Project 1 billion: health ministers of post-conflict Nations Act on Mental Health recovery.

It is estimated that more than one billion persons in nearly every region in the world have been affected by mass violence, embodied in the experience of war, ethnic conflict, torture and terrorism. Conflict has led to the forced displacement of approximately 50 million persons, accounting for the homelessness of 1 out of every 200 worldwide (see UN Chronicle No. 2, 2002, on Refugees and Mental Health) Recent statistics from the World Health Organization (WHO) reveal that 450 million persons suffer from some form of mental or brain disorder, including alcohol and substance abuse; this means that one in four families has at least one member who is affected. It is estimated that 121 million suffer from depression. Projections for the future, emerging from the Global Burden of Disease Study (Murray et al. 2001), reveal the growing toll of mental illness, with the rate of mental and brain disorders expected to rise by 15 per cent between 1990 and 2020. The Study did not include many post-conflict nations; it has been estimated that their inclusion would result in statistical findings two to four times greater than those mentioned above.

International relief and development organizations, public health experts and academics in recent years have increasingly acknowledged the severe mental health impact of mass violence and displacement on individuals, including refugees and internally displaced persons. Their growing interest since the 1990s is largely attributed to the increasing body of scientific evidence pointing to the impact of trauma, psychological distress and mental disorders on populations worldwide. These once so-called "invisible wounds" (Mollica R.F., Invisible, Wounds, Scientific American 2000) are now the focus of operational programming of organizations hoping to address mental health needs in conflict-affected regions.

Despite increasing knowledge of science-based interventions and culturally effective programmes, the current approach to meeting the mental health needs of war-affected individuals and their societies is inadequate Within most post-conflict countries, mental health policy is essentially non-existent Moreover, there is no global and collaborative approach to the mental health and physical healing of traumatized groups Current approaches in many cases fail to include important members of the healing system within the society. Furthermore, individuals from these communities have remained consistently absent from leadership positions in the international mental health movement, and therefore their expertise and views have been pushed to the background of debates in which major participants are more likely representatives from international and nongovernmental organizations (NGOs).

The current approach must be modified in light of several factors: the growing evidence of effective approaches to healing; the likelihood that interventions can positively impact an individual's socio-cultural and economic development and perhaps facilitate the reconciliation process; and the importance of including local experts in the design and delivery of mental health services. First, research has demonstrated the capacity of local primary health care systems, traditional healers, and national and international NGOs to play a major role in reducing the suffering and disability associated with mass violence. Second, studies and interventions have also revealed the very powerful possibility of creating the proper environment for addressing other key aspects of the entire recovery process, including socio-cultural and economic development, and reconciliation within conflict-affected societies Third, experience has demonstrated that limiting the inclusion of experts from the conflict-affected countries themselves precludes valuable guidance while also limiting necessary buy-in, commitment and collaboration, each of which are cornerstones of effective and sustainable service design and delivery. It is on the basis of existing scientific knowledge and the belief that policy makers within countries themselves must intimately be involved in the development of solutions that the Harvard Program in Refugee Trauma (HPRT), with the support of the Fulbright New Century Scholar Program and Istituto Superiore Sanita and Istituto Studi Superiori Assunzione of Italy, is undertaking "Project 1 Billion".

In November 2004, for the first time in history, over fifty ministers of health from post-conflict countries will assemble to endorse an evidence-based, scientific mental health action plan for the mental health recovery of those affected by mass violence The idea and importance of undertaking such an historic initiative was an outgrowth of a meeting held in Sarajevo in September 2002, hosted by HPRT, the Fulbright Foundation and the Ministries of Health of Bosnia and Herzegovina, and attended by ministry officials from numerous post-conflict countries, including Cambodia, Indonesia, Peru, Rwanda and Uganda, as well as scholars, scientists, international policy makers and representatives from WHO, the World Bank, the UN Children's Fund, The Vatican and the Ministries of Foreign Affairs of the United States, Japan and Italy, All participants sealed a commitment to the historic mission of creating a global scientific mental health action plan, unique in its development, scope and adoption.

The framework above illustrates the quintessential elements of the recovery process within the post-conflict context, incorporating a number of key features of the proposed action plan to be developed and adopted within Project 1 Billion. To date, there has been no mental health recovery approach that addresses adequately each of these, thus jeopardizing most collaborative efforts in this field.

Any recovery action plan must not only be founded on sound evidence-based knowledge of psychological distress and mental illness, as well as best practices in providing effective services, but must also ensure that the available knowledge and practices are integrated into a multi-dimensional approach. This includes sustainable funding, mental health policy and legislation, mental health capacity-building through multidisciplinary education, and integrated activities of all international and local key stakeholders. Finally, any action plan must be based on ensuring economic development and respect for human rights within the post-conflict context. This context is characterized by limitations within these realms; yet, without steps to ensure that these economic opportunities for individuals are given significant attention and that human rights are respected within this phase, a full recovery will continue to remain elusive.

Further, the action plan will ensure sustainability and sensitivity to the realities of the post-conflict setting by including experts from countries that are most familiar with the context in which it will be implemented, its design, development and ultimately, its adoption, This makes certain that all areas are addressed, in cooperation with the country's social, political and financial realities.

Our history has been plagued with widespread violence throughout the world. Ministers of health, who have been responsible for healing the suffering of their traumatized citizens, have been unable to provide adequate mental health care for their societies due to a lack of knowledge of effective skills and practices, and the reluctance of international donors and Governments to invest in approaches without demonstrable outcomes and cost-effectiveness. Project 1 Billion will contribute a remedy to this situation--no longer can the psychological damage inflicted upon civilians be ignored by the international community in the social and economic recovery of conflict and post-conflict societies.

For more information, see www.hprt-cambridge.org

Richard F. Mollica is the Director of the Harvard Program in Refugee Trauma (HPRT) at Massachusetts General Hospital and professor of psychiatry at Harvard Medical School.

Laura McDonald is a research associate at HPRT.