Global mental health's colonial history

Just as understanding the history of slavery, the Jim Crow era, and other political and structural exclusions of Black America is vital to responding to the current moment, we in global mental health must know the legacy that has shaped what we are doing – and not doing – around the world. Global health is rooted in tropical medicine, which was used to support the British Empire and other Western powers, and subsequent economic expansions and political control into the twenty-first century (Packard, Reference Packard2016).

Throughout five centuries of colonialism, there was no shortage in global health of disparaging commentaries on the behaviors and customs of colonized populations – as pointed out by Frederick Hickling (Reference Hickling2020), who championed anti-colonial psychiatry in his native Jamaica. Throughout the colonial era, most non-Western groups were considered insufficiently evolved to have the privilege of suffering from mental illness (Littlewood and Dein, Reference Littlewood, Dein, Littlewood and Dein2000). Anthropologists and psychiatrists extolled the idea of ‘cognitive primitivism’, which included a lack of mental development to allow the emotional suffering of mental illness (Bock and Leavitt, Reference Bock and Leavitt2019). The British anthropologist Charles Seligman, at the end of the 1800s, characterized communities in the South Pacific as free from psychotic illness until the civilizing effects of colonialism (Seligman, Reference Seligman, Littlewood and Dein1929).

Continuing for most of the twentieth century, Western institutions supported research on populations in LMICs, often at the nexus of psychiatry and anthropology, but there was a glaring void in support and investment in mental health care and services research (Kohrt et al., Reference Kohrt, Mendenhall, Brown, Kohrt and Mendenhall2015b). It was acceptable to observe, but the moral imperative to engage, dialogue, and support health systems and social change was mostly absent, with notable exceptions (Sartorius and Harding, Reference Sartorius and Harding1983) that laid the groundwork for initiatives today that are working towards global access to mental health care (World Health Organization, 2008).

Global mental health research has progressed significantly from its colonial roots to a global partnership model. Most global mental health researchers share an integrationist perspective, recognizing both the universality in mental disorders across cultures as well as meaningful cross-cultural variability (Sweetland et al., Reference Sweetland, Oquendo, Carlson, Magidson and Wainberg2016). However, even though global mental health research is grounded in the social justice and human rights perspective that all individuals have the right to mental healthcare and the need to decrease mental health disparities, we are far from eradicating social injustices. Despite significant progress, especially that of indigenous researchers, the global mental health movement itself is not immune from longstanding national and global histories of institutionalized racism, and this has not been sufficiently acknowledged.

Diversity in the global mental health workforce

Attempting to chart a new course, the past two decades have witnessed the development of a global mental health workforce that includes practitioners, policy makers, researchers, and people with lived experience of mental illness. It is not surprising that it took advocates originally from the global south, along with allies in high-income countries, to eloquently and definitively call for global mental health to be a field of action to bring equity in care and research (Lancet Global Mental Health Group et al., Reference Chisholm, Flisher, Lund, Patel, Saxena, Thornicroft and Tomlinson2007). As we enter the third decade of the twenty-first century, it is important to reflect upon how far the workforce has come and where we still need to go.

Foundations, multilateral organizations, and government programs such as Grand Challenges Canada, U.K.'s Department for International Development, The Wellcome Trust, and The World Bank have shown commitment to promoting the careers and supporting research of people in and from LMICs. In the United States, the first incarnation of a dedicated global mental health research portfolio at the National Institute of Mental Health – the Office for Research on Disparities & Global Mental Health – highlighted research workforce development to address both national and global mental health disparities (Collins and Pringle, Reference Collins and Pringle2016a). The first decade of NIMH funding in global mental health focused on partnerships for research and research capacity building in LMICs (Collins and Pringle, Reference Collins and Pringle2016a). A flagship initiative was the development of collaborative research hubs in LMICs (NIMH, 2020a) to grow the workforce and also engage policymakers, practitioners, and persons with lived experience (Pringle et al., Reference Pringle, Williams and Collins2019). These were later expanded to research among Indigenous communities in the United States (NIMH, Reference NIMH2020b).

Task-sharing and task-shifting initiatives have led to the people who deliver services being from the same communities they serve. However, this has leaned heavily upon the labor of volunteer or low-paid community health workers, the vast majority of whom are women (Singla et al., Reference Singla, Kohrt, Murray, Anand, Chorpita and Patel2017) and many of whom are racial, ethnic, or religious minorities in their own countries. However, at the professional-health level, higher positions continue to be dominated by men from elite groups – just as in the U.S. health and research fields. Globally, ethnic and racial minorities and members of low-caste groups are often excluded from upper-level medical training and positions.

At the global level, women are underrepresented in health research leadership positions, and they are less likely to receive capacity-building opportunities for career development (Crawford et al., Reference Crawford, Rutter, Manley, Weaver, Bhui, Fulop and Tyrer2002; Doyal, Reference Doyal2004). This leads to a bias with the majority of studies published by men from a male perspective (Gayet-Ageron et al., Reference Gayet-Ageron, Poncet and Perneger2019). When women are equally involved in research, this leads to greater impact of research on health outcomes. Equal involvement of female researchers in global health leadership has been associated with reduced neonatal deaths (Bhalotra and Clots-Figueras, Reference Bhalotra and Clots-Figueras2014), improved higher education among adolescent girls (Beaman et al., Reference Beaman, Duflo, Pande and Topalova2012), and greater support for the involvement of women in income-generating activities (Beath et al., Reference Beath, Christia and Enikolopov2013).

