Yeah, it’s a tough situation involving a lot of tradeoffs. I think we both see some issues with involvement of Western funders here, although the nature of the problems we’re focusing on seem to be different.
To formalize it a bit, as I see it:
Suppose we come up with a potentially cost-effective intervention that requires significant HCP resources of a particular type (e.g., physician, mental-health therapist).
The supply of HCPs in LMICs is pretty much fixed in the short run. Therefore, by default our intervention will divert HCPs from whatever they would otherwise be doing. Not only do we need to count the loss of the value they would otherwise have been creating in their counterfactual job, we’re also weakening the local health service and imposing our own judgment on the allocation of scarce HCP resources in the LMIC.
As an alternative, we could fund a counterfactual increase in HCPs in the LMIC by funding new HCP schools. If we fund enough new training, our contribution to increasing the HCP pool will equal the number of HCPs we are diverting from what they would otherwise be doing, at least largely solving the problem in paragraph 2 in theory. The number of HCPs deployed according to local priorities will be as high as if EA did not exist. However, this is expensive, and requires a significant amount of lead time. Thus, if we are going to take this approach, we have to start funding the new HCP schools years before we’re ready to roll out the intervention.
Paragraph 3 is going to be a real challenge in any EA cost-effectiveness analysis where the alternate use of the money is that we can save an under-5 child’s life from malaria for $5,000 without consuming HCP resources (e.g., through bednets). The cost-effectiveness will be even harder if much of the effect of increasing the HCP population results in increases to the number of HCPs doing relatively less effective work (e.g., therapists opening private practices catering to wealthier individuals with mild-to-moderate depression and anxiety) or working in wealthier countries.
That the new HCPs would exist counterfactually as a result of EA funding makes me more willing to require a period of service in exchange for free training (or else require the HCP to repay the entire cost of providing their education) if that’s what it took to get funding for the new HCP schools.
In the counterfactual—that the cost-effectiveness analysis didn’t work out, and we didn’t build the new schools—these people never had the opportunity to become HCPs at all. Anyone who did not like the post-graduation restrictions could apply to a non-EA, higher-cost school instead, and choose a different career path if not accepted there.
I’m a bit less concerned about the effects of restricting employment choices of HCPs who received free or subsidized training, as long as the conditions are not too tight. For instance, working for the nationalized health service outside of the relatively more economically advantaged areas might be enough for me.
Conclusion: In my view, the avoidance of disruption to a country’s existing supply of HCPs is a major factor in favor of interventions that do not require significant additional use of HCP resources. Pulling HCPs from other roles is problematic, and increasing the supply is both expensive and time-consuming (plus may not achieve the desired results). This will likely pose a particular challenge for interventions targeting severe mental health conditions.
Ah, okay, thanks for this—I think I see why I’ve been confused. I skipped through my arguments for psychosis/schizophrenia research in my OP because I felt my post was already ridiculously long—I see now that it could be read as suggesting a high HCP investment is needed for schizophrenia treatment in an LMIC. You make the fair point (that I entirely agree with) that anything requiring significant additional use of HCP resources is a major problem. Sorry, I didn’t understand where you were coming from and so I’m sure my response to your comment makes absolutely no sense—I thought you were making a completely separate point about HCPs in LMICs and so I was a bit perplexed and needlessly theoretical in my response.
