Give

Last month I was in Canberra for a landmark day in the campaign for National Mental Health Reform in Australia.

I was in the Australian capital for the Budget Lockup, an event at which members of the media and other stakeholder groups surrender their liberty and mobile phones for four hours in exchange for a preview of the nation’s budget. Some of the happier expressions to be seen at this year’s Lockup belonged to representatives of the mental health sector. A central theme of Budget 2011 was a major focus on mental health reform, with an injection of $1.5b of new Government money, complemented by reconfirming or reallocating $700m of pre-existing commitments, as part of a total investment of $2.2b over five years in a new National Mental Health Reform initiative.

This new investment is a response to the large scale unmet need of Australians with mental ill-health that was highlighted by a mental health reform campaign launched at the start of last year. As an adviser to one of the leaders of that campaign - psychiatrist and 2010 Australian of the Year Prof. Patrick McGorry - I have observed the evolution of that campaign at close hand. In this post, I provide a quick overview of that campaign and share some of the learnings to date which may be relevant to both other mental health reform campaigns and to the next phase of the Australian mental health reform campaign.

Campaign summary
To get a quick overview of the Australian mental health reform campaign between January 2010 and May 2011, I recommend this video from grassroots activist group (and key member of the mental health reform campaign) GetUp!:

Background to the campaign
The current mental health reform campaign in Australia has been shaped by the context in which it was originally planned in early 2010, with key factors being:

• Australians with mental ill-health are estimated to be 2-3 times less likely to access appropriate care than Australians with physical ill-health
• At about 7% of the health budget, Australian mental health funding is lower than comparable countries like New Zealand and the UK, and far short of the share of national health burden attributable to mental ill-health (13-14%). One consequence of this underfunding has been a famine mentality within the mental health sector that promoted intense and divisive competition for limited resources that made collegiality in pursuit of a common goal more difficult and which provided Government with an alibi for inaction ("we don’t know what to do because we get such conflicting advice from the sector")
• Although pioneering in the development of new models of care and evidence based treatment approaches to mental ill-health that become international best practice (e.g. in early intervention for young people with emerging mental illnesses), Australia has a weak track record of extending access to these innovations to its own people
• Australia has had individual bursts of increased public awareness of systemic failings in mental health care (including a number of parliamentary inquiries, official reports and media stories) which prompted sporadic reform efforts. Previous reforms included the closing of old mental health institutions during the 1980s and 1990s and a funding boost to increase access to primary care supports for mental ill-health agreed in 2006. However, these individual reform efforts did not form part of a sustained pattern of long term reform and investment, and their effectiveness was compromised as a result. One example of the impact of this stop-start approach to reform is the poor outcomes experienced by many mentally ill Australians discharged from the institutions that were closed - many ended up dead, in prison or homeless as a result of a failure to provide appropriate community based supports to relpace the old asylums.

Lesson 1 - Sometimes coherent strategy emerges out of opportunism
Its probably fair to say that the success of the campaign to date has been due to its ability to develop and execute a strategy that in part was defined by responses to some unexpected opportunities, most notably:

• The appointment of mental health researcher and advocate Prof. Patrick McGorry as Australian of the Year created opportunities for media coverage, enhanced access to key decision makers and influencers and creating a unifying focal point for a divided mental health sector. The reluctance of political leaders to be seen in public dispute with the symbolic value and moral authority associated with the Australian of the Year title further enhanced this opportunity. How this opportunity was exploited is outlined in the Australian of the Year 2010 report
• The lack of a clear vision and seriousness of purpose about mental health care from the Australian Government created a policy vacuum that gave mental health advocates an opportunity to largely dictate the terms of the discussion about mental health reform. This opportunity crystalised with the resignation of the Australian Government’s top mental health adviser A/Prof. John Mendoza, a principled action that created yet another prominent mental health advocate with a unique moral authority.
• The depth of disappointment and anger felt within the mental health sector after a Council of Australian Governments summit agreed a major health reform package that largely excluded mental health care enabled much greater unity of purpose and cooperation amongst mental health groups. The Mental Health Council of Australia secured endorsements from over 60 organisations of a set of common principles contained in two joint letters - the first a letter to the Prime Minister, the second a letter to Prime Minister and Leader of the Opposition that was released as a full page ad in The Australian newspaper and as a video:

Lesson 2 - Shared goals and low ego needs reduce the need for bureaucracy
A notable feature of the campaign to date has been achieving strong, coherent and collective campaign leadership within a loose, ad-hoc and informal campaign structure. This achievement is a direct consequence of the depth of commitment by campaign leaders to the shared purpose of securing much better outcomes for Australians affected by mental ill-health.

