Invited commentary on Globalisation and psychiatry

Dr Kelly's paper (Kelly, 2003, this issue) is a timely review of the effect of globalisation on mental health and its impact on psychiatric services and of the role that psychiatrists and their professional organisations can play in responding to this phenomenon.

Globalisation, defined by Kelly as ‘crossing borders’, is, as he points out, not a new phenomenon. Indeed, peoples have moved around the world, probably since time immemorial, and one need look no further than the Bible for confirmation that many of the reasons for these movements were the same then, millennia ago, as they are today: economic, to seek a better way of life and a higher standard of living (economic migrants); fleeing conflict and persecution (asylum-seekers); and to conquer and colonise. Nor is it only people that have moved across borders. Trade has been international for many centuries, imbued with the romanticism of the Silk Road, the Spice Islands and the tea clippers.

Why is globalisation so important?

So what is so different today, that globalisation is now thought to be important enough to warrant conferences and learned papers? And, specifically, what is its impact on mental health and the consequent role of psychiatry?

The perceived problems of globalisation are related to a number of different factors.

The magnitude and speed of migration

First, there is the combination of scale, speed and distance of migration. This now results in influxes of large numbers of people into distant and often very different cultures. The consequent cultural diversity can justifiably be lauded as enriching, but in practice it can be very difficult for the individuals concerned – both the immigrants and the indigenous population – to cope with. Such differences are often accentuated by the comparative poverty of immigrant communities. Traditionally, immigrants have arrived with little or nothing and, although they might have had high social and educational status in their own countries, often they have no choice but to undertake poorly paid, menial labour in the receiving country. This can be an immensely stressful experience for these individuals, who find themselves on the wrong side of a socio-economic divide in a strange and often unwelcoming country. It is important also to acknowledge that the sudden arrival of a large number of people who are perceived as competing for limited resources (benefits, housing, education, health care) can be worrying and it is unfair to dismiss such anxieties as racism.

Global trade

In contrast to migration, which in its essentials has changed little over the centuries, global trade, in its broadest sense, has changed dramatically, not just quantitatively but qualitatively because of the growth in the number and size of multinational corporations. This has resulted in a worldwide homogeneity of consumer goods and brand names that appears to threaten local traditions. Simultaneously, it has become evident that the real increase in international wealth has not been equally distributed and that some countries are now vastly wealthier than others (World Bank, 2001). Among many possible examples of such inequalities, the following are particularly striking:

1. • the wealth of the world's three richest billionaires exceeds the combined assets of the 600 million people in the world's poorest countries (Sacks, 2003);

2. • Americans spend more on cosmetics, and Europeans on ice cream, than it would cost to provide sanitation and schooling for the two billion people who currently go without (Sacks, 2003);

3. • 10 countries account for more than 80% of global analgesic morphine consumption, and more than 120 countries report little or no opioid analgesic consumption (Ghodse, 2003).

Information technologies

In theory, information technologies could and should help to narrow this gap; as Kelly points out, they are spreading rapidly from developed to developing countries and they are enabling and empowering (Mandil, 1998; Sharma, 2000). But there is also a risk that the current ‘digital divide’ will increase inequalities, with wealthy economies utilising new technologies to speed even further away from those at subsistence level.

Inequalities: acknowledging and redressing

These inequalities between nations are relevant to this discussion because of their acknowledged effect on health in general and on mental health in particular (Saraceno & Barbui, 1997; World Health Organization, 2001). And a significant difference now is that the world knows about the inequalities. Globalisation of communication, in all its diverse forms, means that people in rich countries do know of others’ poverty. More significantly, it also means that those in poor countries know what they are missing; they know that people are better off elsewhere. And combined with this painful knowledge there is often an inability to do much about it, partly because the world's international monetary systems do not favour weak economies and partly because the commercial decisions of huge multinational companies, in terms of movement of money and shifts of production, can work against governments’ policy decisions anyway. Small wonder that such powerlessness generates anger, frustration and mental ill health, which are at risk of being channelled, often via the new information technologies, into powerful and violent responses that threaten national and international security (Global Forum for Health Research, 2002).

Effects on psychiatry

What then of psychiatry? What role can psychiatrists play in ameliorating the current position? Clearly, they cannot alone rectify the mental health problems associated with globalisation, but their unique knowledge and skills can be used to make a valuable contribution in many areas. For example, with their well-honed communication skills, they should be leading the way in facilitating and enhancing communication between immigrants and others in their local community, developing an environment in which diversity and difference are acknowledged, respected and cherished.

Displacement is a global problem

Psychiatrists need to be prepared to treat the higher rates of mental illness that occur in the immigrant population (Bhugra & Jones, 2001; Gavin et al, 2001). This preparation must include adequate education and training, so that the particular cultural features of mental illness in specific populations are fully taken into account. Kelly's paper explores a number of such issues, but adopts a somewhat Eurocentric/UK-centric stance. In the face of frequent headlines about the number of asylum-seekers and targets for their reduction, it is easy to forget that the number of immigrants from, say, Afghanistan to the UK is a tiny fraction of the number crossing the land borders into neighbouring Iran and Pakistan. Those millions of people might not have travelled so far, but they too have given up their homes, their possessions and their jobs, then to live in comparative squalor in refugee camps. They too will be stressed and unhappy and have higher rates of mental illness, but in a situation in which there are far fewer resources with which to treat them – and because such patients generate few scientific papers, they tend to be overlooked in accounts of globalisation and mental health.

International collaboration

Another role for psychiatrists, therefore, is to develop a dialogue with colleagues who might be dealing with similar issues in very different circumstances. The increased speed of communication that has developed as part of the globalisation process will facilitate this dialogue, but it must be a true dialogue, that acknowledges contributions from all participants and provides a learning environment for all. A well-intentioned willingness to share the knowledge and educational courses developed in the West should not become a patronising attempt to impose the findings and practices of industrialised countries on those working in very different situations. Part of the solution might be to use to the full the knowledge and experience of mental health professionals who are part of the immigrant community and to remove some of the barriers to their professional integration.

Human rights

Finally, of course, there is the role of psychiatry in human rights issues. In the past, most attention has been paid to the treatment of victims of torture and also to the abuse of psychiatry for political purposes. What has been lacking is a willingness to expose gross socio-economic inequalities, to explain how they lead to ill health, and specifically to mental ill health, and how this, in turn, is a fertile breeding ground for terrorism.

Conclusion

In summary, as Kelly's article demonstrates, the impact of globalisation on mental health and mental health services is complex. Although globalisation offers enhanced opportunities for sharing knowledge and improving treatment, there is a real risk that it will further widen the existing gap between rich and poor, with adverse effects on mental and physical health. The role of psychiatry in advocacy for the most deprived has not been fully developed.