The things I skipped over in the schizophrenia/psychosis research section were ways to reduce the needs of health services through treatment of psychosis/schizophrenia that would not require increasing numbers of HCPs. Again, none of this is an EA area suggestion—I do not have any authority to talk about LMICs. I’m explaining why I mentioned these things in my OP as I covered this poorly. It was intended as highly speculatively-reasoned areas for a potential deeper look if my groundwork seemed okay
Given prevalence is relatively similar across the world and static over time, LMICs are managing schizophrenia at present—it’s not an illness which is influenced by societal problems or ‘increased awareness’ etc. It’s why I assume that community-approaches and spiritual understandings might be very similar to things like CBT-p and family intervention—I wouldn’t assume these should be ‘rolled out’ to LMICs (rather the opposite that we could have learnt from other cultures a lot sooner to help our patients—we tended to use institutions/asylums instead) and there are non-HCP/non-medical approaches that can and do help people with schizophrenia. We might give the same ideas medical terms and run RCTs, but we likely didn’t ‘invent’ these approaches, nor would it be considered groundbreaking that this helps elsewhere in the world with different cultural understandings of psychosis. It’s an argument against an assumption about the need for therapy/therapists in all LMICs for psychosis.
It helps schizophrenia to treat it early (reducing duration of untreated psychosis to have best chance of complete recovery, faster recovery, reduced length of subsequent hospital admission) and my personal assumption would be in LMICs the issue is access to antipsychotics, particularly newer drugs which have fewer side-effects and are likely under patent—not HCPs/psychiatrists. I could be wrong—it just doesn’t necessarily require advanced training to recognise psychosis when someone is that unwell they need treatment (if it did, expertise-sharing/teleconsults with specialists isn’t necessarily a bad approach if you want to support one doctor working in a remote setting expected to manage a whole range of problems independently—it’s not an exclusively psych issue to consider access to specialities without training more HCPs). Using older drugs is a problem as they have disabling (e.g. Parkinson’s-type) side effects amongst many others, which means patients stop taking them and therefore are prone to relapse (needing more acute/hospital-based care) - I assume these are more commonly used in LMICs as they are much cheaper.
Some of the other (slightly newer) treatments cause obesity, diabetes, high blood pressure, heart disease etc, so will increase the need for other types of healthcare in the long-term. I guess, it could be one option to look into in-patent drug access agreements for LMICs to access the newest drugs for lowest side effect burdens, but as I wasn’t talking about LMICs, research for new treatments which work better/faster or are better-tolerated is another good option. If people can stay well on a medication, they will not need the kind of frequent HCP/social support they otherwise absolutely do need with chronic forms of schizophrenia.
I also assume clozapine is not easily accessed in resource-poor settings. This is the only medication with any evidence in treatment-resistant schizophrenia (which similarly would be highly-consumptive of HCP resources if not treated). Part of this reason is that it requires intensive blood monitoring—weekly blood tests for first 18 weeks, then every 2 weeks for the first year, then monthly thereafter. Heart health could be checked with (at least) an ECG machine which isn’t so rare, but the blood monitoring is clearly an issue if you don’t have ready access to a lab to process blood samples (and the infrastructure/cold chain to support transport/reliable results). It’s risky using clozapine without this monitoring. This is not just about checking levels of clozapine in the blood, but due to the known issue that taking clozapine can cause levels of white blood cells to crash and leave people unable to fight off infection—another issue in any setting with high prevalence of infectious disease (but it can be fatal anywhere). Finger-prick monitoring which I referenced briefly could have huge impact in remote/LMIC settings as it wouldn’t require a lab or anyone able to draw bloods to provide monitoring and might therefore support access to this effective treatment.
And it’s true that our long history of relative neglect of people with psychosis has set us really far back in terms of research. As an example, NMDA-r encephalitis was only discovered in 2007 (“Brain on Fire” is based on this illness) - a treatable form of psychosis when it was discovered patients were actually suffering with an autoimmune encephalitis and so needed immunotherapy, not antipsychotics. It’s generated a flurry of interest in understanding mechanisms for schizophrenia and was a significant breakthrough for identification of auotimmune encephalitis and directing treatment which undoubtably has saved lives. It seems plausible to me that there is a lot of potential gain in psychosis research when we are starting so far behind other areas of medicine.
