“Global mental health” is an oxymoron and medical imperialismBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3509 (Published 31 May 2013) Cite this as: BMJ 2013;346:f3509
- Derek Summerfield, honorary senior lecturer, Institute of Psychiatry, King’s College, and consultant psychiatrist, South London and Maudsley NHS Foundation Trust
A remarkable thing about psychiatry is that its primary object—what is referred to as mental disorder—remains undefined. Bar organic categories, mental disorders are not facts of nature but cobbled together syndromes, with psychiatrists as the cobblers. Given that mental disorders are also grounded in Western culture, how do they translate to non-Western settings?1
Do the methods that identify depression in Spain identify the same thing in Sudan? The World Health Organization has been describing depression as carrying the greatest global burden of all diseases,2 which is a bizarre claim and testament to the dangers of viewing a psychiatric category as if it were a disease like any other disease. Is depression really more burdensome than AIDS (currently 34 million cases, with 1.8 million deaths in 2010), tuberculosis (8.7 million new cases in 2010, with 1.4 million deaths), or malaria (216 million cases in 2010, with 665 000 deaths)?
An emergent discipline entitled “global mental health,” backed by WHO, the US National Institute of Mental Health, and the drug industry, is establishing itself in universities and on the ground. The discipline’s literature concedes the social and economic determinants of poor mental health, but the thrust is of the global deployment of Western biomedical models of mental disorder.3 This is, in effect, the selling of the products of the Western mental health industry to the non-Western world.
The effect of this exporting is to render invisible the multiple mentalities prevailing in Africa, Asia, and South America, which are shaped by different philosophies and understandings of life, different cultural definitions of a person, and different traditions about expressing distress and seeking help. It is a lamentable error of epistemology, a category error, to assume that because phenomena can be detected in one setting or another, they mean the same thing everywhere.
But if mental health, and mental ill health, do not mean the same thing everywhere and are not subject to standard definitions, then the term “global mental health” is an oxymoron. At stake is validity in psychiatric research and practice. Invalid approaches are those that fail to consider the felt “nature of reality” that subjects experience. Invalid approaches cannot be humanistic and so will not work.
The concept of “nature of reality” invokes context as well as culture. Unicef says that 3.5 million children under the age of 5 die of starvation every year. One quarter of the global population lives in utter poverty, and two thirds of those born today have been condemned on the first day of their lives, destined to join what the philosopher Frantz Fanon called “the wretched of the earth.” Would antidepressants and Western talk therapy improve their lot? Who is asking for this? Indeed, the evidence base for these treatments is non-specific or weak even in the West.4 5
Here is an example case. I have recently been in Cambodia with a remarkable local non-governmental organisation, Trauma Care Foundation, which helps landmine victims with resuscitation, surgery, prostheses, and wider rehabilitation. The legacy of the US war on Vietnam and its impact on Cambodia and Laos continues, and there are still new landmine victims, who are largely rural farmers and their families.
One question posed was, “Is there such a thing as ‘depression,’ as defined by Western psychiatry, in Cambodia?” The answer is no: there is a Khmer term that means “fall of heart or mind” applied to some amputees, but this is not a mental disorder. Amputees can also present chronic bodily pain without obvious medical explanation, can seem hopeless about their prospects, and be slow to rehabilitate. These presentations seem encompassed by what might be termed “social suffering,” directing us not to mental space but to a social predicament and to gritty Cambodian reality. As disabled farmers, amputees face a loss of livelihood, social discrimination, and family breakdown; and framing everything is deepening poverty. The organisation tackles this squarely: in a typical case, it was the gift of a cow that brought the farmer out of the states described above. The cow was antidepressant and painkiller.
In London I work in an HIV mental health team where half of referrals are of African women. Depression is commonly given as the reason for referral, and antidepressants have often been prescribed already, but “social suffering” has far more explanatory power. These women face a threat of deportation back to a home country with few or no HIV treatments (and thus to their death); inconsistent access to social benefits or jobs; and social and cultural marginalisation. It is when I help with these problems that I make a difference.
The blithe universalism underpinning global mental health is reproducing the dynamics of the colonial era: the colonised were typically spoken for and unable to control the way they were represented. A salient trait of modern imperialism is to claim to be a progressive movement, setting out to instruct, modernise, and civilise, with Western knowledge taken as definitive.
Only Western culture retains the power to project itself globally. But Western scholarship has consistently failed to move beyond naivety and self righteousness to confront the real, core question: in any particular setting, whose knowledge counts, and who has the power to define the problem?
Cite this as: BMJ 2013;346:f3509
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; not externally peer reviewed.