Episode 8: Championing Mental Health

Devora Kestel is a senior global mental health policy expert with more than twenty-five years of international experience in Europe, the Caribbean and Latin America implementing and advising governments on national policies related to mental health systems. In 2000 she joined the WHO as a Mental Health Officer in post-war Kosovo and later served as WHO Representative in Albania. In both countries, she worked closely with the Ministries of Health to help establish comprehensive community-based mental health systems. In 2007 she joined the Pan American Health Organization (PAHO/WHO) where she first worked as the Mental Health Advisor for the Caribbean Countries, and then at the headquarters in Washington DC, providing technical cooperation in the mental health field to the entire region of the Americas. In 2015 she became the Unit Chief for Mental Health and Substance Abuse and since 2019 has been serving as WHO’s Director of Mental Health and Substance Abuse. She joins us from Geneva, Switzerland.

She speaks to us about:

• outdated views of mental health issues and mental health reforms

• her transition from clinical practice to public policy

• strategies and tools to advocate for increased government investment in mental health

• fighting against the stigmas associated with both mental health and substance abuse

• the building back better approach

• the bureaucratic challenges of working in UN agencies

• country level vs regional level work

• the presence of corporate lobbying in the sector

• the importance of having a more inclusive global representation in initiatives

• mental health as the shadow pandemic behind the coronavirus pandemic - and much more.

Editors note: This transcript has been slightly edited for clarity and coherence.

Transcript

Intro: The other issue that I’m taking into consideration and I think emphasizing a bit is that there is this tendency in most of these international organizations that the work is for and with the English speaking countries and people, colleagues and scientists. And it is very difficult to have a real global representation on everything we do as we should be. There is formally always a global representation, but I didn’t feel it was strong enough, because I felt it over the years when I was located elsewhere, all the technical documents, you read the list of those involved in the meetings, you contact Ministries of Health from a number of countries that are not English speaking countries, and you say, we are inviting you to come to a meeting but by the way, the person should speak English. It is almost offensive because the country does not have English as an official language for example.

Safa: Welcome back to the Rethinking Development Podcast. My name is Safa and I will be your host as we speak with and learn from practitioners of all backgrounds and affiliations around the world. In our conversations, we aim to rethink ethical behavior and best practices through the lived experiences and personal reflections of different practitioners. Our guest today is Devora Kestel. Devora is a senior global mental health policy expert with more than 25 years of international experience in Europe, the Caribbean and Latin America, implementing and advising governments on national policies related to mental health systems. She’s a strong advocate for the rights of people with mental health issues. She obtained her MSc in psychology from the Universidad Nacional de la Plata in Argentina and her MSc in public health at the London School of Hygiene and Tropical Medicine. After completing her studies, Devora spent 10 years supporting the development and supervision of community based mental health services in Italy. Later in 2000, she joined the WHO as a Mental Health Officer in postwar Kosovo and later on served as WHO Representative in Albania. In both countries, she worked closely with the Ministries of Health to establish comprehensive community based mental health systems. In 2007, Devora joined the Pan American Health Organization, where she first worked as the Mental Health Advisor for the Caribbean countries and then later at the headquarters in Washington DC providing technical cooperation in the mental health field to the entire region of the Americas. In 2015, she became the Unit Chief for Mental Health and Substance Abuse, and since 2019 has been serving as WHO Director of Mental Health and Substance Abuse. Devora, thank you so much for speaking with us today.

Devora: Thank you for inviting me.

Safa: Maybe we can begin by you speaking to us a bit about what were some of the experiences that shaped your interest and your motivation to work in mental health?

