Reflecting upon these powerful statistics hopefully makes us all examine our world more closely and critically. An interplay of many factors contributes to global disease burden so heavily weighted with mental and behavioral disorders. Developing countries are facing massive societal changes, including rapid urbanization, chaotic modernization, economic restructuring and forced migration. Although these changes result in a higher standard of living for some, we are seeing the profound effects of disruption of cultural practices, social routines, traditional work and family roles, community fragmentation and loss of traditional value systems. The very fabric which holds societies together - the cultural traditions and support networks - is being torn apart by various stresses (Cohen, Kleinman and Desjarlais). We must wonder about the role these forces play in increasing rates of alcoholism, drug abuse, suicide, and pandemics of violence in places like Latin America and Africa. Poverty, malnutrition, and particular risks to women and children due to their vulnerability and unequal status contribute significantly to the numbers we have seen above. The high rates of preventable neuropsychiatric disorders resulting from micronutrient deficiencies are unacceptable in our world’s children.

It is imperative to highlight the impact of war on the psychosocial health of the world’s population. Today, nearly 20 million refugees have crossed international borders, and about 20 million more are internally displaced. This is nearly 1% of the entire world population. Ninety percent of these refugees are in Third World countries, many among the poorest on earth. The nature of warfare has changed dramatically in this century with its increasing brutality toward civilians. More than 90% of wars today are internal rather than between sovereign states. We know that torture is routine in over 90 countries in the world. Civilians are primary targets of low intensity conflicts, much different than what we saw in World War I and World War II. World War I saw a civilian casualty rate of 5%, World War II, 50%, the Vietnam War, 80%, and currently over 90% of casualties are civilians. This is the new strategy of war -- to create a state of terror that penetrates the entire fabric of social relations and the subjective mental life of the community. What is targeted is the whole way of life of certain populations, including their valued institutions. The main psychic injury of war results from the disruption of social networks (family, work, community, religion) upon which human identity rests (Derek Summerfield).

The international humanitarian workers serving refugees from war were some of the first to highlight the psychosocial impacts of war today. Refugee camps were flooded with people exposed to unspeakable terror and trauma, and the psychological impact was overwhelming to aid workers skilled solely in delivering material goods and general health services. The long-term psychosocial impact of this kind of severe trauma, in addition to losses faced in other complex emergencies such as natural disasters, often became the impetus for examination of inadequate, non-existent or destroyed mental health services in these countries. The profound lack of mental health professionals or facilities, deplorable conditions in existing psychiatric institutions, and the absence of community-based mental health services in many regions of the world (including post-Socialist societies) became glaringly evident in the face of recovery efforts for severely traumatized communities.

But this also opened new possibilities for innovative services and more collaborative approaches in these countries. The psychosocial component of one relief effort in Sarajevo managed to bring together groups of mental health and social service professionals that had nohistory of collaboration in the former society. Psychiatrists, psychologists, social workers and pedagogues mobilized under one organization to address the emerging issues facing post-war Bosnia: most importantly, domestic violence, substance abuse and youth violence. In a project where we have worked in the Andes of Peru, public health nurses were trained to provide the bulk of mental health and trauma education in a large region with no rural mental health services (there is no psychiatrist, and just one psychologist in the entire department). A new public health school in the region has asked for consultation to develop a mental health training curriculum as a major focus of their education.

Other examples of clever uses of scarce human and material resources abound. In Senegal, lack of psychiatric hospitals meant that the mentally ill in need of inpatient care had to travel great distances from their rural villages. Since they were usually brought there by family members, the relative was hospitalized along with the patient. As treatment progressed, the relative participated in education and training, received support along with other family members, and then brought this knowledge of outpatient care for the mentally ill person back to the family and community.

The members of the AACP carry unique expertise in the development of public mental health systems and the strengthening of community-based mental health care in international settings. I applaud the work of the international division of the AACP in developing linkages with professionals in other countries and offering assistance with education, training and policy development to promote mental health awareness and improved services. System-level consultation is also very much needed to promote the funding and greater prioritization of mental health care and social services internationally. Consultation to international humanitarian agencies striving to incorporate the psychosocial perspective into development and advocacy work is also needed.

For our part at Tulane, we have developed a track of study in mental health in the International Health and Development Department of our public health school. This program provides education and training about mental illnesses, community-based care systems, psychosocial impacts of complex emergencies and cross-cultural factors in international psychiatry to future public health practitioners who will work in international settings. Many of our students are professionals from various countries - including psychiatrists from Romania, Czech republic, Senegal, and Vietnam, as well as a director of psychiatric social services from South Africa - who then carry their expertise back to their countries. We see a natural link between community psychiatry and public health and development efforts in international settings. This link with schools of public health, many others of which work in the realm of mental health, is a valuable one that should be strengthened.

We have the opportunity at this juncture to share our expertise with colleagues internationally and to learn with them how to address the new challenges to psychosocial well-being in our modern world. There are no prescriptions today to help populations in Africa and other parts of the world deal with war, disasters, or the emerging crisis of the HIV/AIDS epidemic. The impacts of this epidemic, as it kills off an entire generation of adults and orphans millions of children, will have a profound impact on the entire social and economic structure of these countries. The children left in the wake of this epidemic must bury their parents and confront a society that has lost the majority of its teachers, health professionals and child mentors. Psychosocial programs that work in coordination with other health, economic development, education and legal programs have the greatest chance of impacting these children’s lives. Important too will be efforts to preserve the cultural heritage, value system and traditions for orphans, when the adults who carry that rich history and knowledge are gone.

The keys to effective international liaisons must include collaboration, mutual learning, respect for cultural differences, and promotion of indigenous healing methods into psychosocial programs. In this way, we may be able to contribute in easing the burden of suffering we see today and anticipate tomorrow.