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Why mental health is a human right

The UN rapporteur on the right to health, Dainius Puras, on how Covid-19 offers an opportunity to rethink mental health strategy.

By Alona Ferber

It wasn’t until he was 32 that Dr Dainius Puras first left Lithuania, part of the Soviet Union until 1990. Now 62, with his time as UN special rapporteur on the right to health ending in August, the psychiatrist has made around 30 international trips a year since taking the job.

“I thought only death could stop me,” he told me in a recent phone call from his home in Vilnius. “I never imagined it could be some outbreak that would stop me travelling, so it’s good news that I stopped travelling but I am still alive.”

Growing up in the “closed setting” of the Soviet Union, Puras idealised the West “because the West meant freedom”. When he first took on the mandate six years ago, he still idealised mental health systems in the West and in Scandinavia. But then “in these countries I met the most passionate human rights people who helped me to open my eyes”.

Special rapporteurs are independent experts appointed by the UN to monitor and report on human rights issues in member states. Puras, a mental health and children’s health specialist, took up his role in 2014.

In his 2017 and 2019 reports on mental health, Puras outlined what he believes are systemic problems across the world: pathologisation, overmedicalisation, an overly dominant disease-oriented “biomedical model”, and high levels of coercion in psychiatric care. Puras hammered home his belief that a rights-based approach, which also addresses social determinants of mental health – such as inequality and social exclusion – would be better for the world’s wellbeing. “Inequality is a key obstacle to mental health globally,” he wrote in 2019. “Many risk factors for poor mental health are closely associated with inequalities in the conditions of daily life. Many risk factors are also linked to the corrosive impact of seeing life as something unfair.”

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Beyond the structural, Puras also advocated life-long measures to ease suffering. Alongside steps to reduce inequality and social exclusion, he recommended greater investment in early-years and schools programmes and better social welfare. “As an independent expert I try to avoid terms like mental illness or mental disorder,” he told me, later adding, “We should target more not individuals and their brains, but relationships.”

His conclusions have been endorsed by some professional mental health bodies and criticised by others who think he overgeneralises in placing too much blame on the “biomedical” model and in downplaying the positive role of medication in treatment. Still others have said he is too negative about psychiatry, depicting it as a coercive field.

“There is a very interesting and painful debate globally: Shall we just invest more in the mental health status quo, or shall we move on into the next shift of paradigm? Because my position is that there is much evidence globally that the status quo does not work.”

Puras is positive about the crisis we are living through. First of all, he says wryly, “some people are not unhappy when times are challenging”. And he doesn’t think self-isolation has to equal loneliness: “I don’t like the term social distancing. It is physical distancing.” But he also believes the pandemic offers a chance to overhaul mental health care. “I see a good opportunity now to rethink if we really have chosen a right path.”

In line with his mandate, Puras will not single out countries for criticism, but he is willing to give praise. New Zealand, which he was due to visit when the country closed its borders in March, is an outlier because of the “wellbeing budget” it unveiled last year. “The message from the prime minister was that these things [mental health, wellbeing, and child poverty] are more important than GDP. So for me it’s a very strong message.”

Since lockdown began, a litany of surveys has tried to catalogue the mental health impact of this mass social experiment, with most drawing worrying conclusions. In the UK, for instance, more than 25 million people reported being affected by high levels of anxiety in late March, when the country went into lockdown, according to Office of National Statistics figures. The number of people over 16 reporting concern and stress were more than double the figure from late 2019.

Puras warns against policymakers and health services treating generalised anxiety and depression as an aberrant reaction to trying circumstances. “When people feel not well, this is a normal reaction,” he says, “It even maybe works as a protective thing, to be afraid so that you are cautious.”

Economic downturns are linked to spikes in mental health difficulties. Research has uncovered a surge in suicide rates in Europe and the US after the 2008 financial crisis. But even the long-term effects of lockdown itself “can be quite serious”, says Puras, highlighting the situation of women and children in at risk situations. “Now there is a combination of risk factors like stay-at-home [orders], which may be good for family connections, but we know how many children and women are already suffering from violence in these closed home settings.” He notes that abused or neglected children suffer toxic stress – when stress response systems are activated in the brain or body for prolonged periods – and that this “has lasting effects on the body, mind and brain” throughout life.

But he also worries that measures to contain Covid-19 could reverse global advances in mental health treatment. “I urge governments to use this crisis as an opportunity for progressive changes. Less coercion, less locking people up, less medicalisation, moving more from the idea of treatment as fixing a disorder… Instead we can now move to very innovative… I should use the terms support and care, instead of treatment.”

The pandemic having limited his ability to travel, Puras fulfils his UN function from home while running a small human rights NGO and teaching at the University of Vilnius. What does he find most difficult, personally, about the crisis? “To move to other ways of working and socialising,” he says, as well as the lack of predictability, which is “really challenging for mental health”.

But he is “cautiously optimistic”, too, that the crisis will revitalise respect for human rights and multilateralism. Populist nationalists “were happy that everybody now solves problems in their own country, but this does not work, so maybe people or leaders will come back to the idea that only together we can address such challenges”.

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