Statement by Mr Dainius Pūras, Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health at the 35th session of the Human Rights Council

6 June 2017

Mr President, Excellencies, Distinguished Delegates, Ladies and Gentlemen,

It is my pleasure to be here today to present to this Council a thematic report on the right to mental health (A/HRC/35/21). As you know, mental health is one of the priorities that I identified since the beginning of my tenure and, over the past three years, I have been addressing it in my thematic and country visit reports in a systematic manner. I see my report as complementing the report presented by the Office of the High Commissioner for Human Rights in March this year (A/HRC/34/32) and mandated by Resolution 32/18.

I also present two reports on my country visits to Algeria and Croatia, which took place in April-May 2016 and November-December 2016 respectively.

Ladies and Gentlemen,

There is no health without mental health. Mental health is grossly neglected within health systems around the world. Where mental health systems exist, they do so in isolation, segregated from regular healthcare despite the intimate relationship between physical and mental health. I have ascertained this repeatedly during my country visits over the past few years.

In order to address the grossly unmet need for rights-based mental health care and support, it is imperative to do an assessment of the global burden of obstacles that has maintained the status quo. Addressing the burden of these obstacles is a more effective strategy than the current approach dominating mental health policies and services which focuses on the global burden of disorders neglecting the importance of context, relationships and other important social and underlying determinants of mental health. Such obstacles include: the dominance of the biomedical paradigm; power asymmetries in policymaking, medical education and research, and care relationships; and, the biased use of evidence in mental health

Today, there is unequivocal evidence that the dominance of and the overreliance upon the biomedical paradigm, including the front-line and excessive use of psychotropic medicines, is a failure. Yet, around the world, biomedical interventions dominate mental health investment and services. When resources appear to scale up mental health services, particularly in low and middle income countries, investments tend to be dominated by medicalized service models. I see this not only as a failure to integrate evidence and the voices of those most affected into policy, but as a failure to respect, protect, and fulfil the right to health.

Power and decision-making in mental health policy, services, and care structures is concentrated in the hands of biomedical gatekeepers, particularly biological psychiatry. These gatekeepers, reinforced by the pharmaceutical industry, maintain this power based on two outdated and scientifically unsound concepts: that people experiencing mental distress and diagnosed with “mental disorders” are dangerous, and that biomedical interventions in most cases are medically necessary. These concepts perpetuate stigma and discrimination, as well as practices of coercion that are widely accepted in mental health systems today.

The biased use of evidence has tainted our knowledge about mental health, and this is a serious human rights issue. Power asymmetries and the dominance of the biomedical paradigm distort how evidence is used in policy making and service delivery hampering progress towards rights-based mental health services around the world today.

A troubling example is the use of evidence to inform people with mild and moderate forms of depression that they should receive psychotropic medications (antidepressants), despite the clear evidence that they should not. This is even more shocking when we know that other non-biomedical interventions are more effective, such as the ones targeting relationships and the social and underlying determinants of mental health, rather than the brain. The excessive use and misuse of psychotropic medications violates the right to health.

Mr President,

The evolving normative framework ushered in by the Convention on the Rights of Persons with Disabilities around mental health requires a paradigm shift. There are many paths towards this change, but only one direction. But a shift away from the dominance of the biomedical paradigm and vast power asymmetries requires mental health policymaking to scale across public sectors and integrate mental health throughout public policy.

Such change also requires bold action from within the corridors of power, specifically from within the psychiatric profession. The position and access that the profession has to policymaking establishes a responsibility to use their influence to support the process of transforming mental health systems from isolated silos of mistrust, paternalism and coercion into integrated community models that foster empowerment, resilience, and inclusion.

Psychosocial distress will always be a part of the human experience, particularly in the face of growing emergencies, inequalities and discrimination. Outdated paternalistic concepts of treatment that pave the way to systemic and serious human rights abuses must be replaced with psychosocial care and support in the community and at the primary care level.  Low cost, effective options are possible and being used around

the world today.  I have seen some of these good practices in action during one of my last country visits to Croatia and I would be happy to elaborate on this during the dialogue.

I want to use this opportunity to call for champions of the paradigm shift in mental health, which are necessary to facilitate the rights-based change required. Key stakeholders that could act as champions include Member States, the leadership of organized medical and other professions, including psychiatry, academic centres working on mental health, and civil society, and users of services.

I see the global state of mental health not as a crisis of chemical imbalances but a crisis of power imbalances, requiring urgent policy responses to address the social determinants of mental health as well as the reflection of powerful stakeholders on their role in perpetuating an abusive status quo. In other words, the crisis in the field of mental health should be managed not as a crisis of individual’s conditions or disorders but as a crisis of societal obstacles that hinder individual rights.

Let me close the first part of my statement by reiterating that the failure of the status quo to address human rights violations in mental healthcare systems is unacceptable. This is why I hope that the conclusions and recommendations of my report will contribute to the ongoing process of overcoming the existing status quo in this extremely important aspect of realisation of the right to health.