Devora: I think that I should begin by telling you that when I was a student of psychology in my country, in the fourth year of the career, I had the possibility to do some practice in a huge psychiatric institution, where at the time there were 3,000 people living and the conditions of that institution and the people was awful. I think that they were not considered altogether human beings, they were considered just like maybe animals, as things to be put aside from the society, people that have lost completely their rights, their basic rights as human beings. Soon after that, still a student, I started to work, to volunteer, going there a couple of days a week and it was very upsetting every time going there because of, again, how they were living. I remember a patient that had been there for 48 years, because at the time he had a severe mental disorder and so his wife sent him there at some point, I don’t know the details, but then she told the kids, two kids, that their father had passed away, and that’s it. He was abandoned completely. And then it was thanks to the work that we were doing, digging in about these people and their lives that we found the kids and the kids were initially shocked but then very pleased to realize that their father was alive and to have a relationship, to get to know him. And he was a very sweet old guy. And so those kinds of situations were shocking for me, and in a way, inspired me to go, after graduating, go to Italy, Trieste, where I had studied in the books they had a very nice mental health reform that had taken place in the early 70s, actually. And so I thought, Okay, I need to see what can be done. You know, I think that was what motivated me. What do I need to do in order to change the reality, in order to make sure that people, no matter what they are suffering from, whatever their illness or the problem they have, are anyway considered as human beings with all their rights respected and recognized. So the big question was, why somebody, because of a mental sufferance, and let me stress the word sufferance, somebody who is suffering from something is being penalized and sent away from society, placed in an institution and forgotten about? And that was the case in my country, but in many, many others, and that was 30 years ago, and it is still now in many other countries. People are penalized because of their mental health. So when I finished my studies as I said in Argentina, then I moved, I went to visit Italy and I stayed gradually, little by little, year by year, because I could see that mental health could be embedded in the health system. And people with mental health conditions, no matter how severe they are, could be perfectly receiving care in the community, in services specifically designed for them or integrated in general services, and they could live a life like you and me. And so that is what brought me to the public health issue. So I moved away from the clinical interest of the individual suffering into the public health perspective of how mental health relates to the system and to the population and their rights and so on and so forth. So it was that that was the engine, and I think that this situation is what brought me, a year and something a go, to the position I’m in today. Always the fight against something that I consider very, very unfair. And that unfortunately, as I just said, is still happening in many parts of the world.

Safa: As you say, it continues to be a perspective that’s dominant in many parts of the world. So in your work, when you’re working with governments or advocating or at the public health policy level, when government partners or other organizations show resistance to changing their perspective, moving away from treating mental health issues in the way that it’s traditionally been treated, what are some of the tools or approaches or arguments that you use or that help you in trying to advocate for a more holistic mental health approach or policymaking?

Devora: The strategies used are many, from trying to explain how people live — I always try to touch the inner feelings of a person, asking if they would send their sister, mother, father, brother, wife, kids, to live in a place like that? Because most of us will not. And so that is one of the first tools put in place. Okay, think about what it really means for somebody to be cut off society and treated in that way. But then beyond that is drafting a number of tools that will help in different ways. Will help explaining, informing policymakers about the alternatives. Because what I found out over time and traveling and interacting with many colleagues from many countries is that in many cases, there is — one Minister once said to me, we have an alphabet of mental health issues, really ignorant about mental health issues at the policymaker level — meaning that there is this stigma that is really part of the society, but also the health system and so a policymaker, whether it is a senior person in the Ministry of Health or in any Parliament or anything, unless they have any personal reason for knowing more, in general one would expect that there is limited knowledge. So, explaining that there are other alternatives, that other countries have managed to develop alternatives to the mental institution, that is embedded in the health system, that are in the community, etc, etc. And why that works and why it is even sometimes more economic than the current situation. So that’s one level, more informative by technically informing, not just saying it but proving what’s available out there. Then we have some other tools that we have developed that are related to increasing capacity of the health personnel because in many cases, in many countries, a physician, for example, and the same is valid for a nurse, they get some basic training in the early years of their studies about mostly not mental health but psychiatry, so the most clinical aspects of recognizing symptoms and putting names to the disease. And that’s it. Immediately, as soon as they graduate, they don’t deal with that anymore. A colleague of mine from Canada used to say that when a physician sees somebody crying, they panic and don’t know what to do and so will immediately refer the person to a psychiatrist or a psychologist, so that is the lack of skills, capacity that most health colleagues have to deal with people affected by any mental health issue. And so you need to train and refresh some of the knowledge that some of them may have received but also translate them into practical issues. What do you need to know in order to provide an answer to the person coming to you with any kind of complaint? And then there are a number of further trainings about human rights and what it means to respect human rights according to the most recent developments, and then we do develop more innovative tools that will facilitate different health professionals from the field of mental health respond to the needs in different ways, whether they are specialists or not. And that’s what we do — and in interacting with policymakers, we bring all that information to show that things are possible in another way. And something else that we do is to also explain something that we recently — ‘we’, as in the world — recently are calling the return on investment, right. And we explain if we invest in mental health how much money they will get back in a number of years, money saved from different issues related to a mental health condition. So, also the economic reasons for investing, because something that I didn’t say is that globally, the average government spending on mental health is 2% of the health budget. So it’s really, really little. I was reading earlier today a document of one country that I’m not naming, a low middle income country, and it is spending 0.37 US dollars per year per capita on mental health. It’s clear that with that, very little can be done. So we advocate with that country, and I have a meeting tomorrow, that is why I was reading, to explain what can be done and how to change with this situation.

