Ariel Çomo and the “deep gap” between available resources and the children’s needs

“Albanian child and adolescent psychiatry faces the same situation as any other small country without resources. We are not a desert island with me on it as some kind of Robinson Crusoe.” Dr Ariel Çomo, head of child psychiatry at the Tirana University hospital ‘Maria Teresa’ points out that even in the eighties – in the aftermath of the sometimes exaggerated isolation of Albania – a well functioning system of youth mental health care was already established. The Bulletin of the Royal College of Psychiatrists published an article in 1986, identifying “a very well equipped child psychiatric department in Tirana” and a University Department that was “quite actively involved in research” with the DSM-III being used “quite widely”.

Ariel ÇomoReading back his quotes from a proverbially hospitable reception at the department of child and adolescent psychiatry in the Tirana hospital for the first time, Ariel Çomo says he does not like to make the impression that he is merely lamenting on his difficult circumstances. Surely, Albania has suffered times of dictatorship and political isolation, where only ‘biological psychiatry’ was tolerated, religion as well as political opposition was forbidden and many human rights were poorly respected. But these times have now radically changed. The gap in mental health human resources is now described as the main challenge. Dr Çomo elaborated on this in a recent article for a local medical journal – but in the same time he is convinced that the present trajectory of modernizing youth mental health care is no different from the same development in other regions. “When I read the 2005 WHO Atlas report on child and adolescent mental health, I had the feeling that the type of problems Albania was facing were similar to many societies or countries”, he says. A nuanced picture of the development of youth psychiatry cannot do without mentioning the efforts made by Çomo’s professor in the early nineties, when Albania was in the middle of its political and social transition.

Evolutionary changes
Çomo: “Although professor Anastas Suli is retired now, he is still very active in research and in the education of young psychiatrists in Albania as well as in the US. Professor Suli also designed the 'needed evolutionary changes' of the after-nineties. Some of the early developments – designed and implemented after professor Suli got the chairmanship of the psychiatry association in 1993 – were heavily influenced by the concepts of establishing and making operational new types of services and facilities as well as new approaches dominating international discourse – such as community mental health services. A Mental Health Act was designed and approved in 1996 and a National Steering Committee was established, as a direct result of the attempts for securing legal safeguards on the application of a new, modernizing approach. Postgraduate training curricula was radically reformulated, as well as the undergraduate related courses. Excellent textbooks for students  – of the Oxford University Press and the American Psychiatric Association Press – were translated and published in Albanian. Some hundred library titles of the latest publications were made available through the American Psychiatric Association. Many days of training were organized throughout the country.”
Dr Çomo tends to remain very modest about his own role as the successor of professor Suli: “What I am doing today is just continuing a normal path of development, which might be the natural growth, with the same strength and weaknesses that may be found in any small and poor country. I am trying to go on with a kind of 'development project', designed already during the two previous decades.”
In spite of all modesty it still seems a miracle that the Tirana University Hospital today has so many state-of-the-art services in place, including diagnostics and treatment and an academic training, proper facilities and a sound scientific curriculum. Considering the lack of resources, the energetic and enthusiastic perseverance of the people who are leading the development of Albanian youth psychiatry deserves deep respect.

As a fore fighter of youth mental health care in the region, Ariel Çomo has a few more jobs in developing a better care system for children and adolescents. Like setting up community facilities, seeking collaboration with international organizations and western universities, approaching EU funds and telling the Albanian story to the ones that are prepared carry it further. Çomo: “We need to interfere in policies and look at procedures and drafts. We have to look at development programmes and get international cooperation going. So we have to prioritize. These activities all seem useful in serving our children and families – but all of them are energy and time consuming. Every new contact or project involves more work to be done. Our team is really too small to do it all. On the top of my list right now is getting exchange programmes together with a university in the US or western Europe. That would work both ways, not only for my residents. This is of great importance because these young psychiatrists are essential for the development of this country. At the Bucharest congress of the World Psychiatric Association this summer, I have launched the ambition to find partners and funding for attacking three major issues in Albania: stigma, depression and access to services.”
View Ariel Çomo’s Bucharest presentation (pdf, 27 pages).

