Economic wealth and mental health: questioning the paradoxes
Location Appleton Tower, Seminar Room 2.14
Date and Start Time 20 June, 2014 at 09:00
How are mental health and economic wealth related to each other? This panel invites papers questioning wealth/health relations. We are particularly interested in how the methods used by anthropologists can, or cannot, provide a critical vantage point onto global mental health.
How are mental health and economic wealth related to each other? Economic distress, income disparities, and rapid economic change have been suspected to cause a range of illnesses. But this relationship in cases of mental illness remains paradoxical and contested. Efforts to relate economic wealth to mental health have a long history, but sustained discussions for a social "enlightenment" campaign came in the 1990s with the introduction of 'DALY' calculations, marking a shift towards measuring the burden of disability caused by mental illnesses. New DALY-based statistics pushed mental health higher up global health agendas and a "global mental health movement" emerged to lobby for a drastic "scaling up" of mental health services in low and middle-income countries. Core parts of the "evidence base" are calculations of investment in mental health, and how much growth could be generated with increased spending on drugs and therapies. The causal links between economic wealth and mental health remain unclear, however. Initial World Health Organization conceptualizations of global mental health highlighted the dangers of capitalist growth — a classic tale of "disembedding" was applied to mental health. This critical view was abandoned in favour of a pro-growth vision: poverty meant poor mental health, and economic growth meant improved mental health. But the paradoxes refuse to be resolved easily. This panel invites papers questioning wealth/health relations from the point of view of social anthropology. We are particularly interested in how the methods used by anthropologists can, or cannot, provide a critical vantage point onto global mental health.
This panel is closed to new paper proposals.
Poverty, untouchability and mental health: some initial explorations
Ethnography and mental health disciplines combine to investigate the significance of caste identity in the pursuit of opportunity and mental well-being, and how caste humiliation (for Dalits) is constituted through routes which are psychological(self-worth), social (exclusion) and economic (poverty).
Poverty and wealth are relational; so is mental health, but the links between the relationships producing poverty, and the networks within which mental illnesses are embedded, are difficult to decipher. In South Asia there is a further reported correlation between caste and indicators of poverty and mental ill-heath; but again the interlinked or mediating processes are poorly understood. Ethnographic research combined with mental health disciplines provide a means to investigate the significance of caste identity in the pursuit of opportunity and mental well-being, as well as the manner in which experiences of caste humiliation (in the Dalit case) are constituted through routes which are psychological (self-worth), social (exclusion) and economic (poverty). As a first step towards a framework of analysis we discuss two ethnographic contexts in which Dalit groups or individuals manage caste identities as a means to resolve dilemmas of socio-economic opportunity and personal/social well-being. In one, the stigma of being 'untouchable' shifts following conversion to Buddhism among Dalits in slums of Pune (Maharashtra). In the other, distress of exposure and humiliation are narrative turning points in the making of Dalit activists and of their development discourse which locates poverty in the denial of dignity. Seeing how the connection between economic wealth and mental well-being is central to Dalits whose coping mechanisms for life are shaped by social identities that routinely bring social rejection or stigma, and by strategies that equivocate between concealment, disclosure, public assertion, or 'doubling', provides an opening for exploring connections between poverty and mental health.
Breaking the vicious cycle: mental illness and poverty in global mental health
This paper explores the ways in which the movement for Global Mental Health engages and intertwines the discourses on mental health and poverty reduction.
The movement for Global Mental Health has recently reinvigorated discussions regarding the causal relationship between poverty and mental illness. Beginning in the 1980s, mental illness and poverty were described as being caught up in a "vicious cycle", yet the direction of causality still remains unresolved: proponents of "social causation" claim that poverty causes mental illness, while others argue that mental illness gradually leads into poverty through social drift. These two theoretical positions also suggest very different interventions focusing either on financial and structural aid, or on mental health treatments. New discussions in Global Mental Health have attempted to settle this controversy through conducting a systematic review that applies the principles of evidence based medicine (EBM) - including the privileging of randomized clinical trials (RCTs) - to the body of academic literature in order to reexamine the link between poverty and mental health.
This paper investigates the ways in which Global Mental Health shapes the causality debate in new ways. I will particularly focus on the construction of "evidence" and on the novel ways in which health and economic indicators intersect within the GMH discourse. Against this backdrop, this paper explores whether the endpoint of mental health interventions is shifting from a concern with health towards the improvement of productivity and economic well-being, and how such intersectional evidence base aligns mental health with "development" agendas.
Glocal mental health: community psychiatry and the services reform agenda in Lima
By taking a look at community mental health programmes in Lima where the scaling-up of services agenda is being carried out, I will examine the ways in which this approach, which relies more on technical knowledge than local experience and participation, is disseminating “mental health” in the community.
Peru can be taken as an apt example of an economic wealth / mental health paradox: its impressive record of recent macroeconomic growth is matched by a high prevalence of mental health problems. Encouraged by the auspicious financial situation, some key actors -two psychiatric hospitals and the Pan American Health Organization- are now pushing for a scaling-up of mental healthcare via specific programmes and public investment advocacy. These efforts propel the psychiatrist into the position of a detached expert whose role is to facilitate the diffusion of the technical psychiatric and public health formulas of mental health services reform. A by-product of this expansionist drive is that older community mental health approaches that privilege local experience and community participation -and where the psychiatrist acts as provider of care rather than consultant- are being marginalized due to their limited scope. Based on direct observation of these projects, I aim to examine what effects they have and evaluate psychiatry's possibilities of effectively reducing the "treatment gap" in this particular setting. ¿Would it be possible to combine the expansionist model with culturally sensitive and participative approaches?
