Background and Historical Development of the Pan American Health Organization (PAHO/WHO) Program on Mental Health
1961-1964: First Steps
Mental health was included as a technical area in the structure of the Pan American Health Organization (PAHO/WHO) in 1961, and a specialist from Mexico, Dr. Jorge Velasco Alzaga, was appointed as Regional Adviser, a position he held until 1964.
During his tenure, Dr. Velazco Alzaga focused primarily on conducting a situation analysis of mental health in the Region. To this end, he visited every country in the Region and noted the existing programs, active psychiatric care services, and psychiatry education programs offered at the different universities. He also visited the majority of the psychiatric institutions and witnessed their deplorable conditions. During this time, the Pan American Health Organization established a formal relationship with the World Federation for Mental Health, the Psychiatric Association of Latin America, the American Psychiatric Association, and the United States’ National Institute of Mental Health. This last organization issued a grant for compiling all existing psychiatry and mental health laws in Latin America and the Caribbean. Support was also provided for two subregional mental health seminars, which were attended by representatives from the mental health departments and programs of the countries in the Region. The first seminar was held in Cuernavaca, Mexico in 1962 (Pan American Health Organization. Primer Seminario Latinoamericano de Salud Mental, [First Latin American Seminar on Mental Health] Cuernavaca, Mexico. Washington, DC: PAHO; 1963. [Scientific Publication 18]). The second event took place in Buenos Aires, Argentina, in 1964 (Pan American Health Organization. Segundo Seminario Latinoamericano de Salud Mental [Second Latin American Seminar on Mental Health] Buenos Aires, Argentina. Washington, DC: PAHO; 1964. [Scientific Publication 99]).
Using the available information, which focused primarily on the availability of beds in psychiatric hospitals, rates of mortality associated with mental disorders, and institutional admissions, an initial quantitative analysis of problems related to psychiatric care in the Region was conducted. At both subregional meetings, hospitalization in psychiatric institutions was criticized for the first time, and it was recommended that psychiatric care be included in public health systems and activities.
1964-1986: Positioning and Consolidation of Technical Cooperation in Mental Health
Between July 1964 and October 1986, Dr. René González served as Regional Adviser on Mental Health. After joining PAHO, he devoted himself to completing the situation analysis begun by Dr. Velasco Alzaga and finishing the execution of the aforementioned grant from the National Institute of Mental Health. The compilation of legislation was also completed. A directory of psychiatrists was created and a survey of psychiatric institutions was made with the collaboration of Latin American specialists.
In 1966, the third and final Subregional Seminar on Mental Health was held in Kingston, Jamaica, attended by countries from the non-Hispanic Caribbean (Pan American Health Organization: Seminar on Mental Health in the Caribbean, Kingston, 1969. Final report; Washington, DC: PAHO; 1965. [Mimeographed document]). At this meeting, greater emphasis was placed on a comprehensive approach to mental health as opposed to the more restrictive view of psychiatric care, and psychiatric hospitals were more directly criticized. Indeed, one of the noteworthy final recommendations urged that no more psychiatric hospitals be created and that alternative services to treat mental illness be offered as part of public health programs. Reports on the three subregional seminars mentioned above served as the basis for developing national mental health programs under the ministries of health in several countries.
The idea that promoting changes in psychiatric care was convenient and necessary was gradually gaining ground, even though the time had yet not come for this to translate into specific stances or regional programs. Nevertheless, over the two decades in question, PAHO increased the number of consultancies on the organization of mental health services and developed a fellowships policy for training outside the countries that focused on the public health approach to mental health, leaving the work of psychiatric specialization to the countries themselves.