10% of the Greek budget
Profiling Albanian child mental health services in a few figures is difficult. Çomo says: “It is impossible to give you a real impression by taking just one indicator as an example. It is really too complex to talk only along one line of problems. But the two heaviest burdens are probably the lack of human resources – there are too few of us to handle this situation – and the low government budget. The per capita government expenditure on health care is 142 US dollars a year. This is very little, even compared to the countries in the region. If you look at the 2011 Mental Health Atlas Report by the World Health Organization, you see that our budget is less than half of the money that is spent in neighbouring countries like: Montenegro: 516 dollars, Bosnia-Herzegovina: 340, Macedonia: 444 dollars and even one-tenth of the mental health budget in Greece, where the expenditure per head was 1,580 dollars in the same year. And I avoid the British or Scandinavian benchmark – you can imagine that western countries are no comparison to our budget. I have to say that the government apparently has heard our arguments – the WHO saw that neuropsychiatric disorders contribute some twenty per cent of the total burden of disease – because they grant us relatively more than other medical disciplines and we are allowed to take in a few more students every time the government makes a decision about this.”

“In spite of that, the health system in Albania has not been able to enrol a great many professionals in child psychiatry, nor in allied professions. Today we have fifteen working child psychiatrists, some of them also work with adults, and in the allied professions we have only three psychologists for adults and youth. This scarcity does not only go for mental health services – it is the same in other sciences and services. On a governmental level we just do not have the financial resources to provide our clinical work with enough professionals. Some of the youth mental health services are new to our system. The very first generation of psychologists for example, dates from 1999, just a few years after the fall of communism.”
“On top of this the whole region struggles with the problem of the brain drain. This exodus of young, talented doctors is easy to explain. Opportunities and possibilities in developed countries are evident and physical. These young people simply choose to start their family life in a developed country. Going abroad is in some ways much easier than it was some years ago. This is how globalization is working. It is a fact of life.”

Deeper gap
“The WHO Atlas reports show that the gap between the services provided and the need of child and adolescent psychiatry is even deeper than it is in mental health in general. According to the WHO this is a sign of a lack of funding and a lack of resources in general: the capacity in terms of human resources, the number of students that can attend our training and the pace in which we achieve to train them, and the infrastructure of mental health care that needs to be renewed to be able to absorb all patients… We face the fact that in a poor country – and certainly in Albania after its long-term isolation – people do not have the routine to go out and find this kind of help. We will have to fight stigma before we can reach the ones that need to be treated.”

“A way to make a beginning to work our way out of this could be international collaboration. One successful example is our research training programme with the Berkeley University of California that is working in the region for the last five years now. This long-term project was funded by the Unites States National Institute of Health on socio-economic factors influencing mental health. We got young people from the region working together on different themes or tables and this turned out to be quite productive. These kinds of international relationships are the way to go.”
“I do not think that direct injection of money in the Balkan countries is the solution. I believe in collaborative activities like the ones that are already in place. The Berkeley project is one example, and I hope that we will have chances to participate with ESCAP in EU funded programmes. Our students obviously glance at the steps forward that the ESCAP Research Academy is making and would love to be involved.”

The after-effects of war
Sadly, Albania is very experienced in dealing with refugees. In the years 1990-‘91 thousands of Albanians fled to Greece, Italy and Kosovo. Then, fifteen years ago, there were the after-effects of the Kosovo wars with large numbers of refugees all over the region, as described by Anastas Suli and Ariel Çomo in the World Psychiatry Journal (2002). And today the trauma returns with an unceasing stream of Syrian refugees passing by on their way to a safe haven anywhere in the west. Çomo: “After the Kosovo crisis in ’98-‘99 many humanitarian organizations came into the region. At first not at all focused on Albania of course: they came to concentrate on the most problematic areas in terms of war and violence.  These humanitarian organizations usually bring mental health tools along with them as part of their arsenal. This gave a kind of awareness to the country. Keep in mind that this was only ten years after the change of our political regime. Imagine: we came from a mental health care system that was completely isolated and restricted to biological psychiatry only. Without human resources and not in touch with any new developments. In 1995 we had a new discussion. For the first time we could start thinking about real mental health care for young people. For the first time we looked at mental health care from a human rights perspective. We started to define the reframing of the the care system. Towards community mental health centres and with less hospitalization. To the colleagues in developed countries it may not seem special at all, but to us it feels like a big leap. And we are still in the middle of that, with no intention to slow down.”

