Mental Health and Inequality

Mental health and inequality are undeniably linked. Though it’s easy to generalize inequality as having a unilateral push on an individual’s mental health, with poorer conditions generating pitfalls of depression and alcoholism and wealthier ones fostering healthy mental attitudes, in reality the effect of inequality takes many forms. Taking the broader context of social, economic, and cultural components of a society into account while considering inequality, it becomes clear that this disparity affects the quality of care mentally ill patients receive while being reshaped by the conditions of a particular time and place. Examining this relationship through the lens of medical anthropology provides further insight, but ironically leads to both understanding of the dynamics between the three and complicating potential solutions at the same time. In this essay I examine the issue of mental health and inequality in Romania, compare it to the points in the WHO’s World Health Statistics and Global Health Watch 3, and apply medical anthropology concepts to the global health issue in order to understand the many forces that surround and propel it.

There isn’t really one way to frame mental health and inequality as a global health problem; it is a multidimensional conflict of interests that serves as both a product and an indicator of deeply rooted social problems within a society.  On the very surface, the issue of mental health and inequality encompasses the countless cases of depression, Parkinson’s disease, schizophrenia, and other mental illnesses that affect the ability of millions to live and function normally. However, the issue is magnified when one considers that mental illness is “related to many other factors, including food insecurity, inadequate housing, unemployment, occupational health, a lack of mental health services, and conflict” (People’s Health Movement 2009:154). The compounding effect of inequality on mental health creates conditions that push those with mental illnesses into a black hole of inadequate care and inability to recover once hospitalized. Furthermore, the overshadowing interests of economy and private interests obscure potential solutions and complicate options for affected individuals and their families. By addressing this problem from a medical anthropologist’s point of view, I approach this global health issue while taking into account the cultural, political, and societal pressures that influence the illness experience and healing process of patients. In embracing these factors in our view of mental health and inequality, one can better understand this issue on a more insightful, holistic level.

The perspectives on mental health and inequality offered by the WHO and Global Health Watch 3 frame the global health problem in terms of numbers, largely focusing on statistics and descriptive graphs to provide for a comprehensive view of the problem. Through analyzing data, the WHO addresses a few social indicators of mental health, such as the number of psychiatric beds available to patients (2009:123-131), but doesn’t take into account cultural influences on societies’ access to mental health care. Similarly, Global Health Watch 3 connects mental illness to other indicators of inequality, such as alcohol and drug use, but remains on a more general level when discussing social and economic influences on mental health. In contrast to how a medical anthropologist would approach the problem, Global Health Watch 3 offers potential plans for improving the quality of mental health around the world, advocating for community-level action and more pervasive mental health treatment in areas of non-specialist care. While the approaches offered by the two reports succeed in offering a general panorama of the relationship between global health and inequality, they do not provide for detailed inspection of the issue. From a medical anthropology perspective, examining this global health issue would be framed in many perspectives—the social, cultural, political, and economic ties of a specific society to its state of mental illness and inequality would all be considered. In addition, the specific time period and history of the society would be recognized in order to shed more light on the current state of mental health and inequality. Through viewing the issue through different filters, a medical anthropologist approach to this world health issue analyzes it on the many levels on which it exists.

The article I chose demonstrates how this comprehensive understanding of global health issues outside of the realm of biomedicine can lead to explanations about the present state of the problem. Dr. Friedman’s “The ‘Social Case’” explores a specific phenomenon – the creation of a new category of patients—in modern Romania from a medical anthropologist’s perspective, interpreting it as the product of the economic and social climate of the last century. The term “social case” describes those who were institutionalized for mental illnesses and subsequently have recovered enough to be discharged, but are kept in hospitals because they lack a means of reconstructing a stable, self-sufficient lifestyle outside of hospital care (Friedman 2009:376). Effectively, these patients are trapped in a black hole of poverty and dependence, often leading to a revival of their mental illness.  A number of societal, cultural, and economic conditions create the inequality that fosters the social case, with postsocialism, neoliberalism, and the process of a national shift to deinstitutionalization being the largest contributors to this phenomenon. The inequality of care between the economically poor and wealthy creates an artificial double standard of treatment that puts the impoverished, those with a generally higher rate of mental illness, at a disadvantage for finding adequate treatment. Furthermore, existing perceptions of psychiatry as a lesser practice in Romania results in a lack of funding that adds to the social cases’ difficulties in receiving adequate care. In terms of infrastructure, the process of deinstitutionalization and movement away from Romania’s welfare system puts those without the resources to afford private care at a high risk of ultimately becoming social cases in large hospitals. In the end, Dr. Friedman suggests that psychiatrists have taken on the role of social support in the lives of the social cases where the Romanian welfare state, friends, and family have all failed.

Applications of medical anthropology concepts

As we learned during the very first week of class, medical anthropology utilizes tools that help to filter through the cacophony of voices present in discussing global health issues. The universal downward spiral of mental health and inequality is no exception. Though there are numerous economic, social, and cultural influences on mental health and inequality, they all point to one common message: all aspects of this global health issue must be accounted for in order to examine its true roots within a specific society.  

