Worldwide, some 400 million people are suffering from mental illness and neurological disorders. The really bad news is that this is only going to get worse. Rapid global transformation, poverty, and a generalized aging of the world's population will contribute to that, Dr. Gro Harlem Brundtland, Director-General of the World Health Organization, told a conference in Beijing in November 1999. She called on governments everywhere to improve the coverage and quality of mental health services and to combat the social stigma, discrimination, and misinformation associated with psychological disorders. Health workers and the communities themselves can play an important role in turning the current tide, she said, by creating a culture of prevention and highlighting the tangible results of physical and mental well-being.

At the Forefront

"I won!" she exclaims triumphantly.

Adela Calderón then shows off the gold medal she won for the 400-meter race she ran at the XIX National Senior Athletics Championship held in Copiapó, Chile, in November 1999.

At 73 years old, Calderón knows only one way to go: full speed ahead. The quintessence of physical and mental well-being, she says she never feels down or depressed. She is part of a growing group of older generations today who are making a conscious effort to remain as active in mind, body, and spirit as their more youthful peers. The benefits clearly are there for all to see.

Experts at WHO and its Regional Office for the Americas, the Pan American Health Organization (PAHO), agree that as the world population ages and mental health needs become more complex, the incidence of depression, suicide, and alcoholism will increase, as will the incidence of schizophrenia, obsessive-compulsive and manic-depressive disorders. These changing times, says Dr. Itzhak Levav, PAHO's former Regional Adviser for Mental Health and now a researcher with Israel's Ministry of Health, call for "programs that are at once creative, scientifically sound, socially acceptable, and economically viable."

Regular, vigorous physical exercise, such as the kind exemplified by Adela Calderón, meets all these criteria handsomely. Furthermore, says Dr. Claudio Miranda, head of PAHO's Program on Mental Health, when physical activity is practiced as a sport in a social setting, "the discipline that is learned is transferable to all types of challenges in life. Team sports offer an ideal setting for improving social skills and learning effective problem-solving techniques."

A Time for Redirection

In its work with the countries of the Americas, PAHO's Mental Health Program provides technical cooperation in the development of national mental health programs that are better integrated with other public health programs, and in the reorientation and decentralization of mental health services to reflect the sociocultural realities of the populations they serve. This transformation, according to Miranda, implies the transfer of services and knowledge to communities, together with the expansion of treatment alternatives for patients and their families, the adaptation of educational and training requirements for health workers, more personalized care, greater monitoring of human rights issues, the promotion of legislative reform, and more active participation by both patients and their families in the health care management process.

Despite the intrinsic importance of mental health, government support in this area is usually inadequate, and mental health is undervalued by society, even though an inner life is specifically what makes human beings human. According to Miranda, more than 20 million people in Latin America and the Caribbean suffer from depression, and only 10 to 15 percent of this group receives adequate treatment.

Two groups that are especially vulnerable to mental health problems are the victims of domestic violence-both women and children-and older adults, particularly those who have been marginalized by poverty, one or more disabilities, or lack of contact with loved ones and society in general. Yet beyond the more obvious statistics, PAHO and WHO experts contend, there are many other categories of people who, because of the extremely difficult circumstances in which they live, are at special risk of being affected by mental health problems. Their situation is further compounded by their lack of access to health services. This group includes children and adolescents living on the streets, refugees, immigrants, and indigenous populations. Other vulnerable groups are the victims of prolonged armed conflicts, as in the case of the civil wars recently ended in El Salvador, Guatemala, and Nicaragua; and the victims of natural disasters, which in the past two years alone have produced major human tragedies in Central America and the Caribbean (Hurricanes Mitch and Georges) and Venezuela (torrential rains, floods, and landslides).

One strategy that is increasing the public's awareness of mental health issues has been the highly visible involvement of the First Ladies of the United States, Chile, El Salvador, and others in the Hemisphere in promoting the need for culturally appropriate and humane treatment for the mentally ill. At the same time, forging new multidisciplinary alliances-between the educational and legal systems, for example, as well as with the mass media-is also bolstering the efforts of the public health sector to reduce the burden of mental health problems on society.

