Developing mental health resources for low and medium income countries of the Pacific—The Cook Islands experience

The 14 low and medium income countries (LAMICs) of the western Pacific Ocean consist of thousands of large and small islands in Polynesia, Micronesia and Melanesia scattered over millions of square kilometres of sea. Although economically not confronted with the problems of the poorest low income countries, the western Pacific Ocean nations face the communication, transport and infrastructure difficulties of this geographical and demographic dispersion. For example, the Cook Islands in Polynesia have approximately 22,000 people on 15 populated islands with a total land area of approximately 250 square kilometres in more than 5 million square kilometres of ocean. In addition to the problems created by distance, mental health services have often been marginalised in resource allocation resulting in a scarcity of trained personnel and facilities. The dearth of mental health clinicians has also been exacerbated by their emigration to high income countries resulting in some seven western Pacific countries having no psychiatrist or psychiatric nurse. Nonetheless, in most regions there does remain an adequate number of primary health clinicians, both doctors and nurses, who treat the mentally ill, albeit it reluctantly. The reluctance emanates from a lack of training and a pervasive social stigma toward the mentally ill culminating in many clinicians refusing to attend to psychiatric disorders in their daily work in many island nations. Whereas patients from a consolidated land mass confronting this prejudice may overcome it by seeking help relatively easily elsewhere, through road travel, the prohibitive financial and time costs and dangers associated with air and sea travel limit this solution in the Pacific islands. Alternatively, the only recourses for the psychiatrically ill are traditional healers or the use of police to restrain violent or aggressive behaviour. A practical solution to the parlous state of mental health care in many western Pacific Ocean nations is to utilise primary health clinicians. However, for this to occur primary health clinicians need basic psychiatric training and a positive attitudinal change to those with mental illness.