Safa: You mentioned this lack of allocating budget to mental health. Do you think that comes from just a country’s prioritization of other problems or other reasons? In some cases, mental health intersects with poverty, or with violence at home, or different issues, what would you say is one of the main situations or contexts in which this lack of spending can be explained?

Devora: In a way, I think that the reason for the lack of investment is a bit of what we’ve been saying before. I mean, traditionally, historically, people with mental health conditions were considered something that will not be recovered, that there was no reason to invest because there was no hope. That is the reason for having the mental institutions, institutions were born to take care of people. Now they are penalizing, but initially, a couple of centuries ago, they were developed to take care of people and so okay, the solution is we put them there, and that’s it and the institutions have degenerated and so the cost of living there is low because of the bad living conditions. And so mental health has not been considered as an illness in the same way that a broken arm is considered a health issue, not an illness, but a health issue. In the same way that a person with diabetes is having a health issue, a person with depression is not. So if society and the health sector do not consider mental health issues as health issues, do not consider them as relevant as other issues, then there will always be other priorities and the poorer the country, the challenges are bigger, right. And so the competing with other priorities is even more obvious, but then the stigma also has a big role to play. Then you need to know that until 60 years ago, there was no treatment for severe mental health issues. And so, then, really, there was little hope. But since then, there are a lot of ways for people to get better. It is like the science evolved but it didn’t make it so clear for everybody else that there is a possibility for recovery. There are some conditions that are tough to get over with, but then there are others that are easier or there are some that if you receive some kind of help soon you recover quite soon, but if not, you will get stuck for years and years to come. So that’s part of the of the reason. Then some of the issues that you mentioned such as poverty, there is also some kind of relationship between poverty and mental health because in countries where there is no easy access to treatment, if you are poor, you won’t be getting the help you need because the health system will not take care of that. So you will need a private practitioner, which you can’t afford. Or again, the stigma may be a bit higher, the priorities may also be different. Nowadays, we know more and that’s the reason why we are talking right now about mental health because there is more and more understanding, better understanding that mental health is important and that there are things that can be done. But still it is a challenge. You hear governments saying yes, mental health is important, but then you find out that the budget they assigned to mental health is 1% of the health budget. So again, pay — I can help you to improve the situation but you need to put more money in it, within your current capacities. Now, a strategy sometimes is if we have a person with any disease, particularly long term chronic diseases, there is a big probability that the person will have a concomitant mental health condition. So if you treat the person for the two conditions at once, there are better chances for the person to be better in both conditions. Then, you need a health practitioner that can take care of that, that has enough competencies to do that. So it’s like a chain. I mean, you need to have a system that works. Why does mental health have to be separated from everything else, I think it is sometimes hard to justify.

