Summary of the report: Guidelines for mental health policies- Ministry of Health
Peru within the international context
Life and health are mutually embraced in people’s social context. This context includes the interaction of political, social, ecological, cultural, economic and psychosocial aspects, which mould and change, at the same time, every health status. As such, the processes of health and illness form a continuum constantly permeated by these conditions. The richness of natural and human resources that Peru has could be used as a great source of development if such resources would be equally distributed. Unfortunately, this diversity is a source of imbalance and discrimination, which generate serious psychosocial problems, such as social exclusion, violence and corruption. All these social events hinder the development of people’s mental health status.
Poverty is basically a severe product of inequality. In Peru, poverty is sharply manifested in the quality of life of the population: mortality, malnutrition, illness, low quality of health services, and depredation of the environment. In this sense, social inequalities broaden the gap between the rich and the poor. Social inequalities are also psychosocial stressors and cause several mental health problems.
Peru presents a number of mental health problems which are also prevalent in other parts of the world ("Mental health situation in the world", OPS, 1997), such as:
Mental health: main problems and indicators
In health interventions the term indicator is regarded to be a useful instrument for the measurement of health status, such as morbidity and mortality. However, in the mental health field such indicators do no exist. In this sense, we believe it is necessary to create this kind of indicators in order to have a clear and systematic picture of our mental health situation. In this chapter, we will give information about the main mental health problems. They will not be presented according to conventional categories, but rather, in relation to their prevalence in the population.
Main mental disturbances: depression, schizophrenia and anxiety
In Peru does not exist a systematic and organised epidemiological information about the diverse mental health disturbances which affect the population. This is due to the lack of a centralised database in the Health Ministry, and because of the majority of such mental disturbances are not reported by the patients. However, we have some relevant data, for example, Cecilia Sogui (1997) described the prevalence of depression in ( 32.6% ) suffered mainly by women in their menopause age and by men in their early youth. Anxiety is also increasing, according to data from the Ministry of Health (2001), and schizophrenia follows the same world epidemiological trends.
Suicides
Suicide occupies the fourth cause of mortality in Lima, 8% of the total (Institute of legal medicine, 2001). Statistics shows that men commit twice more suicide than women. According to Honorio Delgado- Hideyo the most frequent causes of suicide are: marital problems (29.6 %), family conflicts (27. 6%), and emotional conflicts (22.1 %). Suicide is also associated to substance abuse and alcoholism.
Drug consumption and substance abuse
According to the National Survey for Drug Consumption, drug abuse is associated to alcohol (10.2 %) and tobacco (8.1 %). Alcohol consumption is grave public health problem, situation that is associated to psychosocial factors. In Peru men have higher alcohol consumption than women, 16% and 4.9% respectively. 30 % of the cases of alcohol consumption develop concomitant psychosocial problems, such as aggressiveness, irritability and depression. In the western world, 10% of men and 3 to 5 % of women who are alcohol consumers develop serious behavioural problems.
Nicotine dependence has the second place in prevalence, and is one of the most expensive consumption, but it is the most treatable. In the world statistics, 50% of the smokers develop any type of cancers, and Peru follows the same trend.
Violence
It is difficult to determine causes of violence since they are multiple and very complex. However, it is important to point out that every type of violence should be evaluated within a bio-psycho-social perspective, in which violence is understood as the result of a unlimited number of conditions - political, socio-economic, familiar etc - available in the daily life of the population.
As J. Gilligan points out "Violence is caused by an internal feeling of shame and humiliation; it is an inferiority complex in relation to the one who feels superior (...) The broader the gap between the rich and the poor, the greater the inferiority complex, and as such, the stronger the violence. (...) It is a complex behaviour, which is manifested in multiple conducts such as homicide, suicide, terrorism, kidnapping, and death penalty. Among the three main causes of violence -the biological, psychological and socio-economic- the strongest are the psychological and socio-economic factors".
We have organised problems of violence in four groups, which interact one another.
Child Abuse
According to Anicama (1999) one out of three inhabitants of Lima commit psychological violence against their children (36,2 %), and two out of four practice physical violence (43.2%). As such, Ponce (1995) indicates that more than the half of Peruvian children are victims of physical violence (52.3%), of these 20.4 % are beaten with belts, the most common method in all social levels.
Violence against women
According to the National Survey on Health and Family (INEI, 2000) 41% of women have been subject of physical abuse. A high number of women have also been victims of psychological abuse, in form of psychological indifference (34%), rowdy talking (48%), and threats (25%). Denounces appear just if physical violence is present, despite of the fact that psychological violence greatly affects women’s well being.
