Soc Psychiatry Psychiatr Epidemiol (1988)23:2-5
© Springer-Vedag 1988
Editorial
Psychiatry in the era of 'Health for All'
B. Cooper
Zentralinstitut fiir Seelische Gesundheit, Mannheim
Many psychiatrists are becoming uneasy about the
future of their discipline, sensing both a lack of pro-
fessional direction and a widespread loss of public
confidence (Shepherd 1982). In some countries a
trend is already apparent towards the 'industrializa-
tion' of psychiatry and its transformation into a cap-
ital-intensive commercial enterprise, likely to prove
more responsive to market forces than to the re-
quirements of sick people (Bittker 1985; Brandon
1986). If such tendencies are to be successfully com-
bated, they will have to be opposed by an alterna-
tive model of care: a public-health oriented psychia-
try, designed to meet the needs of the population as
a whole, and to reduce or contain the burden of
mental ill-health by applying the principles of pre-
ventive medicine. Since at first glance the current
WHO-sponsored campaign for 'Health for All'
(WHO 1985) might seem an ideal basis for the de-
velopment of such a model, it is necessary to ask
why it has aroused so little enthusiasm among pro-
ponents of social psychiatry, and to consider how
this failure might be remedied.
Let us recall briefly the background to the WHO
programme. In 1977 the World Health Assembly re-
solved that "the main social target of government
and WHO in the coming decades should be the at-
tainment by all citizens of the world by the
year 2000 of a level of health that will permit them
to lead a socially and economically active life." It
was not, perhaps, the most auspicious way to for-
mulate the new policy. By thus linking an unrealiz-
able goal to a precise time-table, the Assembly suc-
ceeded in coining a catchy slogan only at the
expense of sacrificing credibility. Much effort has
had to be expended since then, in trying to persuade
sceptical opinion that behind all the rhetoric of
'Health for All' (HFA) there may be a pragmatically
useful concept. Probably, indeed, the original reso-
Social Psychiatryan
Psychiatric Epidemiology
lution would by now have been forgotten, along
with so many others, were it not for the strategy
chosen to implement it, which was first propounded
a year later in the Declaration of Alma-Ata (1978).
"Primary health care", it was affirmed, "is the key to
attaining the target as part of development in the
spirit of social justice." What should be understood
by primary care was spelt out under seven points
which, taken together, amount to a statement of the
basic principles for provision of an equitable, pre-
ventively-oriented health service. It is, above all, this
emphasis on the importance of grass-roots medical
care for entire populations that has given the HFA
programme its appeal for public-health workers the
world over.
In 1980 the WHO Regional Committee for Eu-
rope adopted the strategy proposed at Alma-Ata
and distinguished between four principal compo-
nents: reduction in the incidence and prevalence of
preventable diseases, promotion of healthy life-
styles, control of environmental hazards, and provi-
sion of adequate primary care services and of back-
up support for them, in terms of administration,
teaching and research. Under these headings, a total
of 38 individual targets were specified and, as far as
possible, expressed in quantitative terms. At the
same time, the European Advisory Committee on
Health Research was requested to draw up a 'Re-
search Action Plan' which would help to establish
priorities and mobilize resources in the member
states. The resulting plan, though addressed in the
first instance to governments, is also intended as a
direct appeal for support to the international scien-
tific community.
As set out in the draft document (WHO 1986b),
the action plan ranges from concrete, relatively spe-
cific proposals for disease prevention to well-mean-
ing but quite nebulous adjurations to 'healthy pub-
lic policy', but without losing its over-all emphasis
on the importance of epidemiological and commu-
nity-based studies. Those projects should be given
priority, it is urged, "which are aimed at primary,
secondary or tertiary prevention in relation to the
common diseases in each national population, and
which afford prospects of reducing mortality and
morbidity, and improving quality of life." Research
should not be confined to the investigation of pat-
ients in treatment centres, but should be extended to
cover morbidity in the general population. Thera-
peutic and evaluative strategies should concentrate
on methods applicable at the primary care level,
rather than on those which require the facilities of
high-powered technology.
Among the 38 specified targets, four in particu-
lar are directly relevant to the concerns of psychia-
try in m o d e m industrial societies.