Schizophrenia (and bipolar) are a little unique as they are considered more ‘organic’ than others i.e. they cannot arise from environmental factors alone, there has to be an underling ‘switch’ waiting to be flipped which is likely genetic in origin. While in illnesses like depression/anxiety/substance misuse, people can be more genetically prone to these problems, they can also arise entirely as a result of someone’s environment and—to me—a high prevalence of these illnesses in a country is a ‘canary in the mine’ for greater issues in public health/society. It’s why I’m a bit reluctant to assume medicalised treatments are helpful and think there is room to think about addressing poverty, inequality, hunger, preventable disease etc as ‘societal-level’ highly effective mental health treatments.
I didn’t mention it as a key area for mental health-style interventions for this reason (and thought I’d come too close to talking about SM). In my example about offering CBT vs cash as a trade-off CEA; that isn’t to suggest people in LMICs devalue depression treatments etc, it’s that they might know exactly why they are depressed and it’s therefore more effective to direct treatment to the cause than assume using therapy/medication can help people in the same way while they are living in very objectively bad circumstances. This wouldn’t favour HCPs either.
I hope that’s more helpful to explain where I’m coming from in thinking schizophrenia/psychosis is worth more thought from a wellbeing perspective as it potentially offers scope for larger gains through some of these simpler things outside of HCP training/retention. I’d be relatively certain psychosis research is EA-aligned, but would not suggest any other intervention without more detailed work in psychosis or other mental health conditions in LMICs.
In case my repetition about cultural relativism seems a bit hokey to anyone reading, this is my favourite paper I often suggest as a ‘gateway’ to anyone who doesn’t find psychosis interesting or wants to know more. It’s not overly technical/medical. It’s based on trying to understand how people who were born deaf (i.e. have never perceived sound) or lost hearing later in life/have partial hearing loss “hear voices” as a hallucination experience. It was research conducted by someone who uses sign-language and explains lots of the issues in how certain words are understood to a ‘hearing’ person vs how they are meant in BSL and how they worked around this. It might help explain some of my reluctance to make assumptions and why I constantly talk about within-community research—it’s so easy to have blind-spots (we don’t know how much we don’t know).
Yeah, it’s a tough situation involving a lot of tradeoffs. I think we both see some issues with involvement of Western funders here, although the nature of the problems we’re focusing on seem to be different.
To formalize it a bit, as I see it:
Suppose we come up with a potentially cost-effective intervention that requires significant HCP resources of a particular type (e.g., physician, mental-health therapist).
The supply of HCPs in LMICs is pretty much fixed in the short run. Therefore, by default our intervention will divert HCPs from whatever they would otherwise be doing. Not only do we need to count the loss of the value they would otherwise have been creating in their counterfactual job, we’re also weakening the local health service and imposing our own judgment on the allocation of scarce HCP resources in the LMIC.
As an alternative, we could fund a counterfactual increase in HCPs in the LMIC by funding new HCP schools. If we fund enough new training, our contribution to increasing the HCP pool will equal the number of HCPs we are diverting from what they would otherwise be doing, at least largely solving the problem in paragraph 2 in theory. The number of HCPs deployed according to local priorities will be as high as if EA did not exist. However, this is expensive, and requires a significant amount of lead time. Thus, if we are going to take this approach, we have to start funding the new HCP schools years before we’re ready to roll out the intervention.
Paragraph 3 is going to be a real challenge in any EA cost-effectiveness analysis where the alternate use of the money is that we can save an under-5 child’s life from malaria for $5,000 without consuming HCP resources (e.g., through bednets). The cost-effectiveness will be even harder if much of the effect of increasing the HCP population results in increases to the number of HCPs doing relatively less effective work (e.g., therapists opening private practices catering to wealthier individuals with mild-to-moderate depression and anxiety) or working in wealthier countries.
That the new HCPs would exist counterfactually as a result of EA funding makes me more willing to require a period of service in exchange for free training (or else require the HCP to repay the entire cost of providing their education) if that’s what it took to get funding for the new HCP schools.