Safa: Yes, absolutely. Taking it back to one of your earlier experiences, in your first position with the WHO as a Mental Health Officer in post war Kosovo, could you speak to us about that experience and that setting of working in a postwar environment where perhaps also some of your colleagues, your national colleagues were themselves continuing to process and cope with the after effects or the mental health struggles of living through a wartime experience?

Devora: I was working, setting up policies and trying to develop a system where there was none. And that is something that is important to consider in our current context about how the situation of an emergency could be an opportunity to build something where it previously did not exist, the famous building back better approach. So of course, I interacted with local colleagues and of course, we could discuss about the challenges they have gone through or they were still in the middle of in many cases, but I would say that that was more a personnel interaction. While you were talking, it came to my mind my translator and how she was telling me what she went through, what her family and her neighbourhood and her village went through, and so we would discuss about her situation. Now, what I was doing, from my job perspective, was trying to make sure that everybody like her, having gone through similar or even worse situations, would have a place where their mental health would be taken care of, then and now, even 20 years later. So the concern was not just to see if there was a therapy group for her right now, at the time, there were many post traumatic groups working there and so on. That wasn’t the concern, the concern was, what do we do in order to make sure that whatever is done stays and is sustainable, basically, and so that was a bit what we did and what my job was about. So I interacted with different groups and different partners, and always tried to make sure that I was respectful of what they have gone through and where they were, and where do they want to go. So I think that the attention given to the recent history is similar to the attention I could give to anybody’s situation in a country that I’m visiting to provide technical support.

Safa: The reason I mentioned this is that one of the struggles that some aid workers or development workers, especially those whose most of their career is spent in emergency settings, one of the challenges they face is dealing with the emotional impact of their work. And that’s something that their organizations sometimes provide support for and in some cases, some organizations haven’t provided enough support for. So from the perspective of internal policies, not necessarily policies for the countries that you’re working in, but at an organizational level and the work culture, do you think that over the past 20 or so years, organizations have generally improved their own internal policies about the mental health impact that their work has on their own staff?

Devora: It has improved, definitely, but I don’t think that enough is happening. I mean I think there’s still a way to go. I can talk about probably the UN, I don’t know about some big NGOs that are sometimes exposed on the front lines to these situations you’re talking about, while I work at the policy level and with the Ministry and so on, and visiting the delegates and the health centres, these kind of things. I was recalling a colleague in Kosovo that was working with much tougher situations, let’s leave it there. So definitely the impact was different in this colleague than in me. I think that, for example, a couple of years ago, the UN Secretary General launched a mental health policy for the UN that is being developed, implemented gradually, in order to precisely strengthen the support that the staff receive from the mental health perspective. I think again, there is a long way to go but there is more attention definitely than what it used to be. Sometimes, even in the middle of emergencies, I have in some countries or contexts said to my own colleagues to take a break, go home or have talked to their bosses to say let people have breaks and maintain a routine that is healthy etc, things that we are saying also nowadays but sometimes it’s very challenging to do. I recall somebody from a Ministry of Health in the Caribbean saying to me, but I can’t because I don’t have the staff to replace them. I can’t do more than this. And the person saying that was a very senior person in the Ministry who was himself sleeping in the Ministry of Health because his house was destroyed by the emergency situation. Sometimes it’s very hard and so what can you do to react as soon as possible? We are doing better but no, not yet as much as we should be. If some issues cannot be avoided, for example if you don’t have personnel to properly rotate your staff, well, what do you need to put in place immediately after? Or how can you compensate? Right? These are the things that we are trying to promote in the context of emergency but not only, because, as you know, in many organizations, the working environments, even if it’s not in an emergency may be challenging.