1. As a step towards realizing the population's full
health potential (Target 2), research should be un-
dertaken into the incidence of intellectual and de-
velopmental retardation among children of pre-
school age; into the nature of risk factors present
during pregnancy, at birth and in the neonatal peri-
od, and into the efficacy of preventive measures at
these times. Systematic surveillance of children
known to be at increased risk should be undertaken
and linked to supportive programmes.
2. By the year 2000 the average number of years that
people live free from major diseases and disability
should be increased by at least 10% (Target 4). In
this context, a stated priority is a reduction in fre-
quency of mental disorders among the elderly. Re-
search is proposed into the incidence and distribu-
tion in elderly populations of relatively specific
conditions, such as Alzheimer-type and multi-in-
farct dementia. Simple, reliable tests of cognitive
impairment and decline are called for, which could
be used in the primary care setting, to promote ear-
lier detection and diagnosis.
3. By the year 2000, rising trends in suicide and
parasuicide rates in the European Region should be
reversed (Target 12). This target, it is suggested,
should be seen as one major goal of programmes
aimed at reducing the burden of ill-health and psy-
chosocial stress in populations, rather than as a sin-
gle, isolated objective. Appropriately, however, the
main emphasis with respect to this target is placed
on the need for research. Specific proposals refer to
improved methods for recording and documenting
both suicide and parasuicide, to studies of popula-
tion sub-groups known to be at increased risk, and
to the evaluation of preventive measures by means
of controlled comparative studies.
4. By 1995 there should be, in all member states, sig-
nificant decreases in health-damaging behaviours;
in particular, abuse of alcohol, pharmaceuticals and
illicit drugs. A declared aim of health policy in each
country should be a reduction in total alcohol con-
sumption of at least 25% by the year 2000 (Tar-
get 17). Studies are called for which would link data
on alcohol consumption to accident statistics, and
monitor the effects measures designed to lower con-
sumption have on vehicle accident rates (Target 11).
Some of the other targets and their associated re-
search proposals are at least implicitly relevant to
the prevention of mental disorders. Providing better
opportunities for the disabled by means of effective
rehabilitation services (Target 3) would help to bet-
ter the social prognosis for many chronically men-
tally impaired persons. Measures to reduce parana-
tal and maternal mortality (Targets 7 and 8) would
also tend to prevent non-fatal paranatal damage
and to improve the health of women of reproduc-
tive age. Reduction of traffic accident rates (Tar-
get 11) would lower the numbers of cases of brain
damage, especially in the young adult age-range.
Eradicating certain infectious diseases, such as con-
genital rubella and syphilis (Target 5), would be the
most effective way of preventing their neuropsychi-
atric sequelae. The list could be extended.
Clearly, then, the HFA proposals contain a good
deal that might be expected to command the sup-
port of psychiatrists and other mental health profes-
sionals. But on the whole they are still far too gener-
al and too abstract in form to provide a blueprint
for action. Two sets of unresolved problems must be
tackled before the downstream journey from policy
adoption to specific project planning could be em-
barked upon with any confidence.
First, there are the general problems that arise in
making operational, in the context of m o d e m indus-
trial society, proposals which were conceived with
the needs of developing third-world countries
uppermost in mind (WHO 1986a). This is not an
easy task, since patterns and risk-factors of morbidi-
ty, as well as health-service structures, vary enor-
mously between the different global regions. To take
a case in point, the HFA preoccupation with equity
as the key to better health makes obvious sense in
trying to improve standards of nutrition and hy-
giene in poor developing countries, as for example
in the current 'safe motherhood' campaign of WHO
(Mahler 1987). In the Western industrial nations,
however, there may be other priorities: if poverty is
still the most important single risk-factor, we also
know that some diseases are positively associated
with affluence, while others again display no appar-
ent socio-economic gradient (WHO 1986a). A ratio-
nal approach to prevention must take account of
the distribution and sociodemographic correlates of
each major diagnostic category.