In the counterfactual—that the cost-effectiveness analysis didn’t work out, and we didn’t build the new schools—these people never had the opportunity to become HCPs at all. Anyone who did not like the post-graduation restrictions could apply to a non-EA, higher-cost school instead, and choose a different career path if not accepted there.
I’m a bit less concerned about the effects of restricting employment choices of HCPs who received free or subsidized training, as long as the conditions are not too tight. For instance, working for the nationalized health service outside of the relatively more economically advantaged areas might be enough for me.
Conclusion: In my view, the avoidance of disruption to a country’s existing supply of HCPs is a major factor in favor of interventions that do not require significant additional use of HCP resources. Pulling HCPs from other roles is problematic, and increasing the supply is both expensive and time-consuming (plus may not achieve the desired results). This will likely pose a particular challenge for interventions targeting severe mental health conditions.
Ah, okay, thanks for this—I think I see why I’ve been confused. I skipped through my arguments for psychosis/schizophrenia research in my OP because I felt my post was already ridiculously long—I see now that it could be read as suggesting a high HCP investment is needed for schizophrenia treatment in an LMIC. You make the fair point (that I entirely agree with) that anything requiring significant additional use of HCP resources is a major problem. Sorry, I didn’t understand where you were coming from and so I’m sure my response to your comment makes absolutely no sense—I thought you were making a completely separate point about HCPs in LMICs and so I was a bit perplexed and needlessly theoretical in my response.
The things I skipped over in the schizophrenia/psychosis research section were ways to reduce the needs of health services through treatment of psychosis/schizophrenia that would not require increasing numbers of HCPs. Again, none of this is an EA area suggestion—I do not have any authority to talk about LMICs. I’m explaining why I mentioned these things in my OP as I covered this poorly. It was intended as highly speculatively-reasoned areas for a potential deeper look if my groundwork seemed okay
Given prevalence is relatively similar across the world and static over time, LMICs are managing schizophrenia at present—it’s not an illness which is influenced by societal problems or ‘increased awareness’ etc. It’s why I assume that community-approaches and spiritual understandings might be very similar to things like CBT-p and family intervention—I wouldn’t assume these should be ‘rolled out’ to LMICs (rather the opposite that we could have learnt from other cultures a lot sooner to help our patients—we tended to use institutions/asylums instead) and there are non-HCP/non-medical approaches that can and do help people with schizophrenia. We might give the same ideas medical terms and run RCTs, but we likely didn’t ‘invent’ these approaches, nor would it be considered groundbreaking that this helps elsewhere in the world with different cultural understandings of psychosis. It’s an argument against an assumption about the need for therapy/therapists in all LMICs for psychosis.
It helps schizophrenia to treat it early (reducing duration of untreated psychosis to have best chance of complete recovery, faster recovery, reduced length of subsequent hospital admission) and my personal assumption would be in LMICs the issue is access to antipsychotics, particularly newer drugs which have fewer side-effects and are likely under patent—not HCPs/psychiatrists. I could be wrong—it just doesn’t necessarily require advanced training to recognise psychosis when someone is that unwell they need treatment (if it did, expertise-sharing/teleconsults with specialists isn’t necessarily a bad approach if you want to support one doctor working in a remote setting expected to manage a whole range of problems independently—it’s not an exclusively psych issue to consider access to specialities without training more HCPs). Using older drugs is a problem as they have disabling (e.g. Parkinson’s-type) side effects amongst many others, which means patients stop taking them and therefore are prone to relapse (needing more acute/hospital-based care) - I assume these are more commonly used in LMICs as they are much cheaper.
Some of the other (slightly newer) treatments cause obesity, diabetes, high blood pressure, heart disease etc, so will increase the need for other types of healthcare in the long-term. I guess, it could be one option to look into in-patent drug access agreements for LMICs to access the newest drugs for lowest side effect burdens, but as I wasn’t talking about LMICs, research for new treatments which work better/faster or are better-tolerated is another good option. If people can stay well on a medication, they will not need the kind of frequent HCP/social support they otherwise absolutely do need with chronic forms of schizophrenia.
