Invited commentary on Globalisation and psychiatry

The responses of nations and individuals to globalisation and the effects of the phenomenon on the mental health of the population are many and varied, according to its critics’ perceptions. Kelly (2003, this issue) highlights the greatest criticism of globalisation – the management of cultural diversity. This is related to homogenisation of cultures across the globe and to how that process leads to loss of individual and kinship cultural identities. The act of globalisation is based simply on a capitalist mode of production – moving it around the world to use cheap labour – and on increased access to global media. Both of these influence cultures in the context of industrialisation and urbanisation. Berger (2002) suggests that the dynamics of globalisation are related to diffusion of culture through both elite and popular vehicles: business and the media.

Kelly argues for a return to the biopsychosocial model of psychiatry, and he is right. However, biopsychosocial models never went away – only the biosocial psychiatrists did, in their rush to identify genes leading to schizophrenia or to study brain scans to identify areas that contribute to mental illness. Unfortunately, neither pathway has led to a psychiatric utopia. Today, the social has given way to cultural, spiritual and anthropological aspects of new aetiological models trying to enter the nosology.

Migration in the era of globalisation

Globalisation not only leads to migration of individuals across national boundaries: the borders themselves are ‘disappearing’ because of the internet. Globalisation is seen as the intensification of global interconnectedness (Inda & Rosaldo, 2002). This leads to an itinerant capitalism that demands the cheap production of goods, which in turn results in the industrialisation of nations that have the workforce but not the infrastructure to cope with it. The consequent rural-to-urban migration brings with it a series of problems and expectations. Blue et al(1995) have elegantly demonstrated increased rates of common mental disorders in the urban slums of India, Brazil and Chile. This increase is related to social factors – poor housing and its related infrastructure and economic problems. The loss of social support resulting from migration to urban areas brings its own problems.

There is considerable evidence to suggest that migrants are prone to particular psychiatric illnesses (Bhugra 2001; Bhugra & Jones, 2001). The acculturation due to globalisation may lead to loss of original cultural identity, thereby giving rise to certain psychiatric conditions.

We know that ‘culture shock’ and conflict of cultures also lead to increased psychological morbidity. Kelly places poverty at the top of the list for increase in morbidity, but increasing awareness of discrepancy between what individuals thought that they could achieve as a direct or indirect result of globalisation and what they actually attain is more likely to produce alienation and hopelessness.

Urbanisation and industrialisation

The urbanisation and industrialisation arising from globalisation both lead to a loss of personal identity. The individual and cultural voice of the ‘other’ expected to provide the labour of globalised industry is lost. Gupta & Ferguson (2002) enquire about the identity of the ‘we’ as well as of the ‘other’. A cultural landscape for and of tourists and the presence and worries of the migrants, the refugees, the exiles and the guests affect nation states and the national character.

It is unfortunate that Kelly did not focus more on the impact of political abuse on the migrants forced to flee when the interference of world superpowers allows tyrants take control. The new global cultural economy has to be seen as a complex, overlapping, disjunctive order that can no longer be understood in terms of existing centre–periphery models (Appadurai, 2002), but in the total cultural context. The centralised sources of economic and social power are now giving way to a model in which power and goods move across nation states. The globalisation of culture is not the same as homogenisation.

Impact on mental health

The altering patterns of culture as a consequence of globalisation and media homogenisation have been illustrated by Becker et al(2002), who found that rates of eating disorders in Fiji went up as a result of the introduction of television. To make sense of what Appadurai (2002) calls ethnoscapes, mediascapes, technoscapes, financescapes and ideoscapes, the long-term impact of globalisation on the human psyche must be studied by psychiatrists in conjunction with economists, geographers, anthropologists and sociologists. Appadurai's ‘scapes’ can be understood at both the individual and the collective level, and the world view of individuals and of groups is likely to change with globalisation. Clinicians must be prepared for this.

Mahadevia (2002) highlights an important factor relating to urbanisation by suggesting that the loss of public space to private owners contributes to urban stress.

Another danger of globalisation worth bearing in mind is the drive to homogenisation that derives from the culture of consumerism (Moreiras, 1998). Clinicians must also be aware of the relocation of languages in cultures as a result of globalisation (Mignolo, 1998). The links between languages and the boundaries of humanity have shaped the ideas of literature, the cultures of scholarship and civilisation itself. The articulation of languages and their cultures have reduced barriers to communication. The growing ‘Anglicisation’ of the world is obvious. It is possible that such globalisation may be causing cultures to become more fundamentalist and restrictive, which might in itself contribute further to stress and psychological morbidity.

Conclusion

Kelly is right to caution us that human rights should be a priority, but as Ghodse (2003, this issue) points out, he is offering a Eurocentric view. The attack on New York's ‘Twin Towers’ was not a result of globalisation. Kelly also proposes that the loss of social capital resulting from increased globalisation might be inducing a wave of anomie in Western populations. However, he says little regarding the positive implications of globalisation for world mental health. The international action that the World Health Organization recently took to control the spread of severe acute respiratory syndrome (SARS) shows just how globalisation can benefit people. The dissemination of preventive and public health medicine is clearly a positive aspect of globalisation. Nevertheless, the impact of globalisation on individual migrants is likely to be long lasting in both economic and psychological terms.