A campaign usually relies on consistent messaging and clear strategic direction for success - goals that can be hard to achieve if no-one is formally in charge and team roles are largely undefined. However, this campaign had no formal leadership group, no formal message authorisation process and no formal role definitions. Membership of informal strategy discussion groups was fluid. There was no overarching campaign brand (a mental health equivalent of “make poverty history"). The clarity, consistency and effectiveness of campaign messages therefore relied not on a formal campaign architecture, but rather on mutual understanding and trust. Some of that understanding and trust had been established over many years of campaign leaders working together in previous contexts. However, some key members of the campaign had no shared history (for example activist group GetUp! and mental health professionals were new collaborators) and the effectiveness of their working relationship depended on recognising in each other sincere and deeply held commitment to the same goal.

The manner in which campaign leaders collaborated was also a working proof of the principle that social change agents are generally more effective if they have low ego needs. The campaign had multiple media standard bearers who worked interchangeably and whose efforts were mutually reenforcing as these media interventions were guided by campaign needs rather than self-promotion.

Lesson 3 - A simple compelling idea is the basis of building a coalition
An important next step was to distil the shared purpose of the leadership group into a simple goal that could gain widespread community support. That simple goal is for Australians to have the same access to quality care for their mental health needs as for their physical health needs. This goal has the merit of:

• being compelling on grounds of fairness and ambition and thus able to secure strong community support - over 100,000 Australians expressed their support for this goal in the form of a GetUp! petition.
• specific enough to be measurable (verifiable by survey data)
• broad enough to be endorsed as a unifying goal of diverse organisations from across the mental health sector (as evidenced by the above mentioned joint letters).

Lesson 4 - The confidence to think big is a key step to re-framing a discussion
The campaign strategy could be summed up as “make mental health a vote winner.” In this regard, campaign strategists rejected the dis-empowering received wisdom, common in democracies around the world, that “there are no votes in mental health.” Instead the campaign was planned from the more optimistic perspective that there are millions of potential votes in mental health that had yet to be effectively mobilised. This confidence was based on a view that anything that significantly affects large numbers of people and for which their are effective public policy remedies is a potential vote-winner - and that mental health clearly fits this bill. In just over a year the view that there are votes in mental health has become fairly mainstream and has been adopted by political leaders who have made mental health one of the battlegrounds on which they compete for votes. This view is backed by an Ipsos MORI poll for King’s College London released at the end of 2010 demonstrated that Australians ranked mental health third on their list of national priorities - behind only the economy and the environment. The decision by the opposition Coalition to pledge a $1.5b investment in mental health at the last election was seen as smart politics as well as good policy (as an aside the impact of this decision is a reminder of the importance of pitching advocacy to opposition parties as well as Governments).

Lesson 5 - Size matters
The message that there are millions of votes in mental health was only credible because over 100,000 Australians mobilised as activists for mental health reform. The principal engine that made large scale mobilisation possible was grassroots activist group GetUp!

GetUp! had a pre-existing database of several hundred thousand supporters to whom A/Prof John Mendoza could write asking for support for the mental health reform campaign. Those numbers were further enhanced by mental health organisations writing to their members suggesting they join the GetUp! database. As a result:

• Raising money for media advertisements was made easier including a full page ad in The Australian newspaper and the following television ad:

• The effectiveness of individual activism was amplified and sustained by its connection to a wider movement of activisits. Candlelight vigils were held around Australia and individual messages were combined into events such as the “Fund hope for mental health” message on the lawn of Parliament House:

Lesson 6 - Establishing and sustaining momentum is critical
The adage that in politics whoever sets the agenda normally wins is especially pertinent to the Australian mental health reform campaign. As inferred above, the task of setting the agenda and defining the terms of discussion about mental health reform was made much easier for mental health advocates by the lack of Government direction in this area.

The mental health campaign seized this opportunity by repeating the message that mental health reform is achievable, necessary and popular in a range of media and settings. This message was fleshed out in some detail in set-pieces such as a live televised address to the Press Club and the Maurice Blackburn Oration (both delivered by Prof. Patrick McGorry).