In 1969, PAHO hosted a working group in Viña del Mar, Chile focusing on the administration of psychiatric and mental health services, attended by 44 participants and observers from 22 Latin American and Caribbean countries (Organización Panamericana de la Salud. Administración de los Servicios de la Salud Mental. [Pan American Health Organization. Administration of Mental Health Services]. Washington, DC: PAHO; 1970. [Scientific Publication 210]). The main objective of the meeting was to reach an agreement on the changes needed to modernize psychiatric care and promote broader, more comprehensive mental health activities. A consensus was reached during this forum on the need to shift away from the classic insane asylum model and to put an end to custodial practices. Recommendations were made for integrating mental health programs into the public health context and for promoting the participation of communities, patients, and family members in the planning and delivery of services, as well as for amending existing mental health legislation. This meeting was a precursor to the Conference on the Restructuring of Psychiatric Care in Latin America and the 1990 Caracas Declaration.
In the ensuing years, different countries established demonstration community mental health services with PAHO/WHO support; notable among these were those of “Las Crucitas” in Honduras; “San José de Murialdo” in Porto Alegre, Brazil; and Santiago, Chile; two centers in Panama; and one in Cali, Colombia. Other community mental health approaches also bear mentioning: “Honorio Delgado-’Hideyo Noguchi” in Lima, Peru and the psychosocial health care centers in different parts of Brazil. Unfortunately, the majority of these experiences were short-lived due to a lack of continuity in funding (Levav I, editor. Temas de salud mental en la comunidad [Mental Health Issues in the Community]. PALTEX Series for Health Program Managers No. 19. Washington, DC: PAHO/WHO; 1992).
Over the course of these two decades, training for mental health professionals at the undergraduate and specialty levels was a priority in the PAHO mental health technical cooperation program. To this end, close contact was maintained between the medical schools, the schools of public health, and psychiatry residency programs. Between 1970 and 1980, several technical meetings on mental health education were held, involving professors and subject specialists.
Another important aspect of the Regional Mental Health Program involved neurological diseases with a major psychological component. Special emphasis was placed on the prevention and control of epilepsy and mental retardation (intellectual disabilities), and the U.S. National Institutes of Health provided cooperation in this area. In 1983, PAHO published a manual on epilepsy for primary care workers (Robb P. Epilepsia: manual para trajabadores de salud [Epilepsy: A Manual for Health Workers]. Washington DC: PAHO; 1983. [Scientific Publication 447]). An international epidemiological study on the prevalence of epilepsy in Chile, Colombia, Cuba, Mexico, and Venezuela was also promoted.
During the 1970s and 1980s, the prevention and control of alcoholism and drug dependency were major components of the PAHO Mental Health Program, meaning that a regional adviser was permanently available for collaboration on this topic. Technical and financial support from the U.S. National Institutes of Health was used to create an alcoholism research center in San José, Costa Rica, which operated during the 1970s and conducted important research on drinking and its consequences, as well as on its social and economic implications. Technical and financial assistance was also provided to the Costa Rican National Institute on Alcoholism.
In 1983, PAHO published the book “Dimensiones sociales de la salud mental” [Social Dimensions of Mental Health] and in the same year published the Spanish version of “Depressive Disorders in Different Cultures,” originally drafted by WHO, and “Ambiente, Nutrción y Salud Mental” [Environment, Nutrition, and Mental Health] was also published as PAHO Scientific Publication 450.
With the purpose of reviewing and supporting the PAHO Mental Health Program, the first meeting of the Mental Health Program’s Advisory Group was held in Panama City in 1985. At this event, actions were proposed for the development of regional subprograms on: a) psychosocial health factors; b) prevention and control of alcohol abuse; and c) prevention and control of mental disorders and neurological diseases with a major mental component.
1987-1999: Regional Initiative for the Restructuring of Psychiatric Care in Latin America
Dr. González retired in 1987, and Dr. Itzhak Levav was appointed Regional Adviser on Mental Health, a position he held until 1999.
The launch of the Regional Initiative for the Restructuring of Psychiatric Care in Latin America during the Caracas Conference in Venezuela, held between 11 and 14 November 1990, was an historic event in this period. PAHO organized this meeting, with support from many organizations, such as the Mario Negri Institute of Milan, Italy, the World Psychiatric Association, the Psychiatric Association of Latin America, the World Federation for Mental Health, and the World Association for Psychosocial Rehabilitation, as well as several European countries ( Italy, Spain and Sweden). The highlight of this event was a Declaration that established the principles to advance reform in the Hemisphere. In 1991, PAHO published a summary of the Caracas Conference presentations and discussions (González Uzcátegui R, Levav I, editors. Restructuración de la Atención Psiquiátrica: bases conceptuales y guías para su implementación. Washington, DC: PAHO/WHO, HPA/MND; 1991).
