Mental Health Inequality, and Disparity, in an Unequal World

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In this podcast, we are joined by Consultant Child and Adolescent Psychiatrist Dr. Aisha Sanober Chachar, who is co-founder and Director of Synapse, Pakistan Neuroscience Institute. Aisha has a special interest in transcultural child and adolescent psychiatry.

Having worked as a clinician in Pakistan, and having had her clinical rotations as a trainee in Nigeria and the UK, Aisha sets the scene by talking us through her journey from academia, to not-for-profit, to mental health entrepreneurship.

Aisha provides insight into the global dearth in CAMH specialists, deficits in health training around the world, the impact that COVID has had in terms of global child mental health inequality; and how do these health disparities affect children and families.

Aisha talks us through, in her view, the difference between adult and child mental health in an unequal world, and how we can foster a more global approach to address disparities and inequalities within child and adolescent mental health.

Furthermore, Aisha also discusses what child and adolescent mental health professionals can do to highlight or alleviate health inequalities; as well as what parents, schools, and other stakeholders can do too.

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Listen notes, Radio Public, and (not available in the EU).

Dr. Aisha Sanober Chachar
Dr. Aisha Sanober Chachar

MBBS, FCPS (Psychiatry), Clinical Fellowship, Child & Adolescent Psychiatry (Aga Khan University)

Balint Group Co-Leader since 2016, CommonPurpose South Asia Leadership Program Alumna 2017, Fellow of Helmut Remschmidt Research Seminar 2019, ACAMH Award winner for Clinical Trainee of the Year 2020

Dr. Chachar is a former Medical Director, Alleviate Addiction Suffering (AAS) Trust & AAS Recovery Center, Pakistan. She serves as a peer reviewer for national and international academic journals, has authored several academic papers and book chapters. Additionally, Dr. Chachar is a core member of Pakistan’s Balint Strategy Working Group. She is a member of the World Psychiatry Association Early Career Psychiatrist Committee, IACAPAP Early Career Psychiatrist Task Force, UK Balint Society, and an International Member of AACAP. She is on the Advisory Panel of the International Network of Psychoanalytic Practices.


[00:00:30.490] – Jo Carlowe: Hello, welcome to the In-Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. I have with me Consultant Child and Adolescent Psychiatrist Dr. Aisha Sanober Chachar, who is co-founder and Director of Synapse, Pakistan Neuroscience Institute. She is also the former Medical Director of Alleviate Addiction Suffering Trust, based in Karachi and Lahore, and she has a special interest in transcultural child and adolescent psychiatry.

[00:01:04.240] If you’re a fan of our In Conversation series, please subscribe on iTunes or your preferred streaming platform. Let us know how we deal with a rating or review, and do share with friends and colleagues. Aisha, welcome. We last spoke in 2020 when you won the ACAMH Clinical Trainee of the Year award. Can you tell us a little more about who you are and what you do?

[00:01:25.300] – Dr. Aisha Sanober Chachar: Thank you, Jo for inviting me yet again, and it’s certainly great to speak to you again. So as you mentioned, I am consultant and also co-founder and Director of Synapse Pakistan Neuroscience Institute. I have special interest in developing services that are more like outcome based and culturally contextualised for ADHD across the lifespan, and also I’m co-leader for Balint Groups.

[00:01:52.530] – Jo Carlowe: Great, thank you. Aisha, you have worked as a clinician in Pakistan and have had your clinical rotations as a trainee in Nigeria and the UK. Can you tell us about your journey from academia, to not-for-profit, to mental health entrepreneurship?

[00:02:10.630] – Dr. Aisha Sanober Chachar: I have been blessed to have such a diverse [inaudible], not only in terms of the training, but also having worked all across the world and it also exposes you to different health care systems and how different processes and systems work, especially when it comes to child and adolescent mental health, because it’s not that we work with, it’s really the entire community that we engage in any intervention. So academia, it has its own perks and at times challenges, but I’ve certainly very much enjoyed the academic work, which is why I might not be affiliated with academia anymore but the academic work is something that I have been able to carry forward, despite being Medical Director at non for profit and even now, like getting involved with entrepreneurship. The setting, it shouldn’t be a barrier for what we want to do, what we want to achieve.

