A complex field

Various social factors contribute to poor mental health outcomes. These may include childhood experiences, nutrition, education, poverty, income inequality, housing, transport, etc.

But it is important to realise that these factors mean different things to different people. Any vulnerable population is more likely to be suffering from mental health disorders. For example, in a gendered context, all these social determinants in Pakistan will be exacerbated by systemic sexism that reinforces health inequities. Mere investment will only have a minimal effect without a full understanding of how existing policies perpetuate the system. This is where the role of policymakers is critical.

Like many other health challenges, mental health is a complex field. But little attention has been paid to it, and it lags far behind other areas of physical healthcare. Many LMICs lack the resources to provide access to their communities. Barring areas where the elite reside, neighbourhoods comprising underserved people are likely to be far from hospitals, clinics and doctors - a problem made worse by the lack of public transport to get to medical providers in high-income areas. Stigma and lack of social awareness further aggravate the problem.

Meanwhile, mental health also faces an acute workforce shortage in LMICs. With an estimated one per cent of the health budget devoted to mental health, the psychiatrist-to-population ratio in Pakistan is dangerously low at one to 0.5 million-1m people (against a recommended 1:10,000). The ratio of psychologists is similarly critical. There are only a handful of mental health hospitals across the country, with rural communities almost completely cutoff. At the same time, the workforce we do have is not representative of the population it serves. The result is disparities in the quality of care, constrained access to linguistic and culturally appropriate services, lower patient satisfaction, workforce burnout and overrepresentation in coercive treatment environments for people with serious mental illnesses.

We must address disparities if we aim to advance social justice. This is the part of the story which we have heard countless times. In fact, addressing disparities is equally important to the entire society because it is crucial to overall national economic prosperity. Lack of resources result in stress, loss of productivity, and job absenteeism, costing us trillions of rupees annually.

Not only this, ignoring mental health treatment has a big opportunity cost. When mental health professionals are unavailable, it produces serious spillover costs by loss in economic productivity and by shifting the burden to more expensive, and often unprepared, environments such as prisons, public hospital emergency rooms, and homeless shelters. Mental well-being is critical to all - even those who may not be suffering from an illness will be impacted indirectly.

Studies repeatedly indicate that integrating mental health into primary care, as well as treating mental disorders and other non-communicable diseases in a collaborative model, is effective. Focus on treatment alone will also not be sufficient to close the mental health gap. Promotion and prevention must be boosted. For instance, research points to the early onset of mental health problems, with around 14pc of children estimated to be suffering globally from mental disorders and illnesses. This is clearly an area of focus, otherwise, the issue will aggravate and go undetected, and untreated mental disorders occurring early in life will lead to lifelong disability and preventable early deaths.

The same applies to programmes aimed at mitigating childhood trauma and reducing physical punishment. Or those aimed at modifying cultural norms to accomplish gender, sexual and racial equality. Or to programmes for forced migrants, whether refugees or IDPs, which is a population where trauma and inequality are the norm.

My point, and I hope the most prominent takeaway, is understanding the interconnectedness of health inequities. And it is not merely a resource problem. For example, even before the pandemic, Texas (which had a surplus 'leftover' budget of $24 billion in 2021) had the highest rate of uninsured population at 18pc - double that of the national US average. Three out of four of those were people of colour.

I am not arguing that all aspects of mental health are non-biological; I'm encouraging more serious questions about why our system reinforces itself. As a New York Times article noted, "If someone is driving through a crowd, running people over, the smart move is not to declare an epidemic of people suffering from Got Run Over by a Car Syndrome …