Editor’s note: The 17th IASP World Congress on Pain took place September 12-16, 2018, in Boston, US. At the Congress, 12 early-career pain researchers took part in the PRF Correspondents Program, a science communications training experience that provides participants with knowledge and skills needed to communicate science effectively to a wide range of pain researchers, and to patients and the wider public. As part of this program, the participants conducted interviews with plenary speakers at the meeting.
Here, plenary speaker Vikram Patel, MBBS, PhD, chats with PRF Correspondent Alisa Johnson, PhD, a postdoctoral research associate at the University of Florida, Gainesville, US. Patel is The Pershing Square Professor of Global Health and Wellcome Trust Principal Research Fellow at Harvard Medical School, Boston, US. His work spans the areas of mental health problems, child development, and adolescent health in the global health context, in particular, the use of community resources for assessment, prevention, and recovery. He co-founded Sangath, an Indian NGO that has won the MacArthur Foundation’s Award for Creative& Effective Institutions and the WHO India Public Health Champions Award. He co-founded the Movement for Global Mental Health and is a Fellow of the UK Academy of Medical Sciences. He was named in the TIME 100 Most Influential People of 2015.
In this interview, Patel discusses his research, the importance of person-centered care, and much more. Below is an edited transcript of the conversation.
What was your path to global health research?
I did my first degree, an MBBS—what is called an MD in the US—in India, and then I received a Rhodes scholarship that took me to Oxford, where I spent the next few years, followed by psychiatry training in London. Then I worked in Britain, Zimbabwe, and India developing my global mental health career. I served on the faculty of the London School of Hygiene & Tropical Medicine for 17 years before joining Harvard Medical School.
My trajectory has been as a physician, then a psychiatrist, and then an epidemiologist and public health practitioner in the area of mental health. My deep concern about the lack of access to care led me to refashion myself as a global health researcher with an interest in reducing disparities.
What are some of the themes of your current research?
I’m concerned about the fact that the people who are most in need of mental health care are the ones who are the least likely to get it. This is the heart of healthcare disparities globally.
It troubled me for a long time that our approach to providing healthcare was led by what suited the medical profession and the healthcare industry. I’ve been very inspired by the values of global health, where the focus is much more on the person, and the emphasis—the center of gravity in our thinking—is on what is convenient for the person.
Person-centered care emerges from the ideas of global health, justice, and equity. If our focus shifts to the person, then it means that care is delivered in settings that are convenient for the person, and that healthcare services are affordable.
My work has been largely around integrating the management of chronic health conditions, particularly mental health problems, through primary healthcare in community settings. That means asking what matters to the person rather than what is the matter with the person.
Utilizing available human resources has been a key part of my work. Rather than saying we need certain kinds of specialists, in which case we will have to wait decades to get them in every part of a country or the world, we instead turn the question around and ask, What is the clinical intervention that we need to deliver, and how can we train, scale up, support, and supervise existing providers or widely available human resources to deliver those interventions in a safe and effective way?
By reframing the conversation, we are saying that we have knowledge about what to deliver and who is available to deliver it, and asking how we can match those two safely and effectively.
Was it your clinical experience that shaped these research themes?
Absolutely. Seeing people not turn up for care because they couldn’t afford the time or money was always demoralizing. It’s interesting: We think people don’t come because they’re unreliable patients, but that’s not true at all. People don’t come because they have other very pressing concerns in their lives—economic concerns, social concerns, looking after the kids and getting them to school. People don’t enjoy being sick, and we, as a healthcare provider community, need to recognize that when people don’t come for care, this is a problem for us to address.
How does the topic of pain fit into your research?
Pain and mental health are inseparable. Pain is a very subjective experience, like almost all mental health experiences are; when we assess people’s pain experience, we have to ask them about it, and this is so similar to what we do in mental health assessments. Another similarity is that pain is often a metaphor for social deprivation in the same way that mood and anxiety disorders are. Also, pain is often a presenting feature of mood and anxiety problems, and painful conditions can produce mental health problems. Further, in many cultures and social classes, the somatic experiences associated with poor mental health, such as headaches and backaches, are often what is shared with physicians and health workers. Even the language of emotions is physical—“my heart is hurting,” someone might say. For all of these reasons, addressing mental health alongside pain is a broad area of concern and is critical to person-centered care.
How should we change our current approach to managing chronic pain?
We need to consider a stepped-care model for chronic pain. For example, care could start with a community-oriented psychosocial intervention that addresses mental health difficulties and social determinants. Those who do not respond adequately would move up a step to a more intensive intervention, such as physiotherapy or other kinds of rehabilitative interventions. And then, of course, there will still be some people who have unremitting pain for whom seeing a pain specialist at a pain clinic is warranted.
We need to use the resources we have in an efficient way and achieve maximum coverage of interventions, and we can do this using a stepped-care approach. If the majority of people with pain symptoms can benefit from low-cost, scalable interventions outside the formal healthcare sector, then there is good reason to support those interventions. The health system has to see itself as being responsible for the health of all the people it serves, not only those who consult in healthcare facilities, and this means supporting interventions delivered in the community.