[00:03:04.660] – Jo Carlowe: In a blog for ACAMH last year, and in an earlier podcast interview that we did, you highlighted the global dearth in CAMH specialists. Deficits in health training around the globe. Can you elaborate on this? What is the situation now as you see it?

[00:03:20.920] – Dr. Aisha Sanober Chachar: Unfortunately, I would say that the situation has not changed a lot. In fact, if nothing else the Covid-19 dynamic has just worsened the situation, I would say. Yes, there is a silver lining that now a lot of organisations are talking about mental health overall, but still I would say, especially when we talk about children, there’s a long way to go and even in our clinics what we see is just tip off an iceberg. It’s very like selective and a very, very small cohort that we tend to see in our clinical services in practise.

[00:03:53.660] How do I get to this conclusion, because again, I spoke about how there are very limited number of child and adolescent mental health experts globally, and when I talk about Pakistan there are less than ten child and adolescent psychiatrists, and globally speaking if we again look at numbers, there are more than 2.2 billion children around the world and there are a lot of lack of resources. Even if we extrapolate the number, 15 to 20% of children are actually having some kind of mental health problem, if it’s not like disorder. So that is a huge number and the number of experts are still not rising.

[00:04:37.650] So that is concerning and especially in one year we have seen how these problems are due to online schooling, to like [inaudible] and all those things that is getting really, really difficult even for experts.

[00:04:57.320] – Jo Carlowe: Aisha, can you say more about the impact that Covid has had in terms of global child mental health inequality?

[00:05:04.990] – Dr. Aisha Sanober Chachar: Well, this entire pandemic has really exposed what the conditions were, like pre-existing conditions were, and it has exposed it at many, many levels, not just at clinical numbers or patient overload. So there is a lot of conversation around education system. A lot of people are now questioning whether the typical education system is the right thing. We see people, parents working from home. So now, if that is a possibility, is it something that can be done when the pandemic over?

[00:05:36.160] So these, all of these things and all of these confabulation has started, but mental health burden disease things have compounded the effect on children. So for children, social and physical sort of connection and social activities are very important. So those have been taken away. Social isolation. There’s contact restrictions and there is home schooling, online schooling, and then that is also something very important for us to think about, given that we’re talking about mental health and unequal world.

[00:06:13.080] So now if I talk about Pakistan, it’s so common to hear that now children have to attend classes from home. So that means, for example, if there are three kids, so they have to have three gadgets, right, three laptops, three tablets and what about the Internet? If parents are working from home that means five. So all of those things are actually impacting in a way. That is something that we perhaps might not be able to look at or measure right away, but certainly in a decade or so we will be looking at that would have impact. I really can’t say positive or negative, but different.

[00:06:53.170] – Jo Carlowe: What about other health disparities? How do these disparities affect children and families and what stands out for you from your clinical work and role as a clinician scientist?

[00:07:04.780] – Dr. Aisha Sanober Chachar: I think it’s important what we’re talking about these terms, disparities or health, health inequalities. This is something that we have to know as health care professionals. It’s not something only for policymakers to know. This is something that we need to know. So when we’re talking about disparity in the context of child and adolescent mental health disparity is actually the difference between various groups of population and health care services. Right, within a country, depending upon where the child is, would drive how much of the resources a person can [inaudible].

[00:07:42.410] So, yes, there is health disparity, health disparity significant in terms of the numbers. We can’t even reach to a point where we can cater to services for every child. The mental health inequity that is one step further. We have to find out what are the causes, like what is causing these disparities and that would actually help us understand how because health equity is important and unfortunately we’re not able to address and there are various reasons for this.

[00:08:13.490] It’s because if we talk about child and adolescent mental health, so children are less likely to use whatever mental health services are there, and it is all like research based from the time a child or a teenager experiences the first sign or symptom of a mental health disorder and to the time they seek help is huge as compared to adult population.

