Rebalancing Power in Global Mental Health

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Posted: 5th April 2019

On Friday 22nd March, the Centre for Global Mental Health (CGMH) at the London School of Hygiene and Tropical Medicine (LSHTM) marked its 10-year anniversary by hosting an event on the rebalancing of power in global mental health, chaired by Dr Julian Eaton (CBM International and LSHTM). See how the story unfolded on the night by following our Twitter story below using #FutureGMH.

Discussions around power in the field, have long been considered to be contentious due to the global mental health’s association to transcultural psychiatry, a branch of study and practice which many considered to be routed in colonialism. The unequal distribution of wealth between high income countries in the global north and low- and middle-income countries in the south, have created further imbalance in power structures between the regions. A higher distribution of wealth in the global north has meant that high-income countries have led efforts to address the burden of mental health illness in poor resource settings, in much of the global south.

While steady progress has been made in addressing the treatment gap in mental health care, the global mental health movement has been overshadowed by a critique that it lacks inclusion of the global south.

The symposium starts from a point of critiquing the dominance of the global north in research, policy frameworks, education and training, to explore how knowledge systems can be democratised to meaningfully integrate a broader range of perspectives and create a bi-directional flow of knowledge between the global north and the south.

The Speakers

The symposium included multiple speakers who are emerging in the field, and bring forward a fresh perspective from the global south (Yeni Rosa Damayanti, Brother Jimi Huayta-Riviera, Melquiades Huauya Ore and Victor Ugo), and in relation to women specific issues in mental health (Bonnie Evans).

Speakers also included high profile pioneers in global health, including her Majesty Queen Mathilde of Belgium, a strong advocate for education, children, mental health, the climate and the Sustainable Development Goals; Devora Kestel, the first woman and non-medical professional to be appointed the directorship of Mental Health and Substance Abuse department at the World Health Organization; and Peter Piot, the Director of LSHTM, known for his research into Ebola and AIDS.

The Chair of the symposium, Julian Eaton (Co-Director of CGMH at LSHTM and Director of Mental Health at CBM) opened the event by emphasising the importance of introspection and reflection in paving a new era of cooperation in the field of mental health, in which he said the following:

“Who gets to decide? How do we know our field with the extra resources doesn’t do more harm than good? I think we’ve got loads of sincere people, researchers, important leaders who are trying to think these things through and moving in roughly in the right direction, but how do we know?”

The rest of the symposium saw each speaker provide unique and innovative insights to some of these pertinent questions.

Queen Mathilde of Belgium

We played a recorded video from The Queen of Belgium noting how mental health issues continue to be one of the most neglected aspect of good health and global wellbeing. She argued that mental health should be incorporated into broader strategies to build resilience among vulnerable people, whilst always respecting the dignity of the individual: “[Mental health] is often the invisible problem in international development. Dealing with mental health issues should be incorporated into any international development strategy, in the same way that other health issues are.”

Peter Piot (Director of London School of Hygiene and Tropical Medicine)

In his opening talk, Peter made a clear initial statement on the importance of inclusion. He suggested that there was much to learn from the global south, highlighting how the friendship bench (hyperlink) marked an important export from the global south (Zimbabwe) to the global north (New York). He elaborated further to highlight the following about the inclusion of the population and groups that we serve:

“You wouldn’t dream in social work to develop policies without talking to people affected by the policies. What do we do in health and global health? We have a bunch of experts in a room in Geneva or London and we figure out what is coming out of a systematic review and meta-analysis etc. etc… and then we say that’s best for people and then we’re surprised that people don’t take[up our recommendations]. We have to involve those who will benefit, who are affected or who will be damaged by these policies. That [principle] is important perhaps the number 1 contribution of the AIDS movement to global health.”

Devora Kestel (Director of the Department of Mental Health and Substance Abuse at the World Health Organization)

Devora Kestel, Director of the Department of Mental Health and Substance Abuse at the World Health Organization provided a key note presentation digitally, from Argentina. She discussed a range of complexities and barriers that stand in the way of mutual knowledge exchange between the global south and the north. First she highlighted language as a significant barrier in preventing the global mental health movement from becoming ‘truly’ global.