Safa: Yes, absolutely. As your career progressed, and you began to take on positions of leadership, for example, as the Representative of WHO in Albania or later on when you were working with the Pan American Health Organization, what did you find that in a more senior level, in a position of leadership, were the unique challenges that you faced in terms of leading teams, working on issues that you’re passionate about, but perhaps there were setbacks or maybe sometimes something was not handled well, or perhaps having a project or initiative or a policy effort that in the end, perhaps it had a negative impact or it didn’t turn out the way you had imagined — in those situations, what have you found to be approaches or lessons that you’ve taken away from that, that have helped you continue the work and continue to persevere?

Devora: The argument that I gave you initially at the beginning of the conversation about why I’m doing the job I’m doing is what keeps me pushing ahead, no matter the setbacks. A couple of issues came to mind when you were talking. I used to love to work with people directly but I let that go because I moved into a more public health perspective. And then I used to love working at the country level and then I let that go because I moved into more senior positions that are sometimes more distant from where things really happen. So sometimes the challenge is to remember that what you are doing, even if it’s far away from where things happen, is contributing, what you do contributes to the things happening at country level. So if you do your job well, then there are maybe more possibilities for something else to happen at country level. And so at the end of the day in my case, more people will get the care they deserve. That’s the end of the equation for me. So I think that remembering that helps. One of the challenges that you have to face when you work in big organizations is the bureaucracy and the time that is taken to fulfill the needs of the organization, and not necessarily the scope of the work you do. And that is unfortunately part of it, a natural part of it. Because we are accountable for what we do. So we have to fulfill a number of requests and fill a number of forms and documents and reports and plans and endless demands and requests, but it’s kind of unavoidable if you want to to do more of what you do. So paradoxically, if I want to have a very quiet life, I rather not have mental health relevance to anybody, so I won’t get funding to do anything, so I can write a report once a year or a paper once every whatever number of months and that’s it. Now if I want to change things, I need the resources to have staff that will be able to help countries to move ahead or will be able to develop tools that will help countries again, etc. Then in order to do that, I need money and if I need money, I need to write proposals, I need to justify, I need to add you, I need to make sure that others see how relevant what I do is, etc, etc. All that will require more time and effort. That’s a bit the challenge or the — well, it is not really setbacks but it is a bit of the less pleasant parts of the job. But at the end of the day again, Okay, but if I do this, then more people will get help. And that’s also the satisfaction because another issue of the work when you get a bit far away from where things happen is that you risk to lose track of what’s happening. Or in a way you learn to understand that if nothing is necessarily happening in the immediate moment that you do something, that doesn’t mean that things will not change. When you look from a distant point of view, you then realize that things have changed and that has been also thanks to the work you did. And sometimes others help you in realizing that and that’s where you find the satisfaction and the motivation to move ahead. There is no immediate result of what you do, what you will get. If I meet you, you are a donor, I write the proposal, you give me money, that’s quite immediate, great, nice. But in most case, it is not like that, it is the regular work, the daily or weekly or monthly efforts that will lead into some change that will happen maybe in a couple of years or so. So that’s another perspective that one needs to take to avoid being frustrated and disappointed, but also to learn how to invest better your time, effort, and capacity.

Safa: You earlier spoke about the difference of working at the national level versus the regional level. So I wanted to ask you about what have been your experiences with trying to establish or promote partnerships at a regional level? You were with the Pan American Health Organization, so when countries in a region are trying to work together, different governments, different partners, in that kind of setting, especially related to investing into mental health issues or working together on policy changes to that effect, what have been some of your experiences? What are maybe some of the issues that come up when different countries with different priorities are trying to work together, but at the same time, they do still have their own national agenda or interests or their own restrictions going into these partnerships?

