Statement by Mr Dainius Pūras, Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health

44rd session of the Human Rights Council

Agenda Item 3: Promotion and protection of all human rights, civil, political, economic, social and cultural rights, including the right to development

Mr. President,
Excellencies,
Distinguished Delegates,
Ladies and Gentlemen,

It is my pleasure to make my last presentation to the Human Rights Council amid these challenging times thanks to the advances of technology. The thematic report that I present to you today continues to discuss an issue that has been core to my six-year tenure as a mandate holder. The aim this time is to discuss ways forward for setting a human rights-based global agenda on Mental Health.

On this occasion, I also present the report of my country visit to Ecuador, which I carried out from 17 to 26 September 2019.

Ladies and Gentlemen,

Throughout my mandate, I have sought to amplify the importance of mental health within the right to health. Since my report to the Human Rights Council in 2017 (A/HRC/35/21), mental health has continued to grow in prominence on the global stage, including substantive and commendable Resolutions of the Human Rights Council in 2016 (32/18), 2017 (36/13) and 2020 (43/13).

I welcome the international recognition to mental health, but much more is still needed to comprehensively understand and respond to it. Too frequently, the global mental health status quo follows a “mad or bad” approach, overriding human rights and justifying widely spread coercion in the search of preventing behaviours deemed as “dangerous” or providing treatment considered “medically necessary” without consent.

The dominance of the biomedical model results in an overuse of medicalization and institutionalization, ignoring the social, political or existential context that contributes to a high prevalence of feelings of sadness, anxiety, fear and other manifestations of mental distress.

Mr. President,

As a medical doctor and psychiatrist myself, I appreciate the progress made to understand the role of psychotropic medications, but also their limited effectiveness, which is not comparable to other medicines that are essential for certain physical conditions, for example antibiotics for bacterial infections. This is so because there are no biological markers for mental health conditions, hence the pathophysiology and specific mechanisms by which psychotropic drugs may be effective, are simply unknown.

Unfortunately, the side effects of psychotropic medications and their associated harms have been downplayed in the published literature while their benefits have been exaggerated. This has often led to over-diagnosis and overuse of biomedical interventions, thus moving away from the understanding of the complex context of humans in society and implying that there exists a simplified mechanistic solution to mental distress.

This legacy of excessive medicalization reflects an unwillingness to confront human suffering meaningfully and embeds an intolerance towards the diversity of emotions everyone experiences in life. It further risks legitimizing coercive practices and entrenching discrimination against groups already in marginalized situations, such as persons with disabilities, people in situation of poverty, persons who use drugs, older persons and even children and adolescents given the growing tendency to medicalize children’s’ distress.

Ladies and Gentlemen,

A paradigm shift is urgently needed. Mental health-care should advance towards rights-based support. Treatment and distress must move beyond the biomedical understanding of mental health and acknowledge that, for the majority of mental health conditions, psychosocial and other social interventions are the essential option for treatment.

Mental health care action and investment must be directed to rights-based supports, to non-coercive alternatives that address the psychosocial determinants of health, and to develop or strengthen practices that are non-violent, peer-led, trauma-informed, community-led, healing and culturally sensitive. Key principles in these efforts are, first and foremost dignity and autonomy, followed by social inclusion, participation, equality and non-discrimination, diversity of care for the development of acceptable and quality responses, as well and the importance of the determinants of mental health.

Excellencies,

In the past months, the word has faced the public health threat of COVID-19, which has not only put immense pressure on public health systems, but also exposed decades of mental health neglect. The pandemic has fuelled mental distress, anxiety and fear owing to the spread of the virus, distancing and isolation, economic and social downturns, unemployment, and increase in domestic and other types of violence.

COVID-19 has also exacerbated the failures of the status quo in mental health care. Institutions have become hotspots for the virus. From persons with disabilities in psychiatric institutions, to older persons and children in care homes and people in detention: they have all become more vulnerable to contagion for the confinement and often unsanitary conditions they live in for long periods, and have been experienced the highest rates of infection and mortality.

Both the virus and measures to address it are having serious impacts on mental health. In this context, the conclusions and recommendations of this and my previous reports on the right to mental health, become more relevant than ever. The pandemic provides the global community with a unique opportunity to demonstrate political will to move away from medicalization and institutionalization in mental health-care.

Distinguished Delegates,

In these challenging times, I call on States, civil society, organizations representing the psychiatric and other mental health professions, and on the World Health Organization to advance discussions and actions to change the way we understand and respond to mental health. I also call on the ultimate elimination of segregated psychiatric institutions that reflect the historic legacy of social exclusion, disempowerment, stigma and discrimination.

I also congratulate the leadership of Portugal, Brazil and others who, at the international arena, have championed a paradigm shift in mental health care, provoking meaningful discussions around these complex issues.

Mr President,

I would like to turn now to my country visit report. Ecuador has made progress in the realization of the right to health by investing in health infrastructure and is in a good position to reach universal health coverage and other relevant goals. However, the Government’s proposed austerity measures and budget cuts risk affecting the effectiveness and sustainability of the national health-care system, which in times of COVID-19 have proved to be essential.

Ecuador’s investments in health-care infrastructures must be complemented by the improvement in coverage and accessibility in rural areas in indigenous and Afro-Ecuadorians communities. Substantial investments are also needed in primary health care and mental health services; and because the latter remains underdeveloped there is a golden opportunity to build a mental health system that is rights-based.

In Ecuador like in any other country, public health policies should also look at the determinants of health. Considering the high prevalence of violence, notably against women and girls, and discrimination of certain groups, it is also vital for Ecuador to address discrimination and violence against women and girls, children and adolescents, lesbian, gay, bisexual and transgender persons, people living with HIV/AIDS and people on the move.

During my visit, a new Health Code was about to be adopted and I had hoped that, by the time of presenting my report, this would have happened. Regrettably, it has not. I thus reiterate that an updated and comprehensive human rights-compliant legal framework in Ecuador is essential for the formulation of corresponding health regulations and policies.

Ladies and Gentlemen,

I have presented my thematic and country visit reports in a spirit of a constructive dialogue and engagement with you. I look forward to the dialogue with the Human Rights Council and thank you all for your attention and support throughout the six years of my tenure as Special Rapporteur on the right to health.