Reimagining Mental Health: The Legacy of Paul Farmer (Video of HMS Symposium)

October 20, 2022

Ruta Nonacs, MD PhD

How can we use what we have learned from Paul Farmer’s life and works to address the current mental health care crisis in our country?

In April, the Department of Global Health and Social Medicine in the Blavatnik Institute at Harvard Medical School hosted a symposium Re-imagining Mental Health: The Legacy of Paul Farmer. This symposium on mental health was planned before Dr. Farmer’s death in February of this year. This was an opportunity to reflect on the principles that have guided Dr. Farmer’s and his many important contributions to global medicine, featuring a discussion moderated by Vikram Patel, PhD, HMS Pershing Square Professor of Global Health and co-director of the University-wide Global Mental Health @Harvard initiative.

In his opening remarks, Dr. Patel noted, “The world is experiencing a mental health crisis. This crisis disproportionately affects those who are already on the margins.” Compared to the rest of the world, the United States has an abundance of mental health resources and spends more than any other country on mental health, yet there are incredible disparities. Many individuals in our country — especially those from marginalized communities, low-income neighborhoods, victims of violence, and those living in rural areas — face enormous barriers to obtaining mental health care.

From Mass General, the panelists included Anne Becker, PhD, MD, HMS Dean for Clinical and Academic Affairs, Maude and Lillian Presley Professor of Global Health and Social Medicine, and Professor of Psychiatry, and Giuseppe Raviola, MD, MPH, Associate Director of the Chester M. Pierce Division of Global Psychiatry at MGH and Director of Mental Health for Partners In Health. They were joined by Byron Good, PhD, HMS Professor of Medical Anthropology; Mary-Jo DelVecchio Good, PhD, Professor of Global Health and Social Medicine, emerita; and Arthur Kleinman, MD, HMS Professor of Medical Anthropology.

The panelists, all of them Farmer’s mentors, mentees, or colleagues, referred to the core values that Farmer brought to all of his work. His efforts to bring quality healthcare to under-resourced countries was guided by his fundamental beliefs that health care is a human right and that the current disparities in health outcomes and access to care are the vestiges of deep historical injustices. The panelists noted that addressing the current mental health crisis is not simply a matter of increasing the number of providers but will require far reaching social, economic, and cultural solutions.

In discussing this vision, many of the speakers emphasized the importance of accompaniment. Paul Farmer and Partners In Health have long advocated for accompaniment – the provision of medical, social and economic support by community health workers – as the key to delivering quality health care in low resource communities. This approach ran counter to the previously held concept of global medicine as the delivery of medical care by trained healthcare workers from more privileged medical institutions in other countries. The concept of accompaniment gained momentum in the 1990s as Africa faced the combined crisis of a pandemic disease (AIDS) and a catastrophic shortage of trained health personnel.

As we find ourselves in an eerily familiar situation, still struggling with the COVID-19 pandemic, while at the same time experiencing a dwindling number of healthcare providers and a growing burden of mental health issues in our population, Dr. Patel asked the panelists to reflect on the work of Paul Farmer and asked how we can use what we have learned from Farmer’s efforts to address the current mental health care crisis in our country.

Anne Becker, PhD, MD argues that the corporatization of American medicine in which the healthcare delivery system hinges upon the optimization of efficiency must be addressed. This, she argues, is the polar opposite of Farmer’s concept of accompaniment. Patients do not come with a single diagnosis; their problems are complex — not only medical problems, but also social problems. Understanding this complexity and responding to it with high quality care that meets these needs is fundamental to training healthcare providers.

Giuseppe Raviola, MD, MPH notes that in the United States, we have 42,000 psychiatrists and 8000 child psychiatrists, yet there has been a marked reduction in the provision of community mental health services. Without these community-based services we cannot adequately reach and care for a large swath of our population in need.

Finding creative ways to engage communities is an essential ingredient of strengthening mental health care and, of course, in the US, there’s many problems… the sort of evaporation of community mental health systems in the US over decades and the constant lack of prioritization of investment. — Giuseppe Raviola, MD MPH

Raviola referred to his work In Sierra Leone, where there is a single psychiatrist in the entire country, where Partners in Health has built a mental health care system which relies on task sharing, utilizing non-specialist providers and health workers to deliver elements of culturally adapted, evidence-based psychosocial and psychological interventions for mental health disorders.

Looking back at a paper he wrote with Paul Farmer, Dr. Patel highlights the egregious fact that individuals with mental health disorders die much earlier than those without these disorders. Data from the World Health Organization indicates that the life expectancy of people with severe mental disorders is decreased by 10 to 25 years. He notes, “And this is, of course, not because these disorders are in and of themselves lethal conditions, but almost entirely because of a toxic combination of overwhelming social determinants and poor quality care.” By examining how we can address the challenge of mental health problems through the lens of these ideas, Dr. Patel hopes that privileged medical schools can serve as platforms for social change and can implement strategies to build capacity in less privileged institutions.