The sub-messages that mental health reform was urgently needed and would have widespread community support were most effectively conveyed by Australians with mental ill-health themselves or by their families. In particular, TV shows such as Insight (Minds at Risk and Mental Health) and Four Corners put a strong spotlight on the avertable suffering caused by failings in Australia’s mental health system. Mental health professionals amplified that message with some expert analysis, such as these contributions by Prof. Ian Hickie and A/Prof. John Mendoza:

Messages about the necessity and desirability of acting need to be reenforced with a strong message about the achievability of mental health reform. Previous reform efforts had stalled in part due to pessimism amongst political leaders that there was any available solutions. Sharing evidence of effective interventions ready for roll out was an important part of the campaign, including by e-briefs to parliamentarians and by explaining what 21st century mental health care can look like:

Collectively these efforts generated a significant amount of momentum for change. Furthermore, so long as the Government was unable to set the agenda on mental health care, they found themselves in the vulnerable position of having their “narrative” in mental health defined by others - which made cutting a deal with prominent mental health advocates a more pressing political priority.

However, once Government began responding to that momentum with an engaged Prime Minister, the appointment of a capable and ambitious Mental Health Minister and a credible process for developing a mental health reform plan, there was a danger that some of the momentum for reform would temporarily stall. Key mental health advocates were now working behind the scenes with Government on developing an action plan and the lack of public conflict between these advocates and Government risked killing mental health as a media story. To address the threat that media momentum might stall just as the Australian Government Budget was being finalised, a number of mental health advocates led by a catholic priest Mgr David Cappo developed a Blueprint for reform and investment and provided it to Government. The authors of the Blueprint decided to release the document publicly based on a judgement call that the benefits of sustaining campaign momentum by immediate publication would outweigh the downside from releasing a document that might still benefit from some additional work. At the same time GetUp! made a concerted last push to ensure that mental health remained front of mind for political leaders during the weeks in which Budget 2011 was being finalised.

Lesson 7 - How victory is celebrated matters
Although the relationship between the Australian Government and mental health advocates was tense at times, both had a mutual interest in finding a way to a place where they could shake hands on a deal. Personal attacks on individuals do not help that process and were thus largely absent from the campaign. Furthermore, although a welcome announcement, $1.5b of new investment is not by itself going to solve the problems in Australian mental health care and Budget 2011 is best seen as important step on what needs to be a long term and sustained process of reform and investment. Therefore the mental health reform campaign’s goals in responding to the Australian Government’s new National Mental Health Reform initiative was to both help the Government felt good about its decision and to frame the discussion for the next phase of the campaign. An article by Prof. Patrick McGorry in The Australian captures key elements of this approach as does the following video from GetUp!:

Finally, the 30 minute mental health forum with Prime Minister Julia Gillard and Prof. Patrick McGorry is evidence of a much more positive tenor to relations between the mental healths sector and the Australian Government:

In 2009 Central America experienced its first military overthrow of a government for 16 years with the forced removal of Hoduran President Manuel Zelaya. For this reason the stability of other Latin American democracies has come under more scrutiny, with Guatemala, which shares a border with Honduras, one source of particular concern.

In its recently published report of its polling of public attitudes across Latin America, Latinobarometro reveals that Guatemalans have less faith in democracy than any other Latin American nation (with the possible - though improbable - exception of Cubans, who were not polled). Only 42% of Guatemalans think Democracy is the best system of Government, a similar number would always object to a military dictatorship and 36% think the Government should be able to shut down media outlets.

To an outsider, such apparent public distain for democracy might seem baffling and un-sophisticated. Yet it would be wrong to conclude that Guatemalans are inherently un-democratic by nature or collectively too stupid to assess alternative systems of Government. Rather, the findings of the Latinobarometro poll are more likely to reflect the weariness that Guatemalans feel towards a political system that lets them down on almost every meaningful measure. Guatemalans have learned to expect that their Governments will steal from them, squander their talents and utterly fail to protect them.

For many Guatemalans dizzied by the sheer number of thefts committed by the nation’s official guardians, the murder of lawyer Rodrigo Rosenberg was a clarifying symbol of the scale of betrayal that they feel. Although the Guatemalan Government blames Rosenberg’s death on gangs of criminals, Rosenberg himself recorded a video four days before his death in which he says “if you are watching this message,it is because I was assassinated by President Álvaro Colom, with help from Gustavo Alejos” (Colom’s private secretary). The reason Rosenberg claimed the Government wanted him dead was because he was fighting for justice for a former client, who Rosenberg said had been executed (along with his daughter) because he refused to collaborate with official corruption.