Analogous arguments apply to the basic propos-
als for health-service provision. It may well be that
'primary health care', as envisaged at Alma-Ata,
represents the key to successful disease prevention
and health promotion. But this broad concept can-
not be equated with the realities of first-contact
medical care, based on general-practitioner and
emergency call services, as these are experienced to-
day by many urban populations. Indeed, the gener-
al practitioner in free practice has been provocative-
ly characterized as a potential enemy of primary
health care in the WHO sense of that term (Vuori
1986). When a WHO Working Group, addressing
this question 15 years ago, concluded that "the pri-
mary medical care team is the keystone of commu-
nity psychiatry" (WHO 1973), they were careful to
specify that the team should be a multidisciplinary
one, including community nurses and social work-
ers as well as physicians. They also called for closer
liaison between primary care teams and local psy-
chiatric services, and greater attention to mental
health care in postgraduate and continuing educa-
tion for the general practitioner. Unfortunately,
progress towards these objectives has been tardy,
and in many countries standards of general-practice
care for the mentally ill and handicapped still leave
much to be desired.
Secondly, there are the conceptual and practical
problems that arise whenever psychiatric disorders
are placed under the rubric of preventable disease.
Clinical psychiatrists, not least those working in
public services, know well enough how limited is
the scope for systematic prevention of mental illness
and its consequences; nothing is more calculated to
evoke a sceptical response on their part than an
over-optimistic or facile assessment of the difficul-
ties involved. How formidable these will prove to
be, as the HFA programme develops, is already
prefigured in the draft document (WHO 1986b),
where large discrepancies are apparent between
some of the original proposals for achieving targets
by 1995 or 2000, and the action plan for preliminary
research, which would already intrude into the early
decades of the next century.
The year 2000 should not be regarded as a uni-
versal deadline. What we now urgently need are
guidelines for a steady advance into the preventive
field, which take account of national priorities and
which psychiatrists and their professional associa-
tions can accept as realistic in terms of feasibility
and tempo. An important first step in this direction
would be to establish a number of intermediate
goals, each with its own time schedule and each se-
lected with an eye to the present state of scientific
knowledge and the prospects for success. Inter-
mediate targets of this kind would have to be de-
fined at a number of levels of prevention and ap-
proached by different strategies, as the following
schema suggests.
Primary prevention
Legislation and fiscal measures aimed at reducing
public exposure to known risk factors (e. g., at re-
duction of total alcohol consumption by one-quar-
ter or one third, as a fundamental step in lowering
the prevalence of alcoholism).
Secondary prevention
Establishment of systematic surveillance of defined
at-risk groups of the population, combined with in-
tervention programmes (e. g., screening for the early
detection of developmental retardation in child-
hood, followed by remedial measures).
Tertiaryprevention
Development of rehabilitation and sheltered-em-
ployment services, to contain disability due to
chronic illness (e. g., provision of a network of com-
munity-based workshops for psychotic and mental-
ly retarded adults).
Monitoring and epidemiological research
Development of national and regional information
systems, incorporating both treatment agency and
field-study data, to provide reliable frequency esti-
mates and to identify trends in mortality and mor-
bidity (e. g., monitoring of rates for suicide and de-
liberate self-harm, in relation to unemployment and
other social indices).
The need to construct such frameworks, and to base
agendas on them, presents a clear challenge to na-
tional professional bodies and to the World Psychi-
atric Association. Up to now, organized psychiatry's
attempts to prepare for the future have been largely
confined to expert predictions, which rely on the ex-
trapolation of existing scientific and clinical trends
(Rosenberg et al. 1986). Crystalgazing exercises of
this kind, while useful, can by themselves provide
little guidance to policy; partly because they assume
an unchanging external world, but also because
they are unrelated to any declared objectives which
could serve as criteria of success or failure. The
adoption of explicit preventive goals could thus go
far towards providing psychiatry with precisely that
frame of reference for medium-term planning which
at present it so sadly lacks. If the HFA campaign
can at least serve to stimulate development along
these lines, something positive will have been
achieved and the foundations may yet be laid for a
realistic discipline of preventive psychiatry.
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Prof. Dr. Brian Cooper
Department of Epidemiological Psychiatry
Central Institute of Mental Health
Postfach 5970
D-6800 Manheim 1 J5