is compounded by the loss of employment.

Q. How will you develop your programs in the future?

A. What we do is not nearly enough. I’m trying to raise money to hold a training meeting for our rural coordinators. I would like to develop training that covers the links between AIDS, depression and suicide. There are also many possibilities for telephone conference calls. The fixed telephone lines are unstable, and in many places Internet access isn’t good. But cell phones are widely used, and it’s possible to arrange an educational call for a group of people with a moderator or instructor who uses the local language.

Contact: South African Depression & Anxiety Support Group:
P.O.Box 652548
Benmore 2010
South Africa
Tel: 27 11 783 1474/6
Fax: 27 11 884 7074
Email: anxiety@iafrica.com 

The WFMH Newsletter is published by the Secretary General of the World Federation for Mental Health for its members four times a year.
Editor: Elena L. Berger, D. Phil.
Consultant: Prof. Eugene B. Brody, M.D.
Editorial Office: Sheppard and Enoch Pratt Hospital
P.O. Box 6815
Baltimore, Maryland 21285-6815
Telephone 410-938-3180
FAX: 410-938-3183
Email:wfmh@wfmh.com
Website: www.wfmh.org