Devora: You know, I’m a firm believer that we all always have something to learn from the other, right. And so the same happens for countries but it is not automatic. It is not that everybody can work with everybody else. But there are many more commonalities than what one can see at first sight. So countries, for example that are prioritizing suicide prevention — we talk about the region, you go from your country, Canada, to my country, Argentina, north and south and we go across all the region and we can pick up countries interested in advancing that area of work from every background, level of the economic development, language and whatever else. So, in every group of countries in the region, you will have a few countries that will be interested in advancing that because it is a priority for them. And then it is up to us (PHO/WHO) to generate the opportunity for those countries to talk to each other and find out what can they learn from each other? Or how can they benefit from being together. And this has happened a number of times. In some cases, we have one of the countries, a developed country maybe having a role of advisor to others that are now going through something that this country had years ago. But if you look at Canada, if you look at the US, or if you look at some of the smaller countries in the region of the Americas that are better off, the more high income countries, name me one that has solved the entire mental health problems in the country? If you think about it, you won’t be able to name any, because there are challenges in all these countries, no matter the level of development and there are population groups that are in developing settings and with challenges similar to those of some developing countries, and you can find, I am not going to name any, but you can find areas in any country of the region. So that’s why maybe some countries could have an interest to interact with other developing countries, because there is always something that they can learn and they can get from the experience that they are having. And so I find it fascinating to actually promote, exchange or generate common areas of interest or the network within countries and among countries. I think it is very, very interesting and people enjoy it. That’s why there are so many networks that are more or less regional or global or a group of countries. I mean, because there is an interest in learning from others and in sharing and contributing to others. I think that one of my first experiences in international cooperation was when I was living in Italy. I had some brief consultancies back and forth to another country, before Kosovo, and I was impressed by how nice it was for me to be able to contribute to somebody else. So it wasn’t just one way, because I would go to that country and offer what I learned and I was so fascinated with that possibility. But then I would come back and would bring to my working reality, a lot of learnings from the place I was visiting. And so this experience, I’m sure is also common to many, many colleagues that do not work in international cooperation but whenever there is the opportunity to talk about what’s happening elsewhere, to visit a reality, they can come back and think about their own reality with a different perspective and this is enriching for everyone.

Safa: I also want to touch on the other aspect of the mental health field that you also work on, which is substance abuse or addiction issues. When it comes to addressing those challenges, do you feel or have you experienced that the political will from governments or the objections from partners is more when you address specifically substance abuse issues just because of the more political connotation around it?

Devora: If I were talking about the stigma about mental health, when we move to substances, I think the stigma is even bigger. The blaming a person because of having issues with alcohol or with substance use is pretty normal. You drink, stop drinking, you do drugs, stop doing it, if you have any health issue because of that it’s your fault because you are using that, stop using it. As if it is all a matter of decision, right? So the stigma is higher. In both cases, the cultural issues regarding alcohol in particular play a role and in many cases are justifying the lack of policies. So we won’t be able to change this because it’s a cultural issue. And so that means that no matter how bad alcohol could be for health, all that is ignored because it’s a cultural issue. And I’m sure that in many equivalent issues, you will not accept lack of policies because of cultural issues if they are damaging your health. And then the other issue that is very clear, particularly again with alcohol but also on some of the drugs issues is that there is private interest. There is a big lobby campaign against limiting alcohol consumption. And so there is a clear pressure and a clear policy from the private sector to influence policymakers to avoid issuing policies that will limit alcohol consumption. And this is clear and no matter how positive the impact of some policies are, at country level, like limiting the age of access to alcohol or other policies that are considered best advice to limit alcohol consumption, no matter the evidence I was saying, still the policies are not in place because of, in many cases, the pressure of alcohol lobbying that they don’t want to have policies similar to tobacco, etc. So, yeah, I think that it is more challenging to move in that field than in mental health in general.

Safa: Mm hmm. I see. Have you also been part of initiatives where indigenous healing practices or cultural based healing practices that have been around in a country for many, many years — have you been part of efforts to include those within the treatment offered by public health systems or advocate for those being seen as important or being part of the discussion around resources or approaches that a public health system incorporates?

