Mental Health Care as our Institutions Fail

There are twelve psychiatrists in Zimbabwe for a population of 16 million people. When Dixon Chibanda, one of the twelve lost a patient to suicide because she could not afford the $15 bus fare to get to her appointment, he did not blame her for breaking the appointment. He came up with another system to deliver mental health care. He trained grandmothers.

We also have barriers to psychiatric care in the US. Some of these barriers are similar to Zimbabwe's, distance and lack of providers.

There are less than ten psychiatrists for 100,000 people in eastern Oregon, an area with one of the highest suicide rates in the country. An overworked psychiatrist in eastern Oregon came home one day to find seven cows in his driveway. They were not his cows. It was not the first time. Who knows what his day/week/year had been like. He snapped. He shot seven cows, killing six of them.

Unfortunately, he botched the job. The community might have been understanding if he had shot them in the head. But he didn't. Shot in the stomach, they suffered and died slowly. He settled with the owners for the loss of their property. But animal abuse was not a charge that could be dropped. He spent a couple days in jail, two years on probation, and had his license to practice suspended for a while.

It was a reasonable resolution. With unreasonable consequences. Well, clearly the man needed to take a break. But he is the only doctor certified in addiction treatment for a hundred miles, and the only doctor certified to prescribe a particular medication to treat addiction. And this is where it gets complicated. For a hundred miles, there were a number of people whose parole depended on their ongoing treatment for their addiction, which included taking this medication. So his tragedy meant these guys went back to jail.

Ten psychiatrists for 100,000 people in eastern Oregon beats Zimbabwe's supply. But if you have to wait four months to get an appointment after discharge from the hospital, you might as well live in Zimbabwe. I drove 100 miles over the mountains to my doc for a few years until I simply stopped seeing a psychiatrist at all. But then, I have a car.

So what about Chibanda's solution, grandmothers? Ah, here is our greater and intractable barrier. In Zimbabwe, twelve psychiatrists are responsible for the mental health care of 16 million people. They have to find a solution. In the US, psychiatrists do not. For-profit health care means psychiatrists are responsible to shareholders.  How do you monetize grandmothers? How do you code for that? We can't do grandmothers because there is no place for them in our "health care" system.

Now let me be clear, this is not about the callousness of doctors. Doctors know better than anyone, they live every day with the failings of our health insurance system and generally are supportive of a single payer health plan, none more so than psychiatrists. Because psychiatrists do care about people who are suffering. Sometimes they work themselves beyond their own health limits to provide care. Until they themselves snap and shoot seven cows.

The US has a health care system that incentivizes avoiding sick people, not treating them. And people with mental illness are the easiest people to avoid. We now have a law about mental health parity. But parity does not mean access.

Another story: A young woman I know has health insurance. When she had a psychotic break and was diagnosed with bipolar, she was on Medicaid the first few months. After her hospitalization, she had a few sessions of therapy, but really was barely beginning to get stabilized when Medicaid ran out. Fine, she has insurance, right? Wrong. The clinic that had been providing her therapy had a quota for the people they would treat with that particular plan. And there wasn't room for her. They dropped her.

Here is how it works: the law requires that insurance companies charge patients the same copays for mental health care as for other health care. But there are no provisions about reimbursement rates. So the insurance companies simply reimburse psychiatrists and therapists so poorly that these docs can't afford to accept the patients covered by the insurance company in question. Or in the case of my young friend, they limit the number of patients that they will lose money on. On her meds, she can't drive 100 miles to find a doc who accepts her plan.

What that means - she pays for coverage that she cannot access. The docs stay in business by not treating her - they have a four month waiting list of people who can pay them. The insurance company rakes in profits by never having to pay claims that she has already paid them for. Cool, huh?! Mental health care in the USA.

Meanwhile, you won't take away our worthless private insurance policies unless you pry them out of our cold dead hands.

So what about the grandmothers?

It still is a great idea. And as this country's institutions unwind and fail to serve their purpose, it is time to go back to the way we did things before we were a "developed country."

Hospitals were not invented by insurance companies, after all. In Europe, they were the invention of monasteries fulfilling their Christian obligation to tend the sick. Yes, that is the religious obligation of Christians. Jesus said so.

So while hospitals have been taken over by the money sucking machine, while every other enterprise that used to be performed by voluntary organizations has become monetized -- neighbors, faith communities, voluntary organizations have to recreate ourselves to do what our institutions are no longer willing to do for us.

Health care by GoFundMe isn't cutting it if there are no providers, no access. We have to believe in ourselves again and do for ourselves again. We have to commit to each other. Join stuff. We have to train grandmothers and train ourselves and it's not fair but we have to do something. We have to do this for each other.

Because Jesus said so. Okay, maybe you're not a believer. Do it simply because if "consumer" is your only identity, then "sucker" is your fate.

meme from
photo of grandmother on bench from

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