October 10 is World Mental Health Day, an annual event designed to promote awareness of mental health issues around the world, and to mobilize efforts to address mental health.
Mental health has generally been marginalized in discussions of global development priorities. For instance, it did not make it into the Millennium Development Goals (MDGs) that set the development agenda for the first 15 years of the 21st Century. Yet just this past September, advocates linked to the Movement for Global Mental Health had some success in getting mental health onto the post-MDG agenda, especially through the FundaMentalSDG initiative.
These renewed efforts to get mental health onto the global development agenda, and to get governments all over the world to take mental health seriously, are made on an ethical basis: that there can be no health without mental health. Their advocacy is underpinned by making the case for mental health as a global priority, arguing that ‘mental disorders’ contribute more than infectious diseases to the global burden of disease (WHO, 2013) and calling for the ‘scaling up’ of access to mental health services across the world and especially in low and middle-income countries.
But it is not just that mental health is compared to infectious disease: it is also that global mental health advocacy is explicitly being modeled on HIV/AIDS advocacy.
AIDS advocates from the early 1980s onwards famously fought stigma and discrimination, argued for access to treatment as a human right, and secured HIV/AIDS’ prominent place in global development – a model that might at first glance seem reasonable and attractive to emulate in the field of global mental health.
The question we raise here is whether there might be downsides as well as upsides to using HIV advocacy as a model for mental health advocacy – at least without a more nuanced view of the transferability of lessons.
There are at least four reasons why we may want to be cautious about this approach:
First is the question of whether the ‘right to access treatment’ model is easily exported from HIV advocacy to mental health. In the case of mental health, rights issues around treatment can be much more complicated than whether or not a person has ‘access’. In some cases the problem may not be a lack of access to treatment but quite the reverse: the right to access information about, and to refuse, potentially harmful treatments, including medications. This is evident in the growing international psychiatric survivor movement made up of people who have been subjected to forced and/or harmful treatments, and incarceration, and who have had the personal and political meaningfulness of their distress denied by professionals and by diagnoses.
Second, and relatedly, there are also huge ongoing controversies within global mental health over the desirability of scaling up largely medicalized treatment-based services internationally. Whilst scaling up treatment access – especially in the global South – has been at the heart of global efforts to tackle HIV in recent years, many mental health user and survivor groups in the global South point out problems with applying this model to mental health. They alert us to the colonial history of psychiatry, the right to access non-western forms of healing, and the need to attend not just to ‘symptoms’ of distress but the social and economic conditions in which these ‘symptoms’ develop.
These concerns are doubly worthy of attention when we acknowledge the profound irony that just as calls are made to scale up medicalized mental health services to the Global South, these same services are increasingly under enormous criticism in the global North. Consider, for instance, that studies carried out by the World Health Organization in the 1970s found better outcomes for people diagnosed with Schizophrenia in ‘developing’ countries, such as India and Nigeria, than in high-income countries.
Third, we may want to be skeptical of arguments that place the mental states of people – rather than political or economic systems – at the center of analyses of the solutions to global inequality and poverty. HIV/AIDS has widely come to be understood as a major obstacle to economic development in sub-Saharan Africa and elsewhere, and the case to include mental health on the development agenda has similarly often made in terms of economic cost. The high ‘cost’ of mental distress to the economy, where mental health is portrayed as a barrier to economic development, is set against the fact that mental health treatments (especially those based only on medications) are relatively cheap – estimated at between $3-9 per capita, according to Patel. While this argument is compelling, it is also problematic.
By positioning mental distress as a barrier to economic development, the current economic system is taken for granted and its debilitating effects on mental health come to be seen as ‘problems’ of individual brains. Furthermore, this argument risks slipping into implying that if investment is made in wider accessiblility to psychiatric drugs, then poverty will be reduced, and development will be achieved (and thus there is no need for more structural change). We may also want to be alert to how these arguments are attractive to pharmaceutical corporations, always on the look-out for new global markets.
Fourth, while global mental health advocates have adopted the model forged in the face of the AIDS crisis that health is a truly global phenomenon, there is reason also to be cautious about viewing mental health in similar terms. What problems inhere in the depiction of mental health as a single ‘global’ problem? Mental health is highly culturally-dependent, with no global cross-cultural consensus on what constitutes a ‘mental disorder’ or how such disorders should be diagnosed. Even in the case of HIV, where a blood test is able to determine someone’s status, there has been a move away from viewing HIV as a single ‘global problem’ towards a much more fine-grained understanding of the differences between the epidemics ongoing in different parts of the world.
For these reasons, we may well wish to be cautious about the direct adoption of models of HIV advocacy for tackling challenges in global mental health. Though there are lessons that can be learned from HIV advocates – particularly surrounding questions of combatting stigmatization and discrimination – there are also reasons why modeling global mental health advocacy on HIV advocacy has limitations, and even dangers.