Hello? 149 at Your Service...

"Do you feel more like a man when you beat your wife?" asks the poster on a brightly lit street in downtown Santiago.

The statistics are alarming: one out of every four women in Chile is physically abused, and one out of every three girls is sexually abused.

In the mid-1990s, the Office of Family Protection was created to address the issue of domestic violence head-on. At its helm is Mireya Pérez, who not only happens to be the first female general in the Carabineros, as Chile's national police force is called, but is the first in all of Latin America, as well.

Pérez is unequivocal in her belief that depression and domestic violence are interrelated. "Break the silence," a public service announcement that PAHO transmits locally via CNN en Español, reinforces that connection with its corollary: that domestic abuse often remains behind closed doors and never becomes part of the formal statistics. This is why, says Pérez, "talking about the problem is the first step toward solving it."

And this is what people do when they dial the "149 Hotline." At the other end of the line is a team of police officers specially trained to respond to domestic violence situations. But here the principal focus is peaceful conflict resolution and prevention versus direct police intervention and physical securing of the premises.

Created in July 1999, the hotline opened 5,000 cases in its first six months. What Pérez and her coworkers are finding is that "there are different types of violence," and they apparently are related to socioeconomic factors. In their experience so far, she says, "physical violence occurs at the lower levels of society, while psychological violence occurs more often at the higher levels." Pérez sees another, more long-term dimension to her office's work. Promoting family harmony also reduces the national crime rate, she says, citing studies that indicate the increased propensity of abused children toward criminal activity as adults. "There is a 72 percent higher risk that a child will be abused in his or her own home than by a stranger on the street," she notes, "hence, the importance of strengthening the family, since the home can be less safe than the streets. We can put bars on our windows and install burglar alarms, but if the lack of security is inside the home, that's where the charity must begin."

The impact of the Carabinero initiatives has increased the demand for similar services: in 1994, a Prefecture of Family Matters was established that now includes 24 divisions throughout Chile, and since 1996, Pérez and her team have formed working partnerships with other state and local agencies involved in domestic violence issues.

A Healthy Mind in a Healthy Body

This Greek maxim is the credo Jorge Alzamora lives by. The 68-year-old fitness advocate is vice president of Santiago's Las Condes Athletic Club for senior citizens and has been an enthusiastic athlete for 51 years. "Sports are what keeps your mind clear and alert," he says. "They maximize the capacity to think and visualize beforehand what you want to do."

In 1982, Alzamora helped found an association of older persons in Santiago that now includes many world champions who, like Adela Calderón, didn't take up sports until late in life.

Officials at the World Association of Veteran Athletes, based in Sweden, confirm that the popularity of competitive sports among older persons in the Americas has grown enormously over the past few years. This suggests that while people like Adela Calderón and Jorge Alzamora may still be a minority today, over time their ranks are predicted to swell with others who discover "the excellent quality of life," according to Alzamora, that a commitment to physical fitness offers-a life based on goals and the companionship of other like-minded spirits.

The Unstoppable Erika Olivera

At the other end of the age continuum we find 23-year-old Erika Olivera, a marathon runner and gold medalist at the 1999 Pan American Games in Winnipeg, Manitoba, Canada. Before fame came Erika's way, there was a life of sacrifice with humble beginnings. Her father, Ricardo Olivera, an evangelical pastor, says the physical and mental stamina Erika mastered didn't figure into his own plans for her future: to follow his footsteps into the ministry as a missionary. Instead, his daughter began to run and hasn't stopped since. During practice runs around the track at Santiago's National Stadium, she often ran into the senior athletes during training season and says they've always given her their wholehearted support. In many ways, she says, they served as her mentors and taught her many valuable lessons about the power of perseverance.

The Challenges for Mental Health

A recent report by Harvard University on the global burden of disease indicates that five of the 10 leading causes of disability worldwide are psychiatric in nature-depression being the first, followed by schizophrenia, bipolar disorders, alcoholism, and obsessive-compulsive disorders. The economic burden that this situation represents also is high: in the United States, for example, the annual cost of depression is estimated at US$ 43 billion.

