Perspectives

The art of medicine

Global mental health: a failure of humanity
In the USA, the worlds sliding superpower, the prisons are
the functioning mental-health-care system. Somewhere
between a third and half of all the homeless people in
American cities suer from mental illness. Yet balancing
this abysmal record, mental health care in the USA is nally
receiving renewed attention and resources aimed at closing
the gap in parity with the rest of health care. The worst
abuses of the mental-health-care system are undergoing
near constant, if unsustained, reform and patients rights
are being better, if still not well, protected.
Turn now to the lives of people with mental illness in
poor societies. Appalling, dreadful, inhumanethe worst
of words pile on each other to name the horrors of being
shunned, isolated, and deprived of the most basic of human
rights. But this is not a crisis of the day; it has been the reality
of people with mental illness for the four decades that I have
been involved in global health and probably for centuries
before that. I have personally witnessed individuals with
mental disorders in east and southeast Asian towns and
villages chained to their beds; caged in small cells built
behind houses; hospitalised in for-prot asylums where
they are kept in isolation in concrete rooms with a hole in
the oor for urine and faeces; abused by traditional healers
such that they become malnourished and infected with
tuberculosis; scarred by burns resulting from inadequate
protection from cooking res; forced to dress in prison-like
clothes in asylums with shaven heads and made to perform
child-like dances and songs for gawping visitors; knocked to
the ground and forcefully held down for electroconvulsive
therapy when psychotic in an emergency room; laughed at
by the police; hidden by families; stoned by neighbourhood
children; and treated without dignity, respect, or protection
by medical personnel. The situation has improved in cities
but not that much in small towns and villages. I have read
reports from Africa and Latin America that convince me
that, although the details may dier, the situation of neglect
and abuse is not so dierent.
So ground zero in global mental health is not the 15% of
the global burden of disease accounted for by the cost
of mental disorders; nor is it the under 2% (and often less
than 1%) of expenditure on health that is estimated to
go to services for psychiatric conditions in countries
in Africa, Latin America, and south and southeast Asia
(compared to over 10% in the USA). Nor is it the absence,
or extremely small numbers, of psychiatrists, psychiatric
nurses, psychologists, and psychiatric social workers in
these impoverished nation states. No, bad as these indices
of the deciencies of care are, they are not ground zero.
Ground zero is the routine local condition of people with
mental illness (including those with dementia and autism,
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for example) in communities, networks, and families. It is

their pain and suering. Their moral life. The fundamental
truth of global mental health is moral: individuals with
mental illness exist under the worst of moral conditions.
The widespread stigma of mental illness, which prevails
in countries as disparate as China, India, Kenya, Romania,
Egypt, and the USA, marks individuals with severe psychiatric disorders as virtually non-human. None of the worlds
major religionsno matter how strong is its message of
support on behalf of the most marginal and vulnerable
suerershas been able to break this cycle of misery. Nor
have modern anti-stigma campaigns and mental health
laws. They have somewhat improved practices inside the
asylum, but have had limited eect on those in society at
large. Mental health professionals themselves and family
members, moreover, have repeatedly been shown to be
the most eective and ecient transmitters of stigma.
Globalised cultural changes have brought about important
reductions in the discrimination, fear, and isolation
surrounding depression and anxiety disorders in many
countries, and this is no small improvement that holds
practical relevance for global mental health in general. Yet
the moral conditions for people with psychosis, dementia,
and mental disability remain horrendous most everywhere.
This realisation demands recognition that any eective
change in global mental health will have to prioritise moral
transformation as the foundation for reform of global
mental health, much as it was for the reform that spurred
HIV/AIDS treatment in Africa and Asia. But how is that to
happen? How can delivery and management programmes
for mental illness, which are so tenuous that almost none in
poor societies has ever been scaled up, be expected to take
on this objective? And yet, if they (and we) fail to do so, then
almost certainly mental health programmes are destined to
continue to fail. So what, in actual practice, can be done?
Suppose we begin not with top-down policy and
programme initiatives, but rather with the on-the-ground
ordinary moral experience of people in the worlds they
inhabit locally. For example, in the myriad villages and
towns of China, the worlds rising superpower, ethnographic
research documents that people disguise and hide family
members with mental illness until they are no longer
capable of denying psychosis. Without professional services,
families usually bear the huge burden of caregiving alone.
The folk healers they can turn to have little to oer that
has been shown to be helpful. Finally, family members
run out of energy, patience, and funds. At that point, and
especially after a period of institutionalisation, protection
becomes rejection. The aected person becomes a nonperson in the responses of family members and outsiders
603

Bridgeman Art Library

Perspectives

Philippe Pinel releasing people from their chains at the Salptrire Asylum, Paris, 1795 by Tony Robert-Fleury