I also assume clozapine is not easily accessed in resource-poor settings. This is the only medication with any evidence in treatment-resistant schizophrenia (which similarly would be highly-consumptive of HCP resources if not treated). Part of this reason is that it requires intensive blood monitoring—weekly blood tests for first 18 weeks, then every 2 weeks for the first year, then monthly thereafter. Heart health could be checked with (at least) an ECG machine which isn’t so rare, but the blood monitoring is clearly an issue if you don’t have ready access to a lab to process blood samples (and the infrastructure/cold chain to support transport/reliable results). It’s risky using clozapine without this monitoring. This is not just about checking levels of clozapine in the blood, but due to the known issue that taking clozapine can cause levels of white blood cells to crash and leave people unable to fight off infection—another issue in any setting with high prevalence of infectious disease (but it can be fatal anywhere). Finger-prick monitoring which I referenced briefly could have huge impact in remote/LMIC settings as it wouldn’t require a lab or anyone able to draw bloods to provide monitoring and might therefore support access to this effective treatment.
And it’s true that our long history of relative neglect of people with psychosis has set us really far back in terms of research. As an example, NMDA-r encephalitis was only discovered in 2007 (“Brain on Fire” is based on this illness) - a treatable form of psychosis when it was discovered patients were actually suffering with an autoimmune encephalitis and so needed immunotherapy, not antipsychotics. It’s generated a flurry of interest in understanding mechanisms for schizophrenia and was a significant breakthrough for identification of auotimmune encephalitis and directing treatment which undoubtably has saved lives. It seems plausible to me that there is a lot of potential gain in psychosis research when we are starting so far behind other areas of medicine.
Schizophrenia (and bipolar) are a little unique as they are considered more ‘organic’ than others i.e. they cannot arise from environmental factors alone, there has to be an underling ‘switch’ waiting to be flipped which is likely genetic in origin. While in illnesses like depression/anxiety/substance misuse, people can be more genetically prone to these problems, they can also arise entirely as a result of someone’s environment and—to me—a high prevalence of these illnesses in a country is a ‘canary in the mine’ for greater issues in public health/society. It’s why I’m a bit reluctant to assume medicalised treatments are helpful and think there is room to think about addressing poverty, inequality, hunger, preventable disease etc as ‘societal-level’ highly effective mental health treatments.
I didn’t mention it as a key area for mental health-style interventions for this reason (and thought I’d come too close to talking about SM). In my example about offering CBT vs cash as a trade-off CEA; that isn’t to suggest people in LMICs devalue depression treatments etc, it’s that they might know exactly why they are depressed and it’s therefore more effective to direct treatment to the cause than assume using therapy/medication can help people in the same way while they are living in very objectively bad circumstances. This wouldn’t favour HCPs either.
I hope that’s more helpful to explain where I’m coming from in thinking schizophrenia/psychosis is worth more thought from a wellbeing perspective as it potentially offers scope for larger gains through some of these simpler things outside of HCP training/retention. I’d be relatively certain psychosis research is EA-aligned, but would not suggest any other intervention without more detailed work in psychosis or other mental health conditions in LMICs.
In case my repetition about cultural relativism seems a bit hokey to anyone reading, this is my favourite paper I often suggest as a ‘gateway’ to anyone who doesn’t find psychosis interesting or wants to know more. It’s not overly technical/medical. It’s based on trying to understand how people who were born deaf (i.e. have never perceived sound) or lost hearing later in life/have partial hearing loss “hear voices” as a hallucination experience. It was research conducted by someone who uses sign-language and explains lots of the issues in how certain words are understood to a ‘hearing’ person vs how they are meant in BSL and how they worked around this. It might help explain some of my reluctance to make assumptions and why I constantly talk about within-community research—it’s so easy to have blind-spots (we don’t know how much we don’t know).