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  • 1. Counselling Psychology Quarterly Vol. 22, No. 1, March 2009, 77–84 Mental health as a human right in the context of recovery after disaster and conflict Inka Weissbecker* MPH Candidate, Harvard School of Public Health, NGO Representative of the International Union of Psychological Science to the United Nations, Harvard University, Boston, Massachusett, USA (Received 21 December 2008; final version received 3 January 2009) Natural disaster and armed conflict can have a profound impact on the mental health and psychosocial well-being of the affected population. Furthermore, mental health problems contribute significantly to the global burden of disability, especially in low-resource countries. Several interna- tional human rights conventions affirm the obligation of state governments to protect, promote and fulfill the right to health, including mental health. However, the right to mental health has not received adequate attention from national and international institutions and organizations. Mental health is still not a priority on the global agenda and is often neglected in recovery and development efforts after disaster or conflict. Individuals involved in the mental health field may benefit from familiarity with relevant human rights documents and guidelines which can inform research, practice and advocacy efforts. Keywords: human rights; mental health; psychosocial; conflict; war; disaster; humanitarian; recovery; development Mental health in the context of disaster and conflict Natural disasters and armed conflict can have severe and long-lasting effects not only on physical health, but also on mental health and psychosocial well-being (Norris et al., 2002; Solomon & Green, 1992). Research suggests that more than one third of adult and child (Norris et al., 2002; Vernberg, Silverman, La Greca, & Prinstein, 1996) disaster victims suffer from PTSD after disaster. In the aftermath of such events, the risk increases for developing problems such as substance abuse, anxiety, depression, adjustment disorders, interpersonal problems, suicide, vocational difficulties, long-term physiological changes, and subsequent physical health problems (Norris et al., 2002). These risks affect individuals and communities including those not directly involved in the disaster or armed conflict. In the case of armed conflict, such risks do not only affect combatants but also communities and civilians. Compared with 14% of all deaths occurring among civilians in World War II, the proportion of civilian deaths has reached 90% in several wars during the 1990s (Garfield & Neugut, 2000). This high rate likely reflects the increased proportion of intra-state conflicts such as civil wars, as opposed to *Email: inka.weissbecker@gmail.com ISSN 0951–5070 print/ISSN 1469–3674 online ß 2009 Taylor & Francis DOI: 10.1080/09515070902761065 http://www.informaworld.com
  • 2. conflicts between nation states (World Bank, 2008). After incidences of violence and conflict, the affected population often suffers from lasting psychological trauma and mental health problems (Roberts, 2008; Slim, 2008). Both adults and children, especially those who have committed or suffered atrocities, can experience chronic psychological problems such as PTSD, depression, anxiety, substance use problems and suicidality (Summerfield, 2000; Betancourt et al., 2008). Individuals who were involved in armed forces or victims of sexual violence may also have difficulty re-adjusting to post-conflict life and may experience rejection or stigmatization by their communities (Betancourt et al., 2008). In low resource countries, natural disasters can cause or exacerbate armed conflict, resulting in complex emergencies (Inter-Agency Standing Committee [IASC], 2007). Mental health and psychosocial problems can be very debilitating, as they disrupt essential areas of vocational, family and community functioning (American Psychiatric Association, 1994). Depression was the fourth leading contributor to the global burden of disease (in Disability Adjusted Life Years, DALYs) in 2000 and is projected to reach second place in 2020 (World Health Organization [WHO], 2008). The costs of mental health problems can not only be measured in suffering and reduced quality of life among affected communities but also in economic terms. Mental illness can stifle long-term social and economic development, resulting in decreased work productivity or job loss, reduced educational attainment, physical illness, increased medical service utilization, incarceration or homelessness (Kartha et al., 2005; Kessler et al., 2008). Mental and behavioral disorders are estimated to account for over 30% of all years lived with disability, and this number is expected to increase (World Health Organization, 2003). Lack of access to effective intervention can worsen the problem, particularly in low-resource countries which are already disproportionately affected by disaster and conflict. WHO asserts that mental health is the ‘‘foundation for well-being and effective functioning’’ and that there is ‘‘no health without mental health’’ (Prince et al., 2007; World Health Organization, 2008). The right to health, including mental health is a fundamental human right, an assertion found in several human rights documents and conventions (Office of the High Commissioner for Human Rights [OHCHR], 2008a). Mental health and human rights Several documents have been drafted by international as well as regional bodies, affirming the human rights of people with regard to mental health. Examples of these include the International Covenant on Economic, Social, and Cultural Rights (ICESCR), The Convention on the Rights of the Child (CRC), and the Convention on the Rights of Persons with Disabilities (CRPD). International Covenant on Economic, Social, and Cultural Rights The ‘‘International Covenant on Economic, Social, and Cultural Rights’’ (ICESCR) was opened for signatures in 1966 and has been ratified by 159 United Nations member states as of December of 2008 (OHCHR, 2008a). Article 12 of the ICESCR asserts the ‘‘right of everyone to the enjoyment of the highest attainable standard of physical and mental health’’. General Comment 14 was drafted by the Committee on Economic, Social, and Cultural Rights (CESCR) in 2000, providing concrete 78 I. Weissbecker