[00:08:39.260] Right and now there’s like certain factors that affect this. So mental health services are not child friendly. There is a lot of stigma, and stigma is something that is across the world. I wouldn’t just say it’s between [inaudible] developed countries versus developing countries. So there is like attitude of family and society and literacy. I think it’s important that we talk, not just mental health awareness now, it’s time that we talk about mental health literacy. It has started to happen, but a long, long way to go.

[00:09:10.190] – Jo Carlowe: Aisha, from your explorations, in your view, how is the situation for children? Is it getting better or worse and is there a difference between adult mental health and child mental health in an unequal world?

[00:09:24.250] – Dr. Aisha Sanober Chachar: Yes. So something that I’ve often talked about and this is something I truly believe in and I extensively read upon. So children are living in an unequal world regardless of Covid or no Covid, and we’re talking about that. It’s really about how important do we think children are in our society? There is this idea of two parallel, let’s say areas where privileged versus unprivileged population, but that’s not the case. It’s a very nuanced way of looking at things. For example, two children are going to the same school, but really the parental, let’s say attitude, the family background, culture, values, socioeconomic status, and two children again going to same schools could have very, very difficult and different implications. In terms of inequality,

[00:10:22.510] We don’t have original way of looking into things. So when we talk about mental health services, we know that services are not existing but when we talk about other health related services for children that have gotten been impacted, like they can’t access. So many children are not now vaccinated because of this. So this is again Covid came and created so many of anxieties that adults started combating that and children they were not given the priority, despite the fact that it was a disaster for everyone.

[00:10:58.380] So children who already are living in an unequal world, this was more pronounced for them now because the focus was completely shifted. It was after we got our heads together and after a couple of months the child mental health was then talked about, and even before Covid, like the way the pattern or the trends of the child mental health services which we if explore those Jo, like when we talk about funding, mental health gets the least of the funding, right. Child and adolescent mental health, if we talk about adult versus child, child and adolescent mental health services would get like 0.1% of the funding, right? So if we talk about research, you would find plenty of research in terms of general mental health and psychiatry services, but when it comes to child and adolescent mental health, the research is not there, that drives the treatment, guidelines and recommendations.

[00:12:01.930] – Jo Carlowe: Aisha, how can we foster a more global approach to address these disparities and inequalities in the area of child and adolescent mental health?

[00:12:10.850] – Dr. Aisha Sanober Chachar: So I think it’s important for again to all of us to reflect. So everyone who comes in contact with the child, be it a health professional, be it a paediatrician, be it a school teacher. I think it’s important for us to understand how each step we take is going to impact the generations to come now. So having that sense of urgency for everyone who comes in contact with the child. So once we foster that, we have to see that we can’t work in silos. Multidisciplinary approach is something that we use this word in clinical services, but forming that village, having that village is important and the pandemic has now definitely made… We haven’t used it for so long, like global village.

[00:13:01.260] The pandemic has actually modelled it for us. So this is the opportunity that we can use in terms of child and adolescent mental health professionals. That there are so many things that we don’t need to reinvent the wheel for. The fraternity, Jo, of child and adolescent mental health international, globally, we like to collaborate, we like to sort of like you know. So I think in that way I’m blessed to be part of such a community who are always there to support.

[00:13:31.400] So, for example, I’m part of now IACAPAP early career and the whole idea is to sort of like how to engage trainees. How to engage medical students and psychology students because it’s really not about clinical clinician. It’s really as I said, whoever comes in contact. So fostering those relationships and those sort of like connections globally I think it’s very important.

[00:13:58.660] – Jo Carlowe: Turning to professionals in child and adolescent mental health, is there something that they can do to highlight or alleviate health inequalities?

[00:14:07.940] – Dr. Aisha Sanober Chachar: The first and most important point is here to understand, what are these terms? It’s so easy for us to sort of use these terms. Right and it has to be done at every level, and I personally believe when it comes to children, any child and adolescent mental health professional they have to know. I think given the shortage and given the global disease burden, it’s now mandatory for us to use these concepts. So familiarising yourself with what is a very public health domain, but that’s what child psychiatry partly does.

