Climate change in the Philippines

The Philippines is one of the world's most climate-vulnerable countries.^{Reference Guinto, Alejandre, Bongcac, Guilaran, Salcedo and Sunglao2} It is confronted with at least 20 typhoons every year, which lead to the destruction of houses and livelihoods, displacement of thousands and hundreds of deaths.^{Reference Aruta and Guinto3} It also experiences extreme droughts and rising sea levels.^{Reference Guinto, Alejandre, Bongcac, Guilaran, Salcedo and Sunglao2,Reference Aruta and Guinto3} These not only lead to the forced displacement of communities but also threaten food security.^{Reference Guinto, Alejandre, Bongcac, Guilaran, Salcedo and Sunglao2,Reference Aruta and Guinto3} Given the negative effects of these adverse social and environmental conditions on mental health,^{Reference Morgan and Bhugra4} climate-related anxiety has affected the Philippine population. In 2022, a global survey showed that the Philippines has the highest number of young people experiencing high levels of anxiety and negative emotions associated with the climate crisis.^{Reference Aruta and Guinto3} Thus, there is an ever-increasing need for a strong and resilient mental health system.

Typhoon Haiyan and its mental health repercussions

The intersection of mental illness and the climate crisis in the Philippines is exemplified in the aftermath of Super Typhoon Haiyan (local name Yolanda) in November 2013.^{Reference Enano5,Reference Geronimo6} Typhoon Haiyan is one of the strongest typhoons to ever hit land in recorded history.^{Reference Enano5,Reference Geronimo6} It has turned thriving communities into wastelands, destroyed decades-long livelihoods, displaced four million people, destroyed one million homes and killed at least 6000 people.^{Reference Enano5,Reference Aruta and Simon7} In its aftermath, local health authorities noted that those needing psychological help easily tripled because the population ‘were all shocked’.^{Reference Enano5} Likewise, the authorities also stated that there were rising cases of post-traumatic stress disorder (PTSD) and depression.^{Reference Enano5} Although no official records were collated at that time owing to limited resources and lack of structure,^{Reference Enano5} a study found that about 80.5% of survivors who helped with the typhoon relief response were at risk for mental disorders 4 months after the typhoon.^{Reference Chan, Tang, Hall, Yip and Maggay8} This rate of people at risk for mental disorder following the typhoon is higher than the estimated national rate of common mental disorders in the Philippines, such as schizophrenia (0.4%) and depression (14.5%), before the typhoon.^{Reference Lally, Tully and Samaniego9} It is also higher than the rate of PTSD (7–24%) found after other natural disasters, such as the 2005 Hurricane Katrina, the 2004 Asian tsunami and the 2010 Yushu earthquake, as well as depression (14%) and psychological distress (15%) following the 2011 Japan earthquake.^{Reference Naushad, Bierens, Nishan, Firjeeth, Mohammad and Maliyakkal10}

However, at that time, only ten psychiatrists served a population of 4.7 million in the Philippines’ critically hit region, Eastern Visayas.^{Reference Enano5} This was worsened by the badly damaged regional hospital.^{Reference Enano5,Reference Geronimo6} Thus, international and national organisations became the primary providers of mental health services.^{Reference Enano5} However, it was reported that there was no clear structure in these services: ‘some were already “overprocessed,” having received so many psychological services. But many others, especially poorer communities, were left behind’.^{Reference Enano5} Thus, the months following the aftermath of Typhoon Haiyan led to extreme social and mental health adversities against a background of a fragile mental health system.

A year after, the World Health Organization (WHO) estimated that over 800 000 people in the region suffered from various mental health conditions. Although most of these people could be treated in their homes, at least 10% needed comprehensive psychiatric treatment for depression, anxiety, PTSD or schizophrenia, including further medication and support.^{Reference Geronimo6} For the survivors, it was ‘stark evidence [of] why we need to address the mental health situation, because every time these disasters come, it takes a mentally healthy individual to cope with challenges’.^{Reference Enano5} Hence, mental health adversities from Typhoon Haiyan persisted in a large number of survivors even a year later.