  • 3. guidance for interpreting the right to health in Article 12 of the ICESCR (Committee on Economic Social and Cultural Rights, 2000; Gruskin & Tarantola, 2005). The comment notes that the right to health does not only encompass the right to health care, but also adequate socio-economic conditions necessary for health such as food, water and housing (Committee on Economic Social and Cultural Rights, 2000). General Comment 14 also outlines that ‘‘health facilities, goods and services’’ should be available, accessible, acceptable and of good quality. It further defines healthcare to include ‘‘preventive, curative, rehabilitative health services and health education; regular screening programs; appropriate treatment of prevalent diseases, illnesses, injuries and disabilities, preferably at community level; the provision of essential drugs; and appropriate mental health treatment and care’’ (Committee on Economic Social and Cultural Rights, 2000). Convention on Rights of the Child The Convention on the Rights of the Child (CRC) was opened for signatures in 1989 and has been ratified by 193 UN member states as of December 2008 (OHCHR, 2008a). The CRC specifies the rights of children and adolescents to development, to be protected from physical and mental abuse and to have their views respected (OHCHR, 2008b). It further recognizes that children with mental disabilities have the right ‘‘to enjoy a full and decent life in conditions that ensure dignity, promote self-reliance, and facilitate the child’s active participation in the community’’ and recognizes the right of every child to a ‘‘standard of living adequate for the child’s physical, mental, spiritual, moral, and social development.’’ Convention on the Rights of Persons with Disabilities The relatively recent Convention on the Rights of Persons with Disabilities (CRPD) was opened for signatures in March of 2007 and has been ratified by 45 UN member states as of December, 2008 (OHCHR, 2008a). This document specifically includes individuals with mental illness, stating that ‘‘persons with disabilities include those who have long-term physical, mental, intellectual, or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others’’ (Leonardi et al., 2006; OHCHR, 2008b). This convention recognizes that individuals with disabilities should be free from ‘‘exploitation, violence, and abuse’’ and that those individuals need special protection and safety in situations of armed conflicts or humanitarian emergencies (OHCHR, 2008b). The importance of raising awareness and combating stigma and stereotypes of individuals with disability is also emphasized. Furthermore, the convention notes that member states should collect disaggregated (i.e., separated) data on individuals with disabilities, disseminate this data, and identify and address barriers to the realization of rights of persons with disabilities (OHCHR, 2008b). Regional documents Applicable regional human rights documents have been drafted on regional levels as well. An example is the ‘‘African (Banjul) Charter on Human and Peoples’ Rights’’ (1981) which is supervised by the African Commission on Human and People’s Counselling Psychology Quarterly 79
  • 4. Rights (WHO, 2005). This document contains articles on civil, political, economic, social and cultural rights and affirms the right for ‘‘all to enjoy the best attainable state of physical and mental health’’ and for the disabled to have the ‘‘right to special measures of protection in keeping with their physical or moral needs’’ (WHO, 2005). Human rights standards Several major human rights standards are applicable to mental health and have been used to interpret what specifically is meant by principles outlined in international conventions such as the ICESCR (WHO, 2005). Most notably, the ‘‘UN Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care’’ (MI Principles) outline minimum human rights standards for the practice of mental health (United Nations General Assembly, 1991). These principles apply to persons with mental disorders, regardless of whether or not they are institutionalized. The MI Principles recognize that every person with a mental disorder ‘‘shall have the right to live and work, as far as possible, in the community’’ (United Nations General Assembly, 1991). However, the MI Principles have been criticized for not being effective enough. Compared to international human rights conventions, the principles are not legally binding and do not provide any form of international monitoring or reporting (Harding, 2003). Technical standards Technical standards that have been adopted by different international agencies can also guide interpretation of human rights conventions (WHO, 2005). The Declaration of Caracas (1990) was initiated by the Pan American Health Organization (PAHO) and adopted as a resolution by various legislators, mental health professionals and organizations (WHO, 2005). This declaration emphasizes that mental health services should be community-based and that ‘‘resources, care and treatment for persons with mental disorders must safeguard their dignity and human rights, provide rational and appropriate treatment, and strive to maintain persons with mental disorders in their communities’’ (WHO, 2005). The declaration also states that mental health legislation must ‘‘safeguard the human rights of persons with mental disorders, and services should be organized so as to provide for enforcement of those rights’’ (WHO, 2005). The WHO developed technical standards outlined in the Mental Health Care Law: Ten Basic Principles (WHO, 1996a), which further interpret the MI Principles and can guide countries in developing mental health legislation. Additionally, WHO developed Guidelines for the Promotion of Human Rights of Persons with Mental Disorders (WHO, 1996b) which also interpret the MI principles and can help evaluate human rights conditions in institutions. Those guidelines outline principles for the promotion of mental health and prevention of mental disorders, which should include access to basic mental health care as well as ‘‘mental health assessments in accordance with internationally accepted principles’’ (WHO, 2005, 1996b). United Nations member states who have ratified international human rights conventions such as the ICESCR, the CRC and the CRPD are obligated to respect, promote, and fulfill the right to mental health, which includes the implementation of domestic mental health law and policy as well as the provision 80 I. Weissbecker