Whoever killed Rosenberg, it is unlikely that they will ever see justice. Guatemala is shamed by one of the world’s worst criminal justice systems, which guarantees violent criminals a 98% impunity rate at the same time that their mayhem condemns Guatemala to being one of the world’s 10 most dangerous countries. For many, the starkest expression of this lawlessness is the serial murder of 170 bus drivers during 2009 (often witnessed by up to 50 terrified passengers) - ordinary victims of criminal gangs trying to extort money from transportation companies.

The brutalising effect of this lawlessness transcends all sections of Guatemalan society, but is perhaps most deeply felt by the young. When working as a teacher in a middle class school in the Guatemalan highlands, I was struck by the amount of anxiety my students carried about la violencia, la delincuencia, las maras - (violence, delinquency and gangs).

Growing up with such elevated levels of fear is a profound enough developmental challenge as it is, yet most young Guatemalans are double whammied by being robbed of the education that might give them the skills and self-confidence to confront these problems. Mirroring Guatemala’s Latinobarometro ranking for low popular confidence in democracy, UNESCO places Guatemala stone last in Latin America for education according to its Education For All Development Index. Within Latin America (a region that itself spends only one fifth of the average OECD investment on educating each pupil), Guatemala has the lowest rates of adult literacy and secondary school enrollments and second lowest % of GNP spent on education.

In the context of all this grimness, it is unsurprising to learn that the German Ambassador described Guatemala as being “seconds from midnight from being a failed State.” He made that statement over a year ago and so far the minute hand has yet to call time on Guatemalan democracy. Despite the Latinobarometro poll, it is probable that few Guatemalans would welcome that happening. The only revolution that is likely to have widespread support would be replacing the current counterfeit democracy with the real deal: accountable government that protects its citizens and nurtures their talents. Whether this next decade brings much progress towards this far off dream being achieved is sadly, hard to predict.

Link: http://www.fuegoyagua.com/index.php/nicaraguaphotos/?blog=8

The trail to Cascadas De San Ramon, Isla De Ometepe, Nicaragua

Nicaragua is Central America’s largest country by area (about 130,000 sq km) but has a relatively small population of just short of 6 million people. Located on the junction of three continental plates, Nicaragua is periodically shook by volcanic eruptions and earthquakes - such as the event that destroyed the capital Managua in 1972. The legacy of this techtonic volatility, matched by an equally turbulant political history (revolutionary slogans are still evident on political posters throughout the country) partly explains the desperate poverty of the country - the second poorest in the Western Hemisphere (80% of the population live on less than $2 a day).

In contrast to the difficult circumstances faced by the majority of its population, Nicaragua offers a range of genuine delights for foreign tourists. Spectacular natural beauty (volcanoes, wildlife, lakes and waterfalls) can be found in locations such as Isla De Ometepe, there is a fine colonial heritage to be witnessed in the architecture of cities such as Leon and Granada and beaches on the Caribbean and Pacific Coasts. The country is also safer and less violent than more troubled Central America republics like Guatemala, Honduras and El Salvador.

The news that over 230 children have been killed since Israel launched its recent Gaza campaign is one of the bleaker aspects of a case study in how normally reasonable human beings become complicit in acts of the most stupid and vicious violence.

My own attempts to make sense of this year’s depressing Christmas message from the Holy Land has been shaped by my experiences over the last 16 months in Latin America. Young Israelis crisscross this region in great numbers, propelled by both a thirst for adventure and the emancipating energy of completed military service. Most of the young Israeli travelers I have encountered in Latin America were conscript soldiers only a short time before they began their personal journeys of discovery. These smiling, athletic and curious young people provide the faces I picture when I think of the members of the Israeli Defense Forces who are now killing and being killed in Gaza.

The engaging and thoughtful explorers I met in Latin America are young ambassadors of a society that remains overwhelmingly supportive of a conflict that has claimed over 800 lives in roughly two weeks. I have struggled to reconcile the intelligence and goodness I discovered in graduates of Israel’s military with the dumb and callous violence now unfolding in Gaza.

Rockets periodically lobbed at Israel by Hamas form just one strain of the self-replicating and highly contagious virus of violence that seems able to corrupt even the most healthy of hosts. Other sources of infection revealed themselves to me when I met two young Israeli women in the Bay Islands in Honduras. While watching the film Blood Diamond in their company, I noticed that a tiny, teary stream had formed on the delicate features of one of these women. She was quietly crying in empathy with fictional characters in a war scene. Yet even someone so young and gentle had already participated in military operations in which real people died.