[00:14:46.260] So getting to know more and more about these health indicators or social factors, sociocultural factors. Educating oneself, I think, is the first step, because we can’t just shy away from these things could be very overwhelming, especially if I talk about a clinician. I went to a medical school in Pakistan, right. So, yes, there was community management. I can tell out of ten to 15 people were really interested in that subject because it wasn’t very doctor-like. So I think it’s important for us to now see and if once we understand this, we know what we are talking about. The beauty of this is, Jo, that you then try to understand things, even in your clinic.

[00:15:34.330] So I think it’s important for us to understand and then the implications of it at every level.

[00:15:40.100] – Jo Carlowe: What about parents, schools, other stakeholders? What’s your message to them?

[00:15:46.130] – Dr. Aisha Sanober Chachar: Everyone who comes in contact with a child has a certain role to play. I recently wrote this paper on how the developmental understanding of death and grief and the model that I’ve used is actually focusing on how it’s not something that is only to be talked about in clinic spaces. Everyone has to play their role. So talking to children like doctors. Yes doctors are there, but it’s a family, like parents, the home environment. So when we’re talking about children, it really is about whoever comes in contact with the child has an important role to play. When we talk about schools, I think nowadays, in recent past, people have started talking about school mental health programmes.

[00:16:40.280] The parenting is something again that is very, very important. The thing with parenting is that people believe that it’s something that you just know. I’m not saying that there must be a sort of like written manual. It has to be. There are some principles, I think that is something that can be sort of adapted to, but make your own manual, and one of the things that I’ve recently observed is that there’s a lot of parenting practices bashing. So now we see parents who are traumatised by how they are playing from all walks of life.

[00:17:23.200] As I mentioned before, mental health awareness is important, but mental health literacy is also important. So we just keep on talking about this mental health, mental health, but what are we talking about? So this could also be like if not tackled or will be used against which is something that I’m seeing. So everyone has a role. Media has its own role. That what information are they going? Is it child friendly? Is it developmentally appropriate the way we are sort of like bombarding news?

[00:17:59.350] – Jo Carlowe: So it’s a very broad picture. That’s really helpful. Aisha, is there anything else in the pipeline that you would like to mention?

[00:18:06.610] – Dr. Aisha Sanober Chachar: Yeah. So I think it’s important to build those connections, and the problem that I see is that we are first trained to know what is a disease in medical school. So we know what is disease. We know what is disorder, but disease is absence of ease. Right. So what is health and what determines health? That is one thing that we tend to learn later in our profession. I had that mind-set right from the beginning. Though it’s changing, but not everything. So it’s important for us to now see that what is our role as professionals beyond our clinical space, and when you are doing those things are we feeling not clinical or clinician-like enough?

[00:19:02.820] Because that is the one thing that actually stops a lot of people from doing things in this domain, that they think that this is not my area or this is not my sort of, like, expertise. Identifying your own professional clinical role in all life I think is important.

[00:19:23.230] – Jo Carlowe: It’s a really interesting point. Finally, Aisha, do you have a takeaway message for those listening to our conversation?

[00:19:30.680] – Dr. Aisha Sanober Chachar: Yeah, I think it’s important to reflect that. How do we see this world in terms of opportunities for children? Do we see them? This is this very interesting concept of childism. So when I first heard about this concept childism, I was like, oh my God, like one more ism, but when I read about it I figured out that that is true. So there are conversations in their absence, and then each time they are going to impact their lives and each time a child wants to know or ask a question they are told that this is an adult talk, you’re not part of it. Right, and there are various examples, for example, death of grandparents, parents. Right.

[00:20:23.120] So a change of school. All of these things are directly impacting children, but are we asking them what they want? Are they part of the conversation that we are having? What is the representation, youth representation in what we are doing? A lot of people do claim that, but are we really saying the idea of nothing about me without me? Yeah. I think involving children and having age-appropriate development, appropriate conversations and engaging them in decisions is important because children they understand and they are the ones who are going to have the implication of whatever we are doing today.

[00:21:05.370] – Jo Carlowe: Aisha, that’s a great place to end. Thank you ever so much. For more details on Dr. Aisha Sanober Chachar please visit the ACAMH website and Twitter at @acamh. ACAMH is spelt A-C-A-M-H and don’t forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoy the podcast with a rating or review and do share with friends and colleagues.

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