Sexual Violence
According to the Institute of Forensic Medicine (2001), 73% of all the cases of sexual violence are directed to women in all ages, and the 94% of the maltreated men are under 17 years. In addition, 9.7 % of all the cases of sexual violence are children between 0 and 5 years, 27.5 % are between 6 and 12 years and 51% are between 13 and 17 years old. This data shows than infants and adolescents are more subjects of sexual violence.
Incest
Close relatives, specially the father, brother, uncles or stepfather, commit the majority of the cases of sexual violence. Cases of incest are so frequent that require special preventive policies. DESCO rapport (2000) shows that 21.9% of the cases of sexual violence occur inside the close families, and 15.5% happens to be in relatives or friends households. Male adolescents under 18 years old commit 60% of the cases of sexual violence.
Political violence
A decade of political violence has produce around 25,967 deaths; 435,000 displaced communities, from which 68, 000 have returned to their place of origin; there are also 6,000 cases of disappearance and 9,000 detained. This population has been also emotionally, socially and economically affected and present psychological problems such as severe reactions of stress and problems of adaptation, which includes psychosomatic disorders, gastrointestinal and depressive, and post-traumatic stress disorders.
Social Violence
According to the Ministry of Internal Affairs (2001), 2 out of 5 deaths in the urban suburbs are caused by traffic accidents (42.44%). 15% of the deaths are homicides. Men are more subjects of social violence than women - for each woman 6 men die. It is also described that thievery is also an important cause of violence (15.2%), both in the case of robbery against households (16.3%) and against vehicles (29.6 %). One of three persons suffers from any form of social violence, especially robbery.
Other mental health problems
There are other types of social problems, which are scarcely explored, such as the case of street gangs. Among the causes of such behaviour it is mentioned: family problems, lack of social opportunities, lack of recreation, anomie and social exclusion.
Abortion is another social problem, which cause both physical anomalies - high mortality rates - and negative emotional consequences specially when women are not attended. In relation to this, it is also relevant to highlight the prevalence of pregnancy among adolescents. According to INNEI, 13% of the adolescents between 15 and 19 years old get pregnant or are already mothers. Adolescent motherhood, besides causing physical impairments, produces a number of psychological problems, which are almost unexplored.
Disable people and the elderly are two vulnerable groups in Peru. Both are subject of discrimination and isolation and have difficulties in their development and social integration. There is a small percentage of elderly population who benefits from social security - jubilation, employment -, whereas the great majority is out of the social system. They are also victims of domestic violence, loneliness, and suffer from a number of diseases, which are usually not attended.
AIDS also deserves special attention. Despite of the fact that, since 2000, the number of news cases had not increased it is important to explore the psychosocial consequences of these patients.
Mental health services available
The health sector consists on two sub sectors, the public and the private. The first offers services through the Ministry of Health (MINSA), the Ministry of Social Security (EsSalud) and the Ministry of Sanity of the Armed Forces (FFAA). The private sector is constituted by private clinics and non-governmental organisations (ONG).
Human Resources
According to the II Cense of Sanitary Infrastructure and Resources of the Health Sector, there are 24, 708 doctors (10.32 per 10,000 habitants). From this 16, 324 work in the public sector; 11, 157 belongs to MINSA; 4,495 to EsSalud; and 2,171 to the Armed Forces and other public establishments. There are 8,313 medical doctors who work in the private sector.
Psychiatry is the sixth most frequent speciality (3.7% of the total). From 411 psychiatrist, the 78% (298) works in Lima. The number of psychologist and social assistants is markedly fewer, and the majority work for the public sector.
Infrastructure
1. Centres:
Budget
The national budget assigned to health is 4.4% of GNP, probably one of the lowest in the world. In 1998 the total expenditure to health was 740, 558,000 $US, which was distributed as follows, 27.9% to MINSA, 25.1% to the Social Security, and 20.3% to the private sector. In sharp contrast to this division, 60% of the total population is attended by MINSA, 25% goes to the Social Security, and 15% goes to the private sector.
According to the II Cense of Sanitary Infrastructure and Resources of the Health Sector (1996) there are 7, 306 health centres. The majority belongs to MINSA (81%), 4% to the Social Security, 2% to the Army, and 9% are private. Communal health centres are usually small, and with minor capacity.
2. Beds:
From the 35, 877 hospital beds, 24, 489 belongs to MINSA. For psychiatric services there is available 918 in the whole health sector, which are mainly allocated in Lima. Communal health centres do not have this service.