Given the evident shortcomings in the mental health care system and the persistent mental health problems after Typhoon Haiyan, the Eastern Visayas region partnered with the WHO to establish the Mental Health Gap Action Programme for all its health units.^{Reference Enano5} As a result, by December 2014, it became the first Philippine region where mental healthcare and support are present at primary, secondary and tertiary healthcare levels.^{Reference Enano5} In the same year, 300 community workers and 70 health professionals were trained to assess and treat severe mental health problems.^{Reference Enano5} The regional government further supported these efforts by allocating a budget for disaster response and community-based interventions for psychosocial needs in the succeeding years.^{Reference Enano5} Thus, various mental health system improvements have been accomplished in Eastern Visayas by incorporating mental health services into primary care and augmenting the mental health workforce with the help of non-governmental organisations.

Towards building a climate-responsive mental health system

Although several improvements have indeed been accomplished, several challenges remain for the Philippine mental health system. Among other things, mental health stigma remains pervasive in the Philippines, including Eastern Visayas.^{Reference Enano5} Moreover, only 3–5% of the total government health budget is spent on mental health.^{Reference Guinto, Alejandre, Bongcac, Guilaran, Salcedo and Sunglao2} Human resources are also scarce, with only about 0.5 psychiatrists per 100 000 population and a total ratio of 2 to 3 mental health workers per 100 000 population.^{11,Reference Lally, Samaniego and Tully12} Given this situation, the country's new Mental Health Act in 2018 was met with the hope of filling these gaps in mental health services.^{Reference Guinto, Alejandre, Bongcac, Guilaran, Salcedo and Sunglao2}

The Mental Health Act mandates the government to strengthen mental health research, increase the mental health workforce through training, provide mental health services in all hospitals and community health centres, and expand mental health promotion in schools, communities and workplaces.^{Reference Guinto, Alejandre, Bongcac, Guilaran, Salcedo and Sunglao2,11,Reference Lally, Samaniego and Tully12} In addition, envisioning the future climate crisis needs of the Philippines, it advocates hope that it can act as a springboard for creating a climate-resilient and accessible mental health system.^{Reference Guinto, Alejandre, Bongcac, Guilaran, Salcedo and Sunglao2}

Nonetheless, the Mental Health Act has been critiqued as ‘nothing more than “just an act”’.^{Reference Maravilla and Tan13} This is because healthcare expenditure for mental health remained at 3–5% despite the Act's implementation.^{Reference Maravilla and Tan13,Reference Arevalo, Maslog, Flores, Manlongat and Eala14} Likewise, the ratio of psychiatrists remained low (0.4 psychiatrist per 200 000 population) compared with other Western Pacific countries of similar economic status, such as Indonesia.^{Reference Maravilla and Tan13} Moreover, there remains a paucity of research that can translate to evidence-based culturally sensitive interventions and policies.^{Reference Arevalo, Maslog, Flores, Manlongat and Eala14} The Act's implementation was also criticised for its disproportionate focus on clinical mental health, resilience and individual coping, despite the resonating need for social intervention for social environmental factors, such as climate change, experienced in the Philippines.^{Reference Arevalo, Maslog, Flores, Manlongat and Eala14} Consequently, mental health promotion and services were regarded as outdated despite the new Mental Health Act.^{Reference Maravilla and Tan13,Reference Arevalo, Maslog, Flores, Manlongat and Eala14}

Given the Philippines’ vulnerability to the worsening climate crisis and the weaknesses in its mental health system, reforms and improvements are needed in mental health services, resources and policy implementation. As exemplified by the Eastern Visayas region, this can be started by integrating mental health services into primary care services, increasing the mental health training of health professionals and community workers, collaborating with non-governmental organisations and sustaining support towards achieving better mental health.^{Reference Enano5,Reference Geronimo6} In addition, the low number of psychiatrists and mental health professionals can be addressed by supporting and increasing training institutions and their capacity. Furthermore, since there is high climate-related anxiety among Filipino youth, hope-based climate education for the empowerment of young people can also be provided since there is evidence that this might help them cope.^{Reference Aruta and Simon7} Likewise, mental health information systems need to be strengthened to adequately assess the needs of disaster-affected localities, including accounting for affected populations and mental health workers. By doing so, data from the information systems can inform mental health and psychosocial support services in affected localities. Importantly, the implementation of the Mental Health Act must be strengthened.