  • 5. of technical, administrative, and budgetary resources (e.g., Committee on Economic Social and Cultural Rights, 2000). However, the right to mental health has not received adequate attention from the international community, governments, or international donors (Brendan, 2006). Mental health is still not a priority on the global agenda and is often neglected in recovery and development efforts after disaster or conflict. Mental health as a human right after disaster and conflict Mental health and human rights have often been framed in the context of human rights violations committed against individuals who are suffering from mental illness (e.g., Dhanda & Narayan, 2007; Yamin & Rosenthal 2005). While this is an important aspect, the issue of health including mental health in the context of human rights has much broader implications (Gruskin & Tarantola, 2005; Hannum, 1992). The right to health includes the right to mental health, which encompasses preventative efforts as well as availability, accessibility, acceptability, and quality of mental health goods and services (Committee on Economic Social and Cultural Rights, 2000). Efforts towards reconciliation, psychosocial recovery, and counselling for perpetrators and victims of violence have been outlined as integral elements of post-conflict reconstruction, along with the efforts of re-establishing security, legal systems, good governance and social and economic well-being (Barnett et al., 2007; Center for Strategic and International Studies and the Army of the United States of America, 2002). However, it has been pointed out that very few multi-lateral and US institutions prioritize or engage in such activities (Barnett et al., 2007). Mental health legislation is often absent in developing countries, and does not receive adequate attention in human development efforts (Lancet Global Mental Health Group, 2007; WHO, 2008). Globally, the proportion of Disability Adjusted Life Years (DALYs) attributable to mental disorders is about 11.5%, while the median proportion of the health budget allocated to mental health is only 3.8% (WHO, 2008). This gap is even wider in countries affected by disaster and conflict, which typically experience a greater burden of mental health problems, and a lower or non-existent budget allocation for improving mental health (WHO, 2008). Mental health remains one of the most under-funded areas of health care, especially in low-resource settings (IASC, 2007; Lancet Global Mental Health Group, 2007). As a result, it is estimated that 75% of individuals with mental health problems in low income countries have no access to mental health services (WHO, 2008). Vulnerable populations are likely to be affected the most. Individuals with lower resources, which includes groups such as refugees as well as women, children, the elderly, the disabled and those with pre-existing mental health or substance use problems, are especially vulnerable to poor health outcomes after disaster or conflict. They are more likely to show severe and persistent stress reactions and are less likely to recover socioeconomically (Galea, Nandi, & Vlahov, 2005; Norris et al., 2002). The prevalence of acute and chronic psychological impairment following disasters is likely to be higher among communities with higher losses and low resources (Norris et al., 2002). Adequate mechanisms for evaluation, culturally informed intervention and follow-up regarding mental health problems in such countries, however, are often lacking (Saraceno et al., 2007). Counselling Psychology Quarterly 81
  • 6. Currently, best practices and guidelines are emerging, that can assist governments and organizations in addressing mental health issues from a public health perspective in low resource settings affected by conflict or disaster. The Inter-agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings for example, offer practical advice for protecting and promoting mental health and psychosocial well-being, including aspects of coordination, monitoring and evaluation, human rights, human resources, community mobiliza- tion, health services, and education (IASC, 2007). Furthermore, the World Health Organization has recently launched the mental health Gap Action Programme (mhGAP) which outlines ways in which mental health problems can be effectively addressed in low- and middle-income countries (WHO, 2008). Recommendations include cost-effective interventions at the community level and integration of mental health care into primary health care services (Betancourt et al., 2008; Bolton et al., 2007; WHO, 2008). Further research and evaluation efforts are still needed to elaborate on best practices, ethical principles, monitoring and evaluation, and issues of accountability when addressing mental health and psychosocial needs in affected communities. However, existing documents and guidelines can aid governments and organizations in promoting, protecting, and fulfilling the right to health, including mental health, in countries that have been affected by disaster and armed conflict. Conclusions Natural disasters, armed conflict, and complex emergencies can have profound and enduring effects on mental health and psychosocial well-being, which can significantly impact social and economic development and recovery efforts. The right to health, including mental health, has been affirmed in various international human rights documents and guidelines. However, mental health is often not given a high priority by the international community, including UN member states, and international donors, who attend to competing needs and agendas (Lancet Global Mental Health Group, 2007). Specific guidelines exist for helping governments and NGOs in promoting and protecting mental health and psychosocial well-being after disaster and conflict. Protecting, promoting, and fulfilling the right to mental health requires a comprehensive approach that includes legislation, policy, programming, monitoring, and evaluation activities to be undertaken various national and international stakeholders. Individuals working in the mental health field may benefit from familiarity with international human rights law and relevant recommendations in order to guide programming research, and advocacy efforts aimed at aiding those affected by disaster and conflict. Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV (4th ed.). Washington, DC: American Psychiatric Association. Barnett, M., Kim, H., O’Donnell, M., & Sitea, L. (2007). Peacebuilding: What’s in a name? Global Governance, 13(1), 35–58. 82 I. Weissbecker
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