Devora: What we have been trying to do is to promote the exchange of knowledge among communities, within countries and among countries. We have some meetings organized with indigenous communities from 12 different countries, for example, to promote exchange on specific topics of interest. And so not every traditional practice will be equally considered as a real healing practice because in some cases there are practices that harm more than facilitate because they are restricting movement or issues like that, but in most of the cases, actually what you want is try to promote precisely what people recognize as culturally important and so if there is a trust already given to say a traditional healer, for example, that is very important. So a dialogue between the different communities and the different knowledge and also including the so called occidental medicine and the traditional communities, I think is important in order to learn from each other and to understand what each can contribute to make things better. In many countries, there is also a considerable development of mental health practitioners within indigenous community members, which makes it even more interesting because then they have — in some cases no, they absorb the new knowledge and they don’t connect with cultural roots — but in many other cases, they do and so you have the opportunity of a perfect bridge, I would say, between traditional medicine and the traditional culture and the occidental one that sometimes is needed because they can really complement each other. And so, I find it fascinating sitting at a meeting and listening for hours to the representatives from the community, the way they explain how things are, moving your beliefs that have been consolidated for many years, and you put yourself in another position and try to realize that things may not always be as you think they are or they were. So it is very interesting. Sometimes is not easy. It requires, like everything I think, the interest, the commitment, the willingness to open up and to allow others to say their way of seeing and doing and again learning from each other.

Safa: Mm hmm. On the other side of the spectrum, have you also had to navigate or have you experienced maybe the influence or the lobby of the pharmaceutical industry and their interest in trying to also shape public policy? Or is that something that you haven’t dealt with directly in your own work?

Devora: I would say that I am lucky that my organization is not allowing me to interact much with those in the private sector whom we may have conflict of interest with. We share a few meetings here and there but regularly I do not interact with them. I have a lot to do in my job and a lot of competing priorities and not a lot of capacity in terms of staff and so on so I can’t afford to dedicate my time to things that are not my priority and the pharmaceutical industry is not my priority.

Safa: Sine 2019 when you became the Director of Mental Health and Substance Abuse at WHO, in that role, what have been some of your priorities as you say, or some of the key policies or programmes that you’ve really been trying to champion?

Devora: I arrived with some concerns and some interests and to see how I could reshape them. And one was that I was lucky enough that the prior year to my arrival, our then newly appointed Director General said that mental health was a priority for his mandate. And so I had the opportunity to shape that — as a priority, what does it mean for WHO and what is the priority for us. So I could focus on what I thought was important and in making sure that whatever WHO does or says is for countries to use, for countries that need it of course, who need WHO saying or doing something. And so if we come up with the best technical guidelines, if countries do not know them or do not know what to do with them because they don’t have the capacity to look at them and translate them technically into their reality and make use of them, then for me, they are useless guidelines. I think there are many other networks and universities that could develop science. My effort has been in directing our efforts for the direct benefit of countries and in order to get there you need to also strengthen capacities at country level, to see how to promote leadership. You were earlier mentioning leadership and we didn’t go down that path but it is something that is also very important in the field of mental health, whenever there is no leadership, it is very hard to move the agenda forward. So how do you contribute to promote that leadership? That is one of the directions that we are taking, making sure that whatever we do is for use of countries but also to make sure that the services at country level change. Because as long as 70% of the budget goes to mental institutions, then we won’t get anywhere. Then mental health is not going to be integrated into the health care system because it is going to be like what I was saying at the beginning. Isolated, segregated, something that is not a part of the health care system. We need mental health integrated with other health issues, with primary care. We need it with HIV, we need it with non communicable diseases, with pregnant women, with a child, an adolescent, everybody has to have a view, a perspective, an understanding of what they can do to improve the mental health of a person. And the other issue that I am taking into consideration and emphasizing is that there is this tendency in most international organizations that the work is for and with the english speaking countries and people, colleagues, scientists. And it is very difficult to have a real global representation on everything we do, as we should be. There is formally always global representation but I didn’t feel it was strong enough. Because I felt it over the years when I was located elsewhere, all the technical documents and you read, the list of those involved in the meetings, you contact Ministries of Health from a number of countries that are not english speaking countries and you say we are inviting you to come to a meeting but by the way the person should speak english. It is almost offensive because the country does not have english as an official language, for example. So why do you expect somebody to be there — because there is no translator everywhere, because it is expensive, because we don’t have money — there are always good reasons behind it, but I thought we needed to make an effort to be a bit more inclusive. Because unless, from the very beginning, we involve the countries that are struggling with it more, we won’t be able to provide answers that are meaningful for them. We keep using colleagues from the UK, the US, Canada, Australia — that is great but I don’t think they know what happens in the rest of the world, even if they are individuals who are great and have been travelling and working in many countries, it is not the same as having those people from the countries you want to work with. So that is another area that I prioritize and that means also within my my team and the partners we work with and so on and so forth. So I could say those are some of the key issues that I am focusing on since I became Director. You know, when I joined WHO in Kosovo, I was a consultant. So I entered with the lowest possible contractual modality and I spent my career moving from different contexts, one to the other, just by doing my job. So in a way I feel that I can do what I think needs to be done because I was not appointment because of my political nothing or country or anything like that. Just based on the work that I have done over the last 20 or more years. So I feel that I have won the right to do what I think needs to be done by this organization.