You also need very good coordination from the home to the pain clinic so that people don’t only move up steps, but can also move down steps, for example, when a patient is receiving a long-term medication that needs monitoring for treatment use, adherence, and response. That could be done by a frontline worker; a patient doesn’t necessarily have to keep going back to the pain clinic if there’s no reason.
We have a system in the United States that has been in place for a long time, and it seems like certain changes will be very difficult to put into place. What are the first steps to implement some of these changes you’ve outlined?
Good question. The problem in the US is that healthcare is fragmented. There isn’t a steward for people’s health at the population level, which is the essence of universal health coverage. Instead, care is divided up between different healthcare providers and organizations. So it’s difficult in such a system to really put into place what I have just described. It will require a steward for everyone’s health—somebody who makes sure that every individual is counted—and that requires leadership from the political system.
How, as pain researchers, do we begin to address disparities?
It’s first important to recognize that the issue of pain is not alone in terms of disparities; we see disparities in all chronic conditions, and there is inappropriate medicalization of many of these problems, which further exacerbates disparities. We must recognize that medicalization comes at a cost, not only in terms of unnecessary procedures and interventions, but also in terms of resources that are then being diverted from the people who actually need them.
As a pain community, the first and most important thing is to be more rational and evidence based in approaches to pain relief, so that we use interventions more efficiently and increase coverage of interventions, particularly to reduce disparities.
Second, the pain community should learn from other areas of global health—HIV and mental health care are great examples—where people have sought to address disparities by reimagining who a provider is, sharing resources, involving community health workers, and utilizing collaborative coordinated care models. These innovations in delivery are being scaled up in many other areas of healthcare. What the pain community must ask is, How do these models apply to pain management?
Third, to move toward a person-centered care approach, the pain community will need to actively engage with other key communities, such as the palliative care and mental health communities, where there are obvious synergies with regard to the kinds of individuals who are accessing services, as well as engage with social work providers who help people address social determinants.
What would you say to clinicians treating people with pain?
To link everyone in your clinic with an outreach worker, and if you don’t have an outreach worker, that is something your organization should seek. This would be someone who can act as a link between people in their homes and you in the clinic. In much the same way as we do rounds with our residents, we need to do rounds with our frontline workers. In doing so, you will not only reach out to a much larger group of patients, but you’ll also get much better outcomes.
What challenges are most salient for treating pain in low-resource settings, based on your experience?
It’s important to recognize that pain, as an experience of distress, is very often clustered with social disadvantages and chronic health problems; it rarely occurs in isolation. So, since pain is almost always associated with mental health difficulties and often associated with other physical health challenges and social deprivation, we must move from a singular focus on one symptom to a holistic, person-centered approach. This means that even if we, as practitioners, aren’t able to deal with everything, the least we can do is recognize these other potential health difficulties and try to link the person with appropriate services for addressing those comorbidities.
What projects are you working on most intensely right now?
I am continuing my longstanding focus on psychological therapies and the use of digital platforms for training and supervising providers, and on developing self-help tools for mental health problems. One of my major focus areas is applying these approaches to adolescents based on a stepped-care approach implemented in schools.
I also have a growing interest in the application of digital technologies for assessment of mental health—for example, examining how we can use gaming interfaces to assess brain function in young children so that we can develop an understanding of child development outcomes without the complexity and expense of observational assessments, which is all that we have now.
The third area I’m very interested in is the prevention of mental health problems in adolescents through environmental, social, parenting, and school-based interventions that will reduce violence and lead to better outcomes.
At Harvard I am leading a major cross-university initiative called GlobalMentalHealth@Harvard, which seeks to bring together a community of scholars from different disciplines—neuroscience, social science, clinical science, and so forth—to address fundamental questions about the nature of our mental health, and how we can then find new ways of thinking about interventions for the prevention and care of mental health problems.
What other areas of research hold promise?
One of the areas that I’m most interested in is precision medicine as it applies to mental health. We know that people with depression are not a homogenous group, and yet we give everyone the same treatment. So in the same way that precision medicine has transformed certain areas, such as the cancer field, I certainly think it could transform mental health treatment.
Developing biomarkers for mental health problems is also interesting. The arrival of digital technologies means that our definition of biomarkers has changed; we’re not only looking for blood biomarkers, but also digital biomarkers, such as behavioral phenotypes that can be assessed through behavior monitoring on mobile devices. Another area I am particularly interested in is how to translate emerging knowledge about the connectome of neural circuitry into novel, targeted psychological interventions.
Is there anything about you that people might be surprised to know?
I don’t know if it’s surprising, but I am a great enthusiast for cooking. It’s one of the things that gives me pleasure in life.
Is there a favorite dish that you like to make?
Yes, risotto is my favorite dish to cook, especially because there are so many different things you can put into one.
Do you have a final message that you want people to take away from this interview?
I very much would like the pain community to have a global outlook, to remember that the vast majority of the world’s people affected by pain live in the poorest countries of the world, where the conversations that we’re having at this Congress haven’t even begun. The mental health, HIV, cardiovascular disease, and cancer communities have all been looking at global disparities, and I really hope the pain community does that, too.