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Read about the Albanian academic training in child and adolescent psychiatry.

  • Key figures

    The Republic of Albania, locally called Shqipëri (land of the eagles) is an emerging democracy after being completely isolated under the rule of Stalinist dictatorship followed by a period of violence and unrest until 1997. Albania is now a member of the United Nations, NATO, the Council of Europe, the World Trade Organization and an official candidate for the membership of the European Union. The child and adolescent section of the Albanian Association for Psychiatry prepares its candidacy for the ESCAP membership.
    Albania is about as large as Belgium (28,700 sq km) and has around three million inhabitants. In the years 1991-2004 about 900,000 Albanians left the country. The official language is Albanian; regional mental health conferences and working groups use English as their working language. Albanian economics show potential growth but the estimated gross domestic product (GDP) for 2015 is still as low as 14.5 US dollars (5.26 per capita) and the purchasing power of Albanians counts only 30% of the European average.

  • WHO report

    The data for the WHO-AIMS Report on the mental health system in Albania (2006) were gathered in 2003 and in 2004 using a new WHO instrument, the World Health Organization Assessment Instrument for Mental health Systems (WHO-AIMS), designed for collecting essential information on the mental health system of low and middle income countries.
    The information collected through WHO-AIMS covered the key aspects of mental health system in Albania: the mental health policy and the legislative framework, the network of mental health services and the characteristics of the users, the role of the primary health care, the human resources, the public education and the links with other governmental sectors, monitoring and research. Examples of planned actions were the improvement of the mental health component in primary care, a clear shift of resources from mental hospitals to community facilities, an increase of the outpatient care and an expansion of the mental health information system.
    View or download the complete report (pdf, 17 pages).
    View the updated (2011) WHO Atlas Report (pdf, 4 pages).

  • Neighbouring countries

    Abstract of a paper, published in March 2014 in the Psychiatriki journal (Greece), on the ‘Management in child and adolescent psychiatry: how does it look in the Balkans?’ in Albania’s neighbouring countries, by Milica Pejovic-Milovancevic, Dimitris Anagnostopoulos et al. Both authors are board members of ESCAP.
    This paper examines the situation of child and adolescent psychiatry in the following Balkan countries: Greece, Serbia, Bulgaria, Romania, Bosnia and Herzegovina, FYROM, and Montenegro. With the exception of Greece, these countries are new democracies, with their mental health services in a transitional stage of organization. Overall, they have initiated programmes to move psychiatric care towards deinstitutionalization, developing outpatient infrastructures to handle psychiatric disorders. Child psychiatry as a specialization is still less developed than adult psychiatry at a significant, albeit different degree among these countries. The number of mental health services offered to children and adolescents is deemed insufficient, and the type of services limited and lacking. This situation is also reflected in the small number of child psychiatrists and other mental health specialists for children and adolescents, as well as in the complete lack (Montenegro) or deficiency of special programmes and actions for children and adolescents. The same also applies to mental health legislation. Greece is the exception in the development of the entire spectrum of services, the number of specialists, and the establishment of an adequate legislation framework reinforced by the incorporation of all international treaties on children's rights; although the recent economic crisis has affected the country negatively, threatening with regression to pre-reformational practices. Children and adolescents in need of mental health care have been increasing in all countries. The effect of violent and sudden changes taking place in most countries is a major factor for the emergence of increased and stress-related psychopathology and psychosocial problems in children and families. In all countries, there is a significant development of nongovernmental organizations undertaking a large part of reformation work. There is also the disconcerting phenomenon of professional exhaustion and the migration of experts from their countries. Finally, there is the common need to develop educational programmes and related clinical practices in all degrees of prevention, promoting interdisciplinary cooperation, the biopsychosocial approach to understanding and dealing with mental health issues, as well as the development of cooperation among all institutions concerning children (education, health, etc.). All this should be reflected in a national plan to promote child mental health as the foundation upon which the necessary cooperation among Balkan countries would be established in order to promote research, the exchange of experiences, common practices, mutual understanding, and common interests.
    View the full article.