Once the pandemic releases its grip on the global economy, Cambodia will look towards resuming its string of impressive pre-pandemic annual economic growth rates. Mitigating health risks in the “new normal” will play a key role in ensuring that growth continues unabated. Alongside the familiar health challenges of infant mortality, malaria and, now, COVID-19, stakeholders are calling for a “vital” investment in mental health to ensure socio-economic recovery. Khmer Times’ Tom Starkey reports.
A 23-year-old Cambodian professional in the banking sector, who asked not to be named, said she first began to feel mentally unwell when she was 17.
“At that time, depression and anxiety hit me so hard that I couldn’t sleep for an entire week. My body shook. I felt abnormal. I couldn’t feel my senses anymore. I was taken to the hospital but because the doctor wasn’t a psychiatrist. His advice was to not think too much and he prescribed me drugs. I took the week off work, but the problem didn’t go away. Later on, the symptoms became severe again and I thought about ending my life. I tried several times.”
The recognition of mental health as a development issue is relatively recent. It was not included among the global Millennium Development Goals and the UN only included it as a health target in the subsequent Sustainable Development Goals. A total of 193 signatory countries, including Cambodia, pledged to work towards those updated goals between 2015 and 2030.
The connection between mental health and economic development is even more recent and still being researched, with numerous international independent, private and third-sector actors beginning to document its direct and indirect impact on productivity and sustainable economic growth.
The best example of assessment is a World Health Organization estimate that mental health issues, particularly depression and anxiety, cost the global economy $1 trillion per year.
Unfortunately, data measuring the impact of mental health conditions on Cambodian productivity is scarce. The Transcultural Psychosocial Organisation (TPO), a leading nongovernmental organisation (NGO) in mental health, estimates, however, that 40 percent of Cambodians suffer some degree of psychological or mental health issues.
An accepted baseline pegs the rate of psychological and mental health issues among the global population at 10 percent. Given this rate is estimated to cost the global economy $1 trillion, then the TPO’s estimated 40 percent of Cambodians struggling with mental health challenges, compounded by the Kingdom’s status as a low- to middle-income country (LMIC) with a recent history of tribulations, paints a bleak picture for any mental health-specific productivity cost projection.
Post Traumatic Stresses
A study by the International Journal of Mental Health Systems (IJMHS) reported that the high levels of mental health issues estimated in Cambodia exist as the result of two primary factors. The first is the prolonged trauma the Khmer Rouge inflicted throughout their regime, with the second identified as the challenges Cambodia has faced in completely rebuilding the nation’s healthcare services following the ouster of the regime.
“Despite rapid early growth in the number of mental health professionals during the 1990s [after the United Nations-facilitated elections], once international funding dried up, training opportunities were reduced,” the study said.
“There has been no psychiatric nurse training in the country since 2006. By 2012, 30 percent of psychiatrists and 90 percent of primary care physicians who had received basic mental health training were no longer active in clinical mental healthcare,” it added.
In fact, more than 30 years on since the regime, only 2 percent of health centres (18 of 967) and 59 percent of referral hospitals (50 of 84) offer mental health services to out-patients. Just two psychiatric in-patient units (with a total of 14 beds to service the entire country) exist and the Cambodian mental health professional community consists of 35 trained psychiatrists and 45 psychiatric nurses, with most of them based in Phnom Penn.
The brain drain
Currently, the Ministry of Health’s third strategic plan (2016-2020) does not include mental healthcare or make any specific mention of the need to develop psychological services. The national budget for mental healthcare represents less than 1 percent of health ministry spending.
In short, the IJMHS concluded that the barriers to implementing sufficient mental healthcare to the Kingdom include it being a low priority compared with other public health concerns, a lack of political will in addressing it as a priority concern, the challenge of decentralisation in integrating mental health services into community settings and the shortage of public health-trained mental health providers.
These barriers all pre-existed COVID-19’s battering of local and national economies and the direct increase of worries that followed and further exacerbated mental health issues among the population.
The pandemic and managing the “new normal” will force countries globally to rethink development strategies with stakeholders calling for investment in mental health as playing an important role on the road to recovery.
Calls for investment
The WHO estimates that every $1 directed to scaled up treatment for common mental disorders could offer a return of $4 in improved health outcomes and productivity.
This estimated return on mental health investment and the increasing call for its inclusion in development strategy is the result of a growing number of studies connecting psychological problems with commonly recognised social impacts that have direct ramifications on a society.
A study by Human Rights Watch found that the number of people exhibiting symptoms of poor mental health, (trouble sleeping and other sleep disorders, poor concentration, stigmatisation, mistrust, fear and hyper-vigilance) correlated to addictive and violent behaviour, suicidal tendencies, community mistrust and stigmatisation, lack of education, unemployment, higher rates of extended sick leaves, poverty, malnutrition and depression.
They are all recognised as direct barriers to development.
The study outlined that despite reports showing psychological issues as being connected with activities detrimental to society, the economy and development, governmental policies in LMIC’s have remained predominantly reactionary.
They address the results of social problems, but not their causalities.
“Governments and policymakers ignore the high cost of mental health issues to society either because they are less visible than physical disabilities, or because of a prevailing social stigma,” it said. Yet in bitter irony, a WHO report in 2020 recognised poor mental health as a leading cause of disability, measured on a global scale.
When asked about the impact of mental health in Cambodia, President of the Cambodia Association for Counsellors and Psychologists Hoeur Sethul told Thmey Thmey in September that investment is vital.