Similar analyses are needed to examine the public mental health impacts when leadership is inclusive across ethnicity, nationality, persons with disabilities, persons with stigmatized health conditions, and other marginalized groups. Almost no attention has been given in global health to the mental health of LBGTQ+ individuals, despite the burden of social, economic, and political exclusion faced by these populations.

Police violence and structural violence

George Floyd's killing by the Minneapolis police, and many other named and unnamed victims, are evidence that policing in the United States is broken. Unfortunately, some of the problems that we see in the United States are also seen in other countries, including LMICs. These problems are: (1) lack of mutual trust between local communities and the police; (2) over-securitization of the relationship between the government and local communities; (3) over-militarization of police tactics and equipment; (4) lack of adequate investments in local services, whether social, health, mental health, employment, youth, or education, that can help; and (5) lack of involvement of civil society partners. By virtue of their lack of affiliation with government, community-based organizations can have the trust of and access to individuals and local communities affected by violence in ways that government officials do not.

Whereas there has been an expansion of psychosocial services and initiatives such as World Health Organization mental health Gap Action Programme (mhGAP) in over 90 countries, engagement with police for mental health has received staggeringly scant attention. A low priority has also been placed on the provision of mental health services in prisons in LMICs despite the availability of promising models for how mental health professionals can engage with police, who in LMICs are often the first responders for mental health crises (Jack et al., Reference Jack, Fricchione, Chibanda, Thornicroft, Machando and Kidia2018).

One model to address this is Crisis Intervention Team (CIT) training in which law enforcement, mental health workers, and service users are trained to work together (Compton et al., Reference Compton, Bakeman, Broussard, Hankerson-Dyson, Husbands, Krishan, Stewart-Hutto, D'Orio, Oliva, Thompson and Watson2013). Proof-of-concept testing in Liberia has shown that a 40-hour CIT curriculum and ongoing collaboration between law enforcement and mental health is feasible and beneficial (Kohrt et al., Reference Kohrt, Blasingame, Compton, Dakana, Dossen, Lang, Strode and Cooper2015c; Boazak et al., Reference Boazak, Kohrt, Gwaikolo, Yoss, Sonkarlay, Strode, Compton and Cooper2019, Reference Boazak, Yoss, Kohrt, Gwaikolo, Strode, Compton and Cooper2020). Not only do attitudes change, but suicide attempts in police custody and experiences of violence between police and persons with mental illness are decreased. Crucial to this approach is local ownership of the curriculum and implementation through the national police program and a local service user organization. Moreover, although training law enforcement and supporting collaboration is important, we should heed the call that law enforcement officers should not be first line response for mental health crises. Instead, new cadres of workers should be established in community health systems that specialize in managing risk and facilitating access to care. This type of program has the potential to channel the energy in the streets by providing concrete training and systems changes that not only increase the safety and wellbeing of people with mental illness and other citizens, but also of law enforcement.

More broadly, there are several important gaps in global mental health's approach to violence. Global mental health has not embraced violence prevention like the public health field, which has a growing body of violence prevention theory, evidence, and practice models that are framed as injury prevention. Global mental health has not sufficiently focused on the historic and current role that racism has played in driving violence, nor embraced critical theory perspectives for challenging institutional racism. Global mental health has not comprehensively integrated the concept of structural violence (Kohrt and Mendenhall, Reference Kohrt, Mendenhall, Kohrt and Mendenhall2015a), defined as the systematic exclusion of a group from the resources needed to develop their full human potential. Far too often, marginalized populations confront simultaneous forms of discrimination – race, caste, religion, economic, and gender – necessitating approaches that will mitigate multiple social drivers of mental illnesses. Lastly, global mental health has not sufficiently focused on ideologically motivated violence or targeted violence (violence where a known or knowable attacker selects a specific target prior to attack) and hate crimes. Examples of whole-of-society wraparound approaches to violence in global mental health can be found in Derrick Silove's ADAPT model (Reference Silove2013) for post-conflict societies as well as the work of Mike Wessells (Reference Wessells2009) and Theresa Betancourt (Reference Betancourt, Thomson, Brennan, Antonaccio, Gilman and VanderWeele2020) on rehabilitating child soldiers. Recent efforts in preventing gender-based violence in the global context should also be a role model (Torres-Rueda et al., Reference Torres-Rueda, Ferrari, Orangi, Hitimana, Daviaud, Tawiah, Prah, Karmaliani, Kapapa, Barasa, Jewkes and Vassall2020). Similarly, HIV researchers have increasingly focused on the impact of violence on HIV prevention and care, including especially gender-based violence HIV and intimate partner violence (Maman et al., Reference Maman, Campbell, Sweat and Gielen2000; Meskele et al., Reference Meskele, Khuzwayo and Taylor2019; Rwafa et al., Reference Rwafa, Shamu and Christofides2019).

What should be done?

To address these concerns, much work lies ahead. Here are some starting points.