“We know it is not a global movement as we know there are several biases, the first one being the language…this is a bias not only because it’s limiting access because one has to know English today to be part of a global movement but of course with the language comes culture and a cultural background that will bring differences.”

Second, she mentioned that many of the strategic decisions referenced from the global south, many in fact come from the global north. Third, she highlighted that significantly higher resources in the global north, lead many who have the opportunity to work in low-resource countries to accept knowledge from the global North. For this reason, she suggested that it was difficult for recipient countries to ‘say no’ to input and resources, lending to the tendency of people in the global south to accept the mind-set and priorities set up by countries in the global north.

Yeni Rosa Damayanti (Indonesian Mental Health Association)

Yeni provided a passionate presentation on the current state of mental health perceptions and care in Indonesia. She raised acute concerns regarding the level of institutionalisation and the non-adequate conditions that those experiencing mental illness have to endure. She noted that health workers and psychiatrists presented a resounding barrier for the inclusion of people with mental illness in society.

“One of the biggest issue is that thousands of us are still locked up in institutions… the respect of our decision-making is one of the biggest problems in mental health. One of the biggest problems that I want to address is that the health workers, the psychiatrists instead of being those who support us become our biggest barrier to be involved and included in society as they are the ones who decide if I am mentally fit or not. If I am not mentally fit according to a psychiatrist then I cannot apply for a job or vote in an election.”

Bonnie Evans (Queen Mary Uni London)

Bonnie focused on gender issues in her presentation. She emphasised the importance of including women’s mental health and needs in the global mental health agenda. She highlighted the many risk factors that women experience such as sexual violence, domestic violence, low-income and subordinate social status, impacted women’s mental health further. For this reason she stated that “the experiences of women should be central to the development of new research models in global mental health”.

Brother Jimi Huayta-Riviera (Fracarita International)

Brother Jimi spoke in his mother-tongue, Spanish, which was translated into English by bilingual researcher at the CGMH, Elaine Flores. Brother Jimi discussed the global mental health context in Latin America, which he contrasted with the global mental health arena. He spoke about the importance of integrating local factors that contribute to mental health in addition to prominent models of understanding mental health in the global north, such as the bio-psycho-social model.

"The dominant parody in mental health needs to be changing and needs to take into account additional interpretations each local culture will have regarding the suffering associated with mental disorders.”

In Spanish:

"La parodia dominante en la salud mental debe estar cambiando y debe tener en cuenta las interpretaciones adicionales que tendrá cada cultura local con respecto al sufrimiento asociado con los trastornos mentales".

Melquiades Huauya Ore (Strong Heart)

Melquiades told his story of how at 17 years old he was diagnosed with Multi Drug Resistant Tuberculosis which negatively affected his mental health, causing him to develop depression. He discussed how the combination of receiving medical treatment, alongside psychosocial support aided his recovery.

“My vision is a world free from Tuberculosis, as well as the additional mental suffering that diseases create. A world where mental health is viewed as equally as important as physical health, where quality mental health care is an integral part of medical treatment and is a human right.”

In Spanish:

“Mi visión es un mundo libre de TB. Así como el fin del sufrimiento mental a causa de distintas enfermedades. Es tan importante como la salud física, donde la salud sea de calidad, asequible y de apoyo psicosocial, esto es un derecho para todos.”

Victor Ugo (Mentally Aware Nigeria)

Victor’s talk discussed the importance of addressing the ‘gaps within the treatment gap’. He explained that within the gap of the provision of mental health care in the global south, it was important to recognise that those affected are overwhelmingly young people who are more likely to be dependent on their care givers, and due to economic and cultural barriers, are less likely to access mental health services. For this reason he made a powerful call to include the voices of the youth:

“We need to now build out from the coalition of the willing; young people are acutely aware of and frustrated by the challenges of implementing mental health reforms and the lack of sustained progress that’s evident in the global south and so are ready and willing to champion the push for better. We are ready, willing and raring to go!”