Ladies and Gentlemen,

Let me now turn to country visits. Since I last reported to this Council, I have conducted three country visits to Algeria, Croatia and Indonesia. I would like to express my appreciation to the Governments of these countries for extending me an invitation and for their cooperation before, during and after the visits. I present two of these reports to you today.

Algeria has made considerable progress with regard to the realization of the right to health, particularly improving basic health-related indicators and aligning most of the normative framework with its international human rights obligations. There have also been important achievements regarding the expansion of primary care.

However, during my visit I identified a number of serious challenges that remain connected to the performance of the healthcare system, the existing normative and policy framework as well as to the prevalence of inequalities and discrimination against certain population groups, particularly women, adolescents and youth, people living with HIV/AIDS, and drug users.

Algerian healthcare system has posted impressive results in making care available and accessible with a strong focus on primary care which is a good basis for reaching full coverage. However, equitable access to and the quality of services throughout the country remains a challenge and there is an excessive emphasis on hospital care and specialized medicine. The poor quality of relevant health-related data and analytical studies seriously undermines public health policy efforts. I recommend investing in nationally led evaluations of health policies; and establishing independent mechanisms to monitor the performance of the health system.

Algeria still has high maternal and neonatal mortality and morbidity rates. The health-care sector is one of the best placed public sectors to ensure that women and small children are adequately supported, protected and empowered through equitable access to quality services and evidence-based information. The majority of maternal deaths are preventable, and there is a higher rate of such deaths in remote rural regions which unveils important inequalities in access to health care, as well as in the enjoyment of the underlying and social determinants of women’s health.

Commitments at the highest level of government need to be accompanied by comprehensive measures to ensure substantive equality for women throughout the country. Attention to short-term life-saving interventions should be coupled with investment in long-term socioeconomic and political transformations to address broader patterns of discrimination and violence against women and children which affect maternal, neonatal and under-five mortality and morbidity.

Regarding people living with HIV/AIDS and drug users, I noted that the key populations in Algeria face serious barriers, in law and in practice, to the enjoyment of the right to health. While the adoption of health-related policies and programmes targeting key affected populations is commendable, it does not offset the impact of criminalization of homosexuality and sex work, which is a serious impediment to the enjoyment of the right to health of those at risk as it drives them away from the services they need and increases health- related risks for them and for society as a whole.

I acknowledge the efforts made to address drug use through non-custodial measures. However, I caution against granting criminal courts jurisdiction over a public health issue as it could lead to forms of coerced treatment, which do not ensure the protection of drug users’ rights and are not effective public health measures. I recommend authorities to promote a non-punitive approach to drug use policies and programmes outside the criminal justice system, and expand pilot services for people who use drugs.

Mr President,

Croatia has made significant advances towards the progressive realization of the right to health. Despite a number of challenges, the State has striven to make its health-care system sustainable and accessible. Important measures have been taken to develop and strengthen primary and specialized health care, with the investment of innovative efforts in mental health reforms and interdisciplinary approaches to address drug use and dependence.

However, the right to health should be promoted and protected not only through access to health services, supplies and facilities, which should be available, affordable, appropriate and of good quality. The right to health is also realized through the enjoyment of the underlying and social determinants of health, and it requires the design and implementation of cross-sectoral policies and programmes that focus not only on life-saving interventions but also on long-term strategies to address broader socioeconomic, political, cultural and environmental factors, such as substantive equality of women in society.

Croatia should continue to promote and strengthen primary health care, strengthening primary level capacity for early intervention services for children, with a family-centred approach and clear guidelines for cross-sectoral collaboration among the health, education and social services sectors.

I have recommended the production of official reliable statistics in order to assist in the development of practical measures to address existing challenges for the health system, which include long waiting lists; access to maternity hospitals; access to and use of contraceptives; unmet needs for family planning, and the prevalence of conscience-based refusals to abortion.

It is crucial that Croatia give priority to women’s and children’s rights in the area of sexual and reproductive health rights, with appropriate access to safe, reliable and good quality contraception, comprehensive maternal health services, safe abortion and treatment for complications from unsafe abortion. It should develop comprehensive sexuality education in schools, build the capacities of teachers in this area, and monitor programme performance.

In the context of the ongoing refugee crisis response, Croatia should ensure access by humanitarian organizations to all migrants in need, irrespective of their legal status, and reinstate mandatory initial medical check-ups upon arrival in the country for people on the move. It should urgently develop measures to vaccinate all children without relevant health records that arrive or are born in Croatia, and provide all pregnant women with regular medical care, irrespective of their nationality or legal status.

Excellencies,

Ladies and Gentlemen, 

Let me conclude this presentation by underlying that with my thematic report this year, I provide preliminary guidance on the path toward the realisation of the right to mental health by raising some of the key structural issues that need to be overcome.

My intention in the next few years is to facilitate a dialogue amongst key stakeholders on how the right to health is at stake within the existing mental health paradigm and how rights-based change is possible, affordable, and already happening in communities across different income settings around the world. I count on your support to do this.

I look forward to the dialogue today and thank you for your attention.