Further reading
Chang D, Kleinman A. Growing
pains: mental health care in a
developing China. The Yale-China
Health Journal 2002; 1: 8598.
Desjarlais R, Eisenberg L, Good B,
Kleinman A. World Mental
Health: Problems and Priorities in
Low-Income Countries. New York:
Oxford University Press, 1995.
Patel V, Araya R, Chatterjee S, et al.
Treatment and prevention of
mental disorders in low-income
and middle-income countries.
Lancet 2007; 370: 9911005.
Patel V, Saraceno B, Kleinman A.
Beyond evidence: the moral
case for international mental
health. Am J Psychiatry 2006;
163: 131215.
WHO. Global Burden of Disease:
2004 Update. Geneva: WHO,
2008.
WHO. Atlas of Mental Health
Resources in the World, 2001.
Geneva: WHO, 2001.
WHO. World Health Report
Mental Health: New
Understanding, New Hope.
Geneva: WHO, 2001.

604

(including mental-health-care workers). No longer regarded

as fully human, he or she becomes a target for abuse,
discrimination, and ultimately rejection. The individual
is no longer valued as an eective node in the network of
connections that form social life. Social inecacy means
non-participation in social reciprocity, including gift
exchange, the fundamental cultural process of living an
ordinary life. It means non-participation in marriage, in work,
in education, in celebrations, festivals, mourning rituals, and
in ordinary experience in markets, in stores, and in other
everyday activities. It is to be treated as if one didnt exist.
Small wonder, then, that the single most important
element in the illness experience and treatment of those
with chronic mental illness is this dangerous moral
response. To call this sea of danger stigma is to trivialise its
powerful eects and to be euphemistic about the enormous
barriers it creates for the development of global mental
health programmes that can actually address what is most
at stake for suerers and their networks. This is, pure and
simply, social death.
In international law, the concept of a states responsibility
for protection of its citizens has been gaining ground.
Surely the failure of protection of people with mental illness
is a failure of the state? State resources must be applied to
lessen this human tragedy. Even in the setting of a global
economic downturn, states must be held accountable
for this basic protection. That translates into protection
of patients rights. It means, for example in China, that
the current emphasis of the state and its psychiatric
institutions on protecting society from the potential
dangers posed by people with mental illnessa threat
which while real is grossly exaggeratedmust be turned
completely around to emphasise protection of the rights
and responsibilities of patients. This requires advocacy and

laws, no doubt, but these will be inadequate if they are

not accompanied by a sea change in what is culturally and
institutionally at stake for society in general and for the
mental-health-care community in particular. If this sounds
like a tall order, think of the extraordinary transformation in
ethical, legal, and political responses to the AIDS epidemic,
or to the epidemic of tobacco-related diseases. At their
origins, these transformations grew out of new scientic
evidence; yet eventually their success built on moral change
in lived values over what really matters in peoples lives.
Such a moral transformation has yet to take place for
those experiencing psychosis, dementia, and other mental
disabilities. Bringing about such a change needs to become
the central focus of institutions, professionals, and family
movements in the mental health eld.
There are a few green shoots that could blossom into
more robust cultural change. In China and India, for
example, some family groups are advocating on behalf of
those with mental illness and leading psychiatric institutions
have begun to include ethical issues in the training of
practitioners. In Europe and the USA, narratives by people
with bipolar disorder or schizophrenia, for example, are
attracting a popular audience who read about the real
experience of being mentally ill in their societies. While
slowly but surely, global health experts are beginning to
legitimise psychiatric disorders as an object of attention for
global health programmes, even if they have hardly come to
address the practical issues of resources for implementation.
Meanwhile, in EuroAmerican and east Asian populations,
the media has highlighted the new reality that people aged
85 years and older are the fastest growing population. The
upshot is a huge amount of concern in popular culture about
dementia. That concern focuses on both the plight of older
people with dementia and the responsibilities and conicts
over caregiving facing their adult children. From invisibility
and silence, dementia is moving to the centre stage of
global culture. The fact that a person cannot remember and
has great cognitive failures is no longer taken to erase his or
her humanity or to negate his or her personhood. Of course,
this transformation is in its early days and could be limited.
Yet, if it continues to develop, there is the possibility that a
cultural transformation in how dementia is regarded could
inuence how psychosis is dealt with.
It is not my intention to be overly optimistic. I only seek
to call attention to aspects of global culture that seem
promising and that suggest that an initial change, which is
the crucial grounds for improving the moral conditions of
those with chronic mental illness, may be underway. And
this is what all concerned with global mental health must
work to advance. The moral failure of humanity in the past
does not mean we must tolerate this failure any longer.

Arthur Kleinman
kleinman@wjh.harvard.edu

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