"Economic and social development in the Americas has wrought many changes," according to a recent PAHO report on mental health, which adds that population growth, rural emigration, rapid urbanization, overcrowding in slums, and other factors have led to a major loss of personal values, family income and support, and psychosocial stability. This process "has affected the mechanisms for personal and collective adaptation" and has translated into "violence, substance abuse, and demoralization." Consequently, the link between human development and health-mental health in particular-becomes especially important for populations in extremely adverse situations, the group at highest risk. According to the report, "the more these populations succeed in preserving or recovering their mental health, the better they can negotiate successful solutions to their problems or, at the very least, avoid behaviors that create new obstacles (e.g., alcoholism or violence)."

Population aging is another factor that will contribute to an increase in the incidence of mental illnesses in the future. PAHO statistics indicate that within 25 years, the population over age 60 in Latin America and the Caribbean will grow from some 42 million to more than 97 million. In addition, a WHO study notes that the incidence of depressive disorders increases with age, and it is estimated that depression will be the second-leading cause of the global burden of disease by the year 2020.

In reporting on the current organization and state of mental health services in the Americas, the PAHO study found that while variations exist, there are common and troubling deficiencies: "Care is usually based in mental hospitals, institutions with low coverage and limited access that often carry a stigma." At the same time, these facilities often are "geographically, physically, or socially isolated, and the human rights of their patients are violated, either by omission or commission.

Furthermore, there is little or no integration of these services with the general health system." The basic flaw of this type of structure, says PAHO's Dr. Miranda, is that the network of care is too narrow: it discourages the patient's taking responsibility for his or her own well-being at the same time it excludes participation by the family and other support groups, such as religious and community leaders, health promoters, and other levels of health care in general.

Life Goes On

Adela Calderón gets by on a small pension and lives in the same house she built 40 years ago. She began running at 64, partly to keep a promise she made to her husband shortly before he died. "What will become of you when I die?" he asked her. "I am going to be a great person, known throughout the world," was her reply. And now that she has achieved her dream, she says: "These days, when I go to the National Stadium, all the kids greet and applaud me. Their affection makes me feel happy."

Creating a More Caring Society

In an elegant colonial-style house in suburban Santiago, Dr. Juana Silva Opazo shares her thoughts on mental health care for older adults in Chile. As the Director of the National Geriatrics Institute, which operates as part of the health ministry, Silva is encouraged by the progress made in recent years. The most important sign, she says, is the emergence of a "cultural change" in the way Chileans perceive the aging process and the value of older persons to society.

On the other hand, great obstacles lie ahead. She notes, for example, that as the population ages, the incidence of dementia in people over 80 will weigh heavily on society: "there are statistics indicating that up to 20 percent of the population will have problems of this type." At the same time, she says, the percentage of patients currently on file at the center suffering from depression may be as high as 30 to 40 percent.

Still, Silva remains optimistic, noting the positive impact the Institute's programs have had at the community level and the Ministry of Health's commitment to "recognize the various situations of older adults" and design activities that respond to these different needs.

The Future Unfolds

"Even in the calmest and most prosperous corners of the world, people are facing a breath-taking pace of newness," Dr. Brundtland told her Beijing audience. "Yet with change also comes insecurity, unpredictability, and apprehensions deeply rooted in the human mind." Therefore, she said, it is more imperative than ever that governments and communities work "to ensure mental well-being, a state in which individuals can realize their abilities, can cope with the stresses of life, can work productively and satisfactorily and make a positive contribution."

In the face of rapid change, it will also be a matter of keeping our social fabric intact-of creating cohesive bonds be-tween generations of young and old, and inviting the participation of First Ladies, teachers, schoolchildren, mayors, police forces, religious leaders, journalists, health workers, men, and women, in the promotion of good health as a preventive measure for all.

Meanwhile, there is much to learn from the examples of Erika Olivera, Adela Calderón, and Mireya Pérez, who open a new millennium with both a challenge and a promise: the goal of mental well-being is worthy of our very best efforts.

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Irene Helmke Wijnant is a freelance journalist based in Santiago, Chile, where she has served as coordinator of the Diarios América Group for El Mercurio and as a correspondent for Channel 13 and Radio Cooperativa.