Among other things, the Caracas Declaration emphasized that conventional care focusing on psychiatric hospitals made it impossible to achieve objectives compatible with continuous, comprehensive, decentralized, participatory, and preventive community care.
A meeting was later held with the countries of the English-speaking Caribbean, in which a declaration similar to the Caracas Declaration was adopted (first in Devon, Barbados, and later at an expanded meeting that included Martinique).
Monitoring was another important element of the Regional Initiative for the Restructuring of Psychiatric Care in Latin America that bears mentioning. A technical collaboration program was launched in almost every country in the Region, which lasted for several years in the 1990s. Several self-financed European consultants, as well as Latin American consultants, played a key role, with PAHO as coordinator.
As part of these processes, the Central America and Panama Action Group was created, which lasted for several years. A similar, shorter-lived group was created in the Andean subregion.
In 1992, the work “Temas de Salud Mental en la Comunidad” [Mental Health Issues in the Community] was published and widely disseminated throughout the Hemisphere, particularly in universities and technical health schools.
Later, in 1997, the Directing Council of the Pan American Health Organization (PAHO/WHO) renewed its support for the restructuring of psychiatric care. Resolution CD 40/R19, issued during that session of the Directing Council, urged Member States to:
Develop National Mental Health Programs;
Refocus mental health services (from institutional to community settings);
Implement measures to control emotional disorders, epilepsies, and psychoses;
Strengthen activities to promote the mental health and psychosocial development of children;
Increase funding for mental health training programs;
Improve legislation and regulations to protect human rights.
In 1997, the Regional Program on Mental Health and Healthy Lifestyles was created within the PAHO organizational structure as part of the Division of Health Promotion and Protection. Dr. Levav was the coordinator of this program.
1999-2005: Mental Health in the New Millennium
Dr. Levav retired in October 1999, and Dr. José Miguel Caldas de Almeida was appointed a few months later.
Some major events took place in 2001. In September, the PAHO Directing Council discussed and adopted a technical document and a resolution on mental health that, among other things, urged the Member States to:
Make mental health part of public health priorities;
Increase efforts to reduce the stigmatization against people with mental disorders and the discrimination against them;
Continue efforts and strategies to ensure that mental health care shifts from psychiatric hospitals to the community;
Promote and support the implementation of psychosocial rehabilitation programs;
Work to create and/or update legal instruments protecting the human rights of people with mental disabilities;
Improve services and programs for population groups with special needs (women, the elderly, children, refugees, victims of disasters, and indigenous people).
Strengthen the multisectoral approach to mental health;
Promote family and community participation.
One of PAHO’s most important activities at the start of the new millennium was the conference “Mental Health in the Americas: Partnering for Progress,” which was held in Washington D.C. on 5 and 6 November 2001. Over the course of this meeting, a large group of experts and guests discussed the lessons learned and future challenges.
In 2001, the World Health Organization (WHO) decided to launch a series of initiatives to put mental health on the global policy agenda and make it more visible throughout the world, and developed a set of extremely useful instruments and programs. The Pan American Health Organization (PAHO) joined WHO in these efforts and has been working diligently to develop policies, plans, and services and to update legislation on mental health and the promotion of human rights.
Another notable element in 2001-2005 was a major project financed by the U.S. National Institutes of Mental Health (NIMH) to strengthen research capabilities in the Region. Three conferences were held as part of this project: Brazil-2004, Mexico-2007, and Jamaica-2008.
In 2004, PAHO created the position of Subregional Adviser on Mental Health. Based in Panama, a consultant was appointed to advise the Central American countries, Mexico, and the Latin Caribbean.