Neoliberalism and modernity can control the illness experience of those with mental illnesses, and in third world countries, condemn them to a lifetime of institutionalization. Modernity carries the context of individualization (Janzen 2002:30), which can cause the perceived causes of mental illness from societal influences to an individual’s actions, resulting in indirectly stigmatizing those who are diagnosed with mental illnesses. These cases can be viewed as falling into mental illness due to the ramifications of their personal choices and therefore scorned as irresponsible. Furthermore, rapid neoliberalization of countries whose economies are not mature enough for privatization may result in a lack of employment. Employment, as demonstrated in Dr. Friedman’s findings (2009:385), can play a vital role in the healing process of patients as a way of transitioning to a self-sufficient lifestyle as well as serving as a productive distraction from the illness itself.

In terms of socioeconomic status, its influence on perceptions of those with mental illnesses can lead to not only unfair treatment in terms of affordability, but inequality based on blatant stereotyping. Outward “indicators of wealth” such as clothing, transportation, and appearance influence the standards of treatment that doctors and nurses envision when approaching patients, producing different healing processes based solely on socioeconomic status (Friedman 2009:388).  Furthermore, the difference in the perception of those with money and those who do not can also affect the epistemologies and nosologies involved in diagnosing mental illness. In “The ‘Social Case’”, depression among the affluent was assumed to be caused from the stresses of “’adapting’ and ‘adjusting’ to the new demands of capitalism”, while the same illness among the destitute was recognized as a “somatic illness, a purely brain-based disorder” (Friedman 2009:380).  On the surface, socioeconomic status functions as a limiting factor on the options a patient has access to when seeking care, but also continues to influence their illness experience once hospitalized.

Finally, biopower and biopolitics define the resources available in treating mental illness and determines a society’s ability to improve its infrastructure relative to this global health issue. In some countries, including Romania, a social stigma against psychology exists—psychology is perceived as a low-tier field of medicine, reserved for the “’least talented’ doctors” (Friedman 2009:383), leading to a lack of professional help in treating mental illness cases. Furthermore, doctors within the field may feel afraid or not empowered enough to advocate their needs as practitioners, maintaining the gap in authority. The size of the psychiatric resource pool within a society as defined by biopolitics also decides how well the specific needs of institutionalized individuals are met.

Conclusions

From a conceptual standpoint, my understanding of the medical anthropology concepts we learned in class deepened and expanded through applying them to the “social cases” of Romania. Before reading about a specific problem, I felt metaphorically like a medical student in their first or second year—I had knowledge but didn’t know how to connect it to today’s problems. During lecture and quiz section I learned numerous medical anthropology terms and concepts, and throughout the quarter I’ve read about, listened to, and observed the experiences of medical anthropologists through articles and videos. As much as I had absorbed, for me application was particularly difficult because analyzing real world issues was more challenging than just understanding ideas. I feel like analyzing the case of mental illness and inequality in Romania was like diagnosing my first patient—I struggled in the beginning due to hesitation, but gradually grew more comfortable with exercising the concepts I recognized in the article.  Most importantly, this experience has inspired me to think even more about the individual’s right to health and the massive leverage inequality has in impeding the universal liberty.  Unfortunately, it’s impossible to fulfill everyone’s right to health within a society due to the access to resources that inequality causes; however, it’s possible to recognize that such complexities in providing mental health care exist in all societies.

It’s this awareness that medical anthropology can promote to reshape what needs to be done about mental health and inequality. Examining this global health issue from the lens of medical anthropology reveals the monstrous scale of inequality and how it is deeply rooted in each step of mental illness experience, from diagnosis to recovery. Furthermore, it forces the complications of the problem to the surface, bringing deeper social subproblems to the forefront. Though in recognizing these obstacles, a sustainable solution to this global health issue becomes more and more obscured, a multifaceted perspective augmented with the help of medical anthropology allows policy makers from the local to global scale many potential angles of approach. With this insight, a more holistic understanding of the countless actors and voices involved is possible.

To conclude, I’d like to relate the importance of this case study to the very first lecture of the quarter—the meaning of an apple. How do individuals within a society view mental illness differently, and how are the person-to-person differences significant? Undoubtedly the perceptions of an individual and the collective hegemonic perception of a society shape a patient’s illness experience and provide the foundation for what is considered appropriate healing processes. However, as demonstrated through the social cases of postsocialist Romania, inequality imposes an equally prominent force on the community’s response to mental illness. It becomes clear that, ironically, biomedical and scientific knowledge alone are insufficient in improving the conditions of the mentally ill. Furthermore, solutions to these global health problems are impeded by the surrounding framework of specific societies. When taking the social, economic, and cultural complications of a global health issue into context, medical anthropology is necessary to analyze and interpret the effects of such factors to construct more meaningful and accurate conclusions about communities. It is only through this standpoint, a comprehensive perspective, that paths toward improvement in mental health care can be found.

References:

Friedman, Jack R.

2009  The “Social Case”: Illness, Psychiatry, and Deinstitutionalization in Postsocialist Romania. Medical Anthropology Quarterly, Vol.23, Issue 4, pp. 375-396. American Anthropological Association.

Janzen, J.M..

2002  The Social Fabric of Health: An Introduction to Medical Anthropology. McGraw Hill.

People’s Health Movement, Medact, Health Action International, Medicos International and Third World Network.

     2011  Global Health Watch 3: An Alternative World Health Report. London: 

Zed Books Ltd.  

World Health Organization.

2011  World Health Statistics 2012. World Health Organization.  

Allison Kuo