“At the national level, high rates of mental health problems contribute to increases in social unrest and decreased labour productivity, which places a huge burden on governments.
Better mental health care in the country would improve productivity and this would encourage economic growth. Investing in mental health services would be “cost-effective” and produce added value because communities would be better able to relate to one another. By not making mental health a priority in line with international recommendations, the lack of human resources and inadequate national funding to address it will continue. A government must initiate any action for it to have a nationwide impact.”
Sethul said studies showed that people with mental health issues are more prone to drug and alcohol abuse, which in turn can lead to violence and traffic accidents, concerns towards which the government has taken a very proactive, direct response.
For instance, an Asian Development Bank report from 2019 said: “Road crashes cause suffering, fear and trauma to victims and their families, which impose a heavy burden on the national economy.”
In response, a sub-decree was passed in March designed to deter traffic accidents by significantly hiking traffic fines. Interior Minister Sar Kheng cited traffic accidents as directly inflicting significant economic costs on the country.
“Increasing fines and enforcing the law is not meant to raise [government revenue]. It is a means of saving money,” he said.
However, there has been no response to another report by the ADB stating that policies promoting and facilitating health and overall wellness are vital to Asia’s recovery from the pandemic.
“This pandemic has had a significant negative impact on physical and mental health. Governments should incorporate wellness-promoting policies into their recovery plans to promote economic growth that will benefit both individuals and society. Wellness is a big part of the global and regional economy and that highlights its potential role in post-COVID-19 recovery efforts,” said ADB Chief Economist Yasuyuki Sawada.
ADB Principle economist Donghyun Park says the answer is loud and clear.
“In addition to [wellness] being a major engine for economic growth, it supports inclusive growth, such as creating jobs for women. Wellness makes people happier, which leads to people being more productive,” he said.
“It is absolutely necessary for governments around the region to explicitly incorporate wellness as an objective in their policymaking,” he added.
Food for thought
The growing onus on the adverse effects of mental health issues has spurred the private sector to begin recognising it as part of their corporate social responsibility programmes and integrating mental wellbeing components into the workplace.
Internationally, one of the early adopters in corporate recognition of the importance of mental health was Canadian telecommunications company Bell, which launched the “Let’s Talk” initiative in 2010.
The “Let’s Talk” campaign focuses on four core pillars: anti-stigma, care and access, research and workplace health. In 2020, Bell pledged to donate $100 million over the next five years, nearly double the amount it had spent in the previous five.
The impact has been substantial within both the company and the wider community, with multiple awareness-raising and solution-focused projects having been funded as part of the initiative.
In Cambodia, technology, innovation and telecom industry leader Smart Axiata recently donated part of its $1 million Flood-Relief Fund to collaborate with TPO to deliver free counselling services in Banteay Meanchey.
The good news for stakeholders is that providing mental health services is cost-effective.
A WHO report said that many mental health conditions can be effectively treated at relatively low cost, with only short-term mental health training needed for the effective addressing of many common issues.
“Training non-specialist workers in mental healthcare is an effective strategy to increase global provision and capacity, and improves knowledge, attitude, skill and confidence among health workers, as well as clinical practice and patient outcomes,” a 2019 WHO report said.
International Committee of the Red Cross director-general Robert Mardini agreed, saying: “Mental health programmes are some of the least expensive interventions in humanitarian response, but they have a lifesaving and priceless impact on the lives of people who need them,” he said.
In Cambodia, not only would this benefit development, but training could offer valuable opportunities in upskilling the population while raising further awareness around the issue.
Indeed, the increase in awareness of mental health issues has led to a growth in private care facilities, organisations and social enterprises, an example of the latter being Phnom Penh based My Beekeeper.
Managing Partner and a psychologist at My Beekeeper Robert Common said: “I do think there is a growing awareness of mental health in Cambodia, although there are still a lot of taboos around openly discussing it.”
“Mental health support can completely transform life for an individual. The ripple effect caused by people struggling unsupported with mental health needs can be extraordinary. Unhappy people have a huge impact on those around them. But if they are given support, this ripple effect becomes a positive one and extends into communities. The happier and better adjusted a country is, the more productive it is,” he said.
“I think we need more investment in well-trained mental health professionals in Cambodia. I hope that one of the ways Cambodia responds is by making mental health part of its plans for recovery,” he said.
When asked where people are currently learning about mental health, Common responded, “In a word, Facebook.”
He said: “Facebook remains by far the most popular single source of information in Cambodia, particularly on mental health issues. Social media gets a lot of criticism for its negative impact on mental health, but it can also be a tool, telling stories that aren’t often told. A young Cambodian who wrote a moving Facebook post sharing his own struggles with severe depression, found his story ending up being shared tens of thousands of times – and stories like that can do an enormous amount of good by showing people who are struggling that they are not alone.”
Indeed, the 23-year-old Cambodian banking sector worker says that she also found help through social media, internet research and by opening up to friends.
“I just thought it was normal for people to live with suffering. I never told my family because I didn’t want to be a burden. Luckily, I met a friend who shared a similar experience with me. When I shared mine with her, we wept together and I knew then, I wasn’t alone,” she added.
Regarding the future of mental health in the Kingdom, she says that the youth are becoming more aware.
“However, this still doesn’t reach many people, especially those in the countryside. It would be more effective to put mental health in the school curriculum as a subject. That would inform children at an early stage.”
“If I had known about this earlier, I would not have suffered so much. When one experiences mental health issues it affects you a lot, in every aspect of your life.”
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