From 5 to 7 November 2005, the “Regional Conference on Mental Health Services Reform: 15 Years after the Caracas Declaration” was held in the capital of Brazil. The Brasilia Declaration mentioned the new challenges that had become more evident over the past 15 years. Even though the new Declaration addressed already existing problems, no direct focus had been placed on these issues during the Caracas meeting, which centered more on reforming services and protecting the human rights of people with mental disorders. These emerging issues, which had a tremendous social and heath impact, required appropriate responses from the health sector—and still do. Five major subject areas are mentioned:
The need for mental health care for vulnerable groups, such as indigenous populations and communities stricken by natural disasters;
Childhood and adolescent mental disorders and psychosocial problems;
Problems related to alcohol and/or substance abuse;
The increase in different types of violence, requiring active participation by the mental health services.
2006 to Date: Toward More Ambitious Goals for PAHO in Mental Health Cooperation
Dr. José Miguel Caldas retired from PAHO/WHO in November 2005. From December 2005 and October 2006, Dr. José Luis Di Fabio temporarily coordinated the Program as the Area Manager of Technology and Health Services Delivery; Dr. Itzhak Levav was hired as a Temporary Adviser until a new unit chief was appointed.
In 2006, the name of the technical unit was changed to the Mental Health, Substance Abuse, and Rehabilitation Unit to indicate the subject areas in which it worked.
In October 2006, Dr. Jorge J. Rodríguez was officially named Chief of the Mental Health, Substance Abuse, and Rehabilitation Unit. Some of the most important elements of the 2006-2009 period were:
Dissemination of the Brasilia Principles, a programming document marking a major adjustment in the approach to restructuring mental health programs and services in the Region;
Evaluation of the countries’ mental health systems using the methodology of the World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS);
Emphasis on technical support for countries so that they can meet appropriate achievement levels in the implementation of their National Mental Health Plans;
Strengthening technical cooperation in child and adolescent mental health. In August 2008, in Miami, USA, a regional workshop on the subject was held in conjunction with SAMHSA (U.S. Substance Abuse and Mental Health Services Administration).
New publications were also released:
Innovative Mental Health Programs in Latin America & the Caribbean (published on CD);
Informe sobre la Epilepsia en Latinoamérica (published on CD);
Epidemiología de los trastornos mentales en América Latina y el Caribe;
Salud Mental en la Comunidad.
Between 2006 and 2007, the Regional Program on Mental Health decentralization policy was strengthened, and two new subregional advisers were appointed, one in Argentina (to cover South America) and another in Barbados (to cover the English-speaking Caribbean).
In January 2008 there was an organizational restructuring of PAHO, which affected the Program on Mental Health to a certain extent:
The Technical Units became Projects, whose nature is essentially technical. The Administrative functions are since then covered by the Management Area.
A project known as “Mental Health, Disabilities and Rehabilitation” was created, which, in addition to mental health, included the component of physical and mental disability. The project was grouped under a new area: Technology, Health Care and Research. Dr. Jorge J. Rodríguez is responsible for coordinating the Mental Health, Disabilities, and Rehabilitation Project and is the Principal Adviser on Mental Health for PAHO/WHO.
The issue of alcohol and substance abuse was separated from mental health so it could be included in the Tobacco, Alcohol, and Substance Abuse Project, under the Sustainable Development and Environmental Health Area. Dr. Maristela Monteiro coordinates this technical project and is the Senior Adviser on Alcohol and Substance Abuse.
If we were to evaluate the historical development of mental health services in Latin America and the Caribbean, using the Caracas Declaration as a point of reference, marked progress would clearly be observed in the majority of countries. Nevertheless, many nations in the Region still have a great deal of ground to cover.
In June 2009, the issue of mental health was taken to the Executive Committee, which approved the Mental Health Strategy and Plan of Action. Final approval will be discussed during the PAHO Directing Council, which will meet in September of this year. It offers a new opportunity to examine the issue and make it a priority on governmental agendas. Information dissemination and mental health advocacy are key tasks for 2010, when the 20th anniversary of the Caracas Declaration will be celebrated.
525 23rd Street, NW, Washington, D.C. 20037-2895 Teléfono: (202) 974-3330 Fax: (202) 974-3641