Safa: Absolutely. That is wonderful to hear. As a final question to wrap up our conversation, now we are living in the time of the coronavirus pandemic and some people are saying that a shadow pandemic that is emerging from this period of physical distancing is a mental health pandemic or a mental health crisis. Do you agree with that statement or do you have particular thoughts on the mental health challenges that are emerging from the global coronavirus pandemic and what would you say are the opportunities, as you say, in a kind of emergency context, to build back better or to address this?

Devora: I do think that this is right, that the mental health impact that COVID is having is significant right now and it will be in the near future. The reasons are related to what we already know — the fear, the anxiety, those dying around us, the risk of being sick, the reality of having lost somebody, the challenges of working from home, the challenges of having the kids at home, the loss of employment, the increased risk of domestic violence against women and children at home — all of that, all the stress related to many of these issues, regarding isolation, etc, all of that is having an impact in our mental health. In some cases it will go away as soon as we get back to normal, whatever normal will be, and others we will have to struggle with for a while. What we know from emergency situations in previous experiences with countries in conflict is that 1 in 5 persons will develop a mental health condition in a context of emergency, so if that applies to the current situation than really the numbers are huge, are significant. But there is a lot of talking about mental health so we are hopefull that there is going to be more attention right now, not in the future. The same efforts that we were discussing earlier about the need to transform mental institutions into community services now is more important than ever because you won’t be able to provide an answer to those who need it from an institution, it has to be in the community, integrated with other issues. So there is an opportunity there and, again, as mentioned earlier, the building back better. We hope that then we can come out of this experience with stronger mental health systems everywhere, with services that provide the answer to the different levels of needs that people will have so that they avoid issues to develop, we prevent some consequences of those mental health challenges. We could do better if we take action right now. So that is what we are proposing. What can be we do now to improve the situation that people are going through in the present time but also in the future?

Safa: Absolutely. Also very relevant to what everyone is going through not only on an individual level but also at a national level these days and these weeks. Devora, thank you so much for speaking with us today.

Devora: Thank you for giving me the opportunity to think loudly about some of these issues that are always interesting to spend some time talking about, so thank you very much.

Safa: It has been a pleasure to learn from you and we really appreciate it. Thank you so much. I also want to thank our listeners. To keep up with our latest episodes you can listen to us on your preferred podcast provider and follow us on our social media platforms and join in on the conversation. If you have any listener questions that you would like me to ask our future guests, please feel free to email them to us. I look forward to continuing similar conversations with you all next time. Until then, take care.