Alejandra Paniagua-Avila
Why do you do this work?
I came to the Global Mental Health field through my clinical work as a primary care worker and through research, mainly in primary care settings and community settings in Guatemala. I wanted to become a doctor because I was really frustrated and concerned with the lack of access to primary care services, especially in rural Guatemala and among Indigenous populations. While I was in medical school, I realized that while I could help people at the individual level by being a primary care doctor, I couldn’t improve access to primary care services and address health disparities at the population level. This issue was particularly pronounced in the area of mental health care. I would see people being treated for their chronic diseases, and they obviously had a mental health problem, but there were really no mental health services in these rural settings. In Guatemala, the public health service invests only 1-2% of its budget into mental health. Most of that budget goes to one hospital in Guatemala City, which is 6-8 hours away from many communities and has been identified as one of the most dangerous hospitals in the world. Over the past few years, I’ve been dedicated to improving access to mental health services by integrating these services into existing institutions that are reaching large groups of people.
What is your proudest moment working in global mental health?
I’ve been really proud to partner with community members, the Ministry of Health, and different institutions in Guatemala, like the Inclusive Health Institute. When you talk to community members, leaders, and providers, they recognize that mental health is a priority and should be considered priority. However, there is a very limited budget and mental health services in most of the rural areas. I am proud to cultivate partnerships with administrators, healthcare workers, community leaders—like traditional healers—and people living with and relatives of those with mental illnesses. In my conversations with them I’ve discovered there are a lot of people who are interested in working on mental health in the communities. With limited training, they are providing social and emotional support to community members. So I’ve been proud and surprised in a really good way that even when it’s challenging, it’s possible when you partner with these members from the community, you can really start designing services that respond to real needs and build off of what’s already available.
How do you envision the future of global mental health as a field, and what contributions would you hope to have?
The field of global mental health, up until now, has been led by researchers and mental health professionals from what we would call the “Global North,” which is a classification that is not completely accurate. A researcher from “Global North” would try to take an evidence-based intervention and adapt it to a different setting, for example in a low or middle-income country. From there they would implement and evaluate it to see if it’s working in this setting.
It’s okay to use these interventions. However, it would be great if we start developing service implementation and research leadership in the settings where the work is conducted. There are already many resources and leaders available in these settings, and different ways to provide mental health support or psychosocial support. These aren’t necessarily through mental health professionals, but through community leaders or people who are respected in their communities, like traditional healers.
These community leaders have a different perspective on mental health; they don’t see it as something separate from physical health, and they don’t see it as an individual problem. They see it as something we have to address from a family or community perspective. So I think we should start to learn from those perspectives and understandings of mental health too.
What are you currently working on that you are particularly excited about?
I just finished working on my doctoral dissertation where I partnered with the Ministry of Health and the Inclusive Health Institute in Guatemala. We worked together to develop a set of implementation strategies for the integration of mental health services within primary care settings in rural Guatemala. We worked specifically with a Mayan Indigenous community, and used a systems thinking perspective where we tried to understand the setting as a whole. We mapped the system as it is working now and identified leverage points that can be used to implement mental health services within the existing infrastructure.
Another is a grant I received from the Council of Global Mental Health Research. We are going to be working in the same setting, in a rural area in Guatemala with a primarily Indigenous population. However, in this case, we are going to be looking at severe mental illnesses. We are going to co-develop a service model focused on recovery for people living with psychotic disorders. Additionally we will work with different stakeholders to develop this service model focused on addressing the recovery outcomes that matter to them. Later, we are hoping to do a pilot study of this model and determine if this is an effective model that can be scaled up. I’m excited because it is one little first step, and it is one of the first community-based mental health research projects in Guatemala, but we are planning for it to grow into something larger.
Milli Wijenaike-Bogle, an MPH Candidate in the Department of Sociomedical Sciences, interviewed Alejandra Paniagua-Avila for this Q&A.