Worried sick: food insecurity and mental health in the Ghanaian savanna
I explore the causality of a condition in rural Ghana known as worry sickness. I present contextualized data that not only establishes how wealth is understood to relate to mental health in a subsistence economy, but exposes how such a relationship is often deleterious.
This paper argues that the role of anthropology in assessing the relationship between wealth and mental health is to provide more nuanced analysis of these two variables so as to clarify how wealth variably contributes to mental health. Wealth is a broad category that always deserves contextual definition. Furthermore, mental health is understood and experienced in widely differential ways. The long-term and empirical tools of anthropology, including interviews and participant observation, are vital to documenting how people's perceptions of their economic circumstances contributes to mental well being.
I use my current dissertation research in Ghana to explore how food insecurity, as an indicator of low or unstable wealth standing, contributes to a local condition known as worry sickness. Worry sickness involves symptoms similar to what would be labelled as an anxiety disorder or depression and is described as a condition that can limit productivity. Importantly, I draw attention to how gender roles associated with the local food economy reveal differences in how worry sickness is experienced by men and how it is experienced by women. By exploring the causality of worry sickness as well as capturing the experiential effects of the condition, I present case studies that not only establish how wealth is understood to relate to mental health in this rural savannah context, but expose how such a relationship is experienced and often deleterious. Such microscopic analysis of a generalized relationship helps explains why the relationship is important to acknowledge.
The more severe the illness, the better you're off in the public system: economic wealth and mental health care in Hong Kong
Drawing on recently completed fieldwork in Hong Kong, this paper examines the role of psychiatrists in both dismantling and re-enforcing the paradoxes of the mental health/economic wealth relation.
Modern psychiatry has moved towards an understanding of mental health and illness as inherently multifactorial, a conceptualization that also brought forth an urgent need to establish causalities that could be swiftly and cost-effectively addressed. Although the incentive behind such processes is well-intended and apparently rational, this paper suggest that the empirical data collected by anthropologists through interviews and observation highlights discrepancies between expected causalities and mental health as it is perceived and treated in clinical realities.
As mediators between psychiatric knowledge, systems of health care, patients and society, psychiatrists as subjects of study provide a novel angle through which the paradoxes of the mental health/wealth relation can be explored. Hong Kong, a developed region with a comprehensive and extensive public and private health care system, provides evident examples to discuss. Here, it seems on the surface that the public system caters to the more severe mentally ill and the private consoles those ''with so much money they get depressed''. Although in theory this pushes the relations further by linking economic wealth with emotional distress and depravity with more organic disorders, deeper inquiry belies such simplification.
Different stakeholders, such as the WHO, local health governments, and the pharmaceutical industry, construct their own frameworks of causalities, all traversed and negotiated through by patients and doctors alike. Drawing on fieldwork in Hong Kong, this paper looks at how the clinical experiences and perspectives of psychiatrists address and contribute to the understanding of economic wealth as a potential core factor of mental health issues.
Social capital, altruism and well being, in low income communities of Pune city
CAMH, Pune, provides comprehensive mental health services in urban slums. The paper argues that social capital, altruism and the pursuit of happiness through community participation keeps communities resilient in the face of socio-economic adversity and consequent mental illness.
The CAMH has been working since 2004 providing mental health services in urban slum communities of Pune, in India. For 5 years we provided psychotherapies and medication, built on a traditional client-therapist individualistic model. Other than being culturally dissonant, this model replicated therapist-client power relationship, with net result of low client enrolment and high drop out. As social workers, we also faced dilemmas about our role in the coercive care of those with severe mental disorders. In 2008, we changed the frame of community mental health practice to a more equitable one of community development, participation and self determination, engaging, through participatory methods, in understanding how communities defined and responded to their health / mental health problems. How the communities framed, formed, interacted, exchanged and transacted psychosocial areas of life, has, to a large extent, determined our project design. In the last 4 years, we have found that the precepts of social capital, altruism and the pursuit of happiness through community participation are key elements that may keep those communities protected and resilient in the face of socio-economic adversity and consequent mental illness. In this paper, I argue against the view, of Global Mental Health Movement that poor communities, while may be at higher risk, have organized their lives around a strong notion of 'community', from which they can draw their support and care, in the pursuit of their life purposes including happiness.
Poverty and mental health: contextualizing 'access' and 'care' in northern India
Ideas about ‘access to care’ and ‘treatment gap’ are central to ‘global mental health’ discourses. This paper explores the relationship between poverty and mental health by examining how individuals and their families deploy notions of ‘access’ and ‘care’ in everyday life.
Ideas about 'access to care' and 'treatment gap' are central to 'global mental health' discourses. This paper explores the relationship between poverty and mental health by examining how individuals and their families deploy notions of 'access' and 'care' in everyday life. This paper draws on ethnographic research from northern India that examines the nature of engagement (and non-engagement) of rural people with a government community mental health programme. Specifically, I focus on ethnographic interviews with five families identified by the community, family and/or mental health service as having an individual with a 'mental health' problem. Interviews sought to understand the persons' and families' own understanding of the individual's problems, factors that have shaped help-seeking, and how decisions about accessing help are made.
Data suggests that understanding the relationship between wealth/poverty and mental health relationship requires a contextualized understanding of how families make choices at different points within the illness trajectory and how conceptualizations of problems shift over time. The data does not suggest a clear cut relationship between mental health and poverty. Rather, medium term ethnographic engagement with the 'field' permits an unfolding 'picture' of this relationship, particularly consideration of how factors such as caste, gender and 'treatment fatigue' contribute both to 'access to care' and economic impacts of mental health problems. The paper concludes by discussing how notions of 'freedom' play out in relation to 'access' to psychiatric care in this region, particularly in the context of the spread of market forces and neoliberal ideas of 'freedom'.
This panel is closed to new paper proposals.