The Moral Argument for Mental Health

My blog posts throughout the year have focused on how to implement a rights-based approach in global health efforts. For my final post, I will focus on the global health issue I am most passionate about and explore an underused argument for its prioritization: the moral case for mental health. Mental health disorders account for approximately 12% of the global burden of disease, and they are a leading cause of disability worldwide. Researchers and policymakers often make economic arguments for scaling up mental health services; common mental disorders cost the global economy $1 trillion lost in productivity annually. In addition to economic and epidemiological arguments, the moral argument should be made to prioritize mental health in global health efforts. Growing recognition of the burden and costs associated with mental health has led to significant developments in mental health research, treatment and funding. However, mental health care reform should also include a focus on the human rights of those with mental illnesses, as they experience some of the worst possible human rights violations. A moral argument focused on human rights can be used to continue elevating mental health on the global policy agenda. In the words of Arthur Kleinman, “The fundamental truth of global mental health is moral: individuals with mental illness exist under the worst of moral conditions.”The World Health Organization estimates that 450 million people in the world have a mental health disorder, and approximately 80% of people who need mental health treatment do not receive it. This is largely due to a lack of mental health care providers; almost half of the world’s population lives in countries where there is one psychiatrist to serve 200,000 or more people. Evidence of the disease burden and the proven effectiveness of task sharing interventions in improving mental health have helped to elevate the status of global mental health, but action still remains insufficient.
Male patients spend time in the main courtyard at the Psychiatric Hospital in Managua, Feb. 5, 2009. The World Health Organization warned that the financial global crisis will probably worsen the situation of mental health care in poor countries, as the majority of people who suffer from a mental disorder in developing countries do not receive treatment and many are stigmatized and are subject to rejection and abuse. (AP Photo/Esteban Felix)
Moral arguments should be used to sustain mental health’s rise up the policy agenda. For HIV/AIDS, moral arguments were effectively used by academic researchers, community organizers, people living with AIDS, and celebrities. Responses to the AIDS epidemic grew partially out of scientific evidence and progress for treatment, but vast transformations came from focusing on the lived experiences of those with AIDS. Countries all over the world changed their policies on antiretroviral drugs to reduce the cost of medicines, including India, United States and South Africa. As articulated by Patel, Saraceno and Kleinman (2006), moral arguments were made that “those living with HIV/AIDS in developing countries had the right to access antiretroviral drugs, that the state had to provide them for free, that drug companies had to reduce their prices, that apparently complex treatment regimens could be provided by primary health care providers with appropriate training and support, that discrimination against people with HIV/AIDS had to be combated vigorously, and that knowledge about HIV/AIDS was the most powerful tool to combat stigma.” These arguments facilitated a moral transformation in how the entire epidemic was viewed and addressed. “Effective change in global mental health will have to prioritize moral transformation as the foundation, much as it was for the reform that spurred HIV/AIDS treatment in Africa and Asia,” wrote Kleinman in 2009, almost ten years ago. Consideration of the human rights of those with mental disorders is still mostly absent from mental health policy and dialogue. Transformations to focus on the lived daily experiences of those with mental illnesses, including anxiety and depression disorders and those with psychosis, dementia and other severe illnesses, should be incorporated into mental health programs, policies and advocacy efforts. As shown by activism and action centered on the lived experiences of those living with AIDS, prioritizing the moral conditions of those with chronic mental illness is possible.In making the moral case for mental health, Patel, Saraceno and Kleinman focus on the connections between mental health and physical health, the need to make psychiatric drugs affordable, the effects of urbanization and globalization on lifestyle changes and suicide, the lack of mental health specialists in low-resource settings, how it is unethical to deny effective and affordable treatment to those with from treatable disorders, and lastly, human rights violations. Their final point, the tragic history of human rights violations, speaks to the dire need to promote morality and human rights in global mental health initiatives.In poor societies and wealthy societies, those with mental illnesses experience discrimination, abuse, and rejection. Today, America’s prisons and jails are the country’s de facto mental health system. More than 383,000 people with mental disorders are behind bars in the United States, which is nearly ten times the number of patients in all of the country’s psychiatric hospitals. Moreover, 25% of homeless people in the United States have a severe mental illness at any given point in time, and 45% of homeless people in the United States have had any mental illness. 

In this Oct. 12, 2017 photo, Dominic, who battles mental illness, sits on a sidewalk under the Smith Ave. Bridge in Everett, Wash., which is a constant gathering place for homeless people battling addiction and mental illness. Dominic has been identified as one of the top chronic and costliest users of emergency and other services in Everett, but despite the efforts of a specialized team of experts, he remains on the streets. (AP Photo/Ted S. Warren) 
Some of the most disturbing examples of human rights violations are in low-resource settings. In Ghana, those with severe mental illnesses have been caged and chained to tree stumps, not out of malice but because of a severe lack of resources for mental health and a dearth of policy implementation. In India in 2001, over 20 people with mental illness were burned to death when a fire took place in a healing temple where they were chained to their beds, known as the Erwadi tragedy. A Time article from 2003 describes how those with severe mental illnesses throughout Southeast Asia are often kept in crowded wards where they rarely see health care providers, are given electroconvulsive therapy without anesthesia, and frequently lose contact with their families. Stigma contributes to those with mental disorders being unable to find jobs, attend school, live alone, purchase insurance, attain friendships, or participate in everyday social activities. Understanding and articulating the systemic and structural ways in which the human rights of the mentally ill are denied could help empower those with mental illnesses, their family members, and other supports to advocate for their rights.A human rights framing should be incorporated into mental health policies, programs and awareness campaigns to prioritize the individual dignity of those with mental health issues, ultimately helping to reduce stigma and mobilize resources. Focusing on the “on-the-ground ordinary moral experience of people in the worlds they inhabit locally” could not only allow mental health to gain political clout, but could make mental health interventions more feasible, acceptable and effective. The evidence exists to implement change in mental health, but research alone does not seem sufficient to bring mental health treatment to all who need it. The moral argument matters now.

Julia Kaufman is a T’18 Alumna and a 17′-18′ Human Rights Scholar at the Institute.

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