It was revealing to note that someone with natural empathy could have her ability for human connection to be selectively choked. The same young woman who cried at film representation of violence told me how her time in the Israeli army had changed her attitudes to Palestinians. “I used to be really sympathetic - now I hate them.” Her work in Israeli intelligence involved listening to intercepted conversations in which Palestinians lustily rejoiced in the deaths of Israelis killed in recent terrorist attacks. Part of the sickness that infected those she listened to had spread along the phone lines to claim her ability to empathize with an entire people.

Trust and empathy are perhaps the most important parts of the immune system that protects us from succumbing to cruelty. The Israeli military claim that the deaths of hundreds of children and other civilians is really the responsibility of Hamas fighters who use their compatriots as human shields. Yet, it is hard to imagine Israeli bombs exploding with such indiscriminate lethality if the human shields were Israeli civilians.

As an Irishman, I note that even during the most vicious violence perpetrated by the IRA against British civilians, the British Government did not engage in large scale bombings of nationalist areas of Ireland where IRA leaders were known to sleep at night. That relative restraint in the face of unjustified terrorist violence akin to that Israelis now endure from Hamas proved to be wise. Yesterday I was in Belfast and able to enjoy the easy charm of a city moving on from decades of savage conflict. I hope that the Israeli friends I have made while in Latin America soon discover a similar sense of security in the streets of cities such as Netivot and Ashkelon that are currently targeted by the Qassam rockets fired by Hamas. But with great sadness, I feel that Israel’s response to its terrorist threat makes it much harder for that day to come soon.

Driving In Cuba

Bolivia’s Old Yungus Road is widely reported as the world’s most lethal. The spectacular Andean route between Coroico and La Paz has earned a grisly cache amongst adventure travelers wanting to earn “I cycled the Death Road” t-shirts.

The Yungus is just one of six Latin American roads that make the Association for Safe International Road Travel’s list of the twenty most dangerous roads in the world. Interstate 116 in Brazil, the Panamerican highway in Costa Rica, the Cotopaxi Volcan road in Ecuador, Highway 1 in Mexico and Kuelap-Celendin-Cajamarca road in Peru are the others.

Latin America’s death toll from road accidents of 26.1 per 100,000 population is the highest in the world according to the 2004 World Report on Road Traffic Injury Prevention. Although fear of violence is often highest on the list of security worries of visitors to Latin America, USA Today reports road traffic accidents as the most probable cause of death for healthy American travelers.

The same USA Today report indicates that motorists are more vulnerable when driving abroad due to a combination of lack of familiarity with local roads and driving conditions and the effects of jet lag. However, the road safety conditions in Latin America, in common with other developing world regions, add significantly to driving risks.

Latin America’s share of poorly maintained and inadequately signed roads, are made more dangerous by an often alarming driving culture. Indicating with lights when making turns appears to be thought of in some countries as a superfluous eccentricity. Widespread poverty results in the use of vehicles that are over-crowded, may lack mirrors and have poor quality windshields, breaks and shocks.

In Rio De Janeiro and Sao Paulo, motorists may ignore road signals for fear that stopping at lights may invite car-jackings. In Guatemala’s highlands, Chicken Buses hurtle down winding roads like tanks strapped to skateboards - unstoppable forces in search of their immovable object. Passengers traveling in tourist shuttles through Honduras regularly hold their breath as their drivers weave terrifying crochet patterns between oncoming juggernauts.

Sketchy enforcement of road safety regulations does not help. When a Guatemalateca friend of mine recently dented her car, I asked her why she accepted her father’s reaction of banning her from using her car. “You’ve got a license - so he knows you can drive” - “Yes, but I never sat a test - dad just bought me the license.”

Unfortunately, things may get worse before they get better. A joint report by the World Health Organization and the World Bank estimates that by 2020, there will be an 80% increase road deaths in low- and middle-income countries (where 85% of global road deaths already occur). During the same period a 30% decline in road deaths in high-income countries is predicted.

However, such grim predictions are not inevitable and real improvements are possible. Over the last 15 years Chile’s road safety program has achieved reductions in fatalities of about 20%. Lessons from Chile were highlighted at the first Latin American and Caribbean Road Safety Forum two years ago. It is to be sincerely hoped that the forum, now claiming representatives from 24 countries can succeed in making exploring this wonderful continent by road a safer experience for all.