In the United States, our prisons remain our largest mental-health system. Rates of anxiety, depression, and other social ills continue to rise across the country, mirroring trends across the developed world. But left out of many discussions of our global mental-health crisis is the profound impact it is having on the Global South, where over 80 percent of the people suffering mental disorders actually live.
In Ghana today, treating mental illness means chaining people indoors, where they are shunned and rendered pariahs by their communities. Misunderstood or misdiagnosed, youth and adults are denied opportunities to live independently, work, or attend school, and stigmatized families seek either to treat or to protect their loved ones by keeping them locked up at home—a method known as “shackling.” Some end up locked in isolated “prayer camps,” often forced to live in squalid conditions and fed concoctions thought to offer a spiritual remedy. Voluntary, appropriate treatment, meanwhile, is virtually nonexistent, and many communities lack awareness of, or misinterpret the symptoms of, mental illness.
Across the Global South, treating mental illness is less than a priority in communities that are often struggling just to provide adequate vaccination coverage, or to contain HIV infection. In poorer countries, threadbare health-care systems are failing to stay staffed with general-practice physicians, and mental-health clinicians are seen as a rare commodity.
Amid these structural barriers, where traditional religious beliefs dominate and public healthcare infrastructure is weak, isolation may be seen as a last resort for recovery, or perhaps a way to conceal a family’s shame. But the underlying culprit is the inability of the mainstream mental healthcare field to promote a diverse, culturally nuanced appreciation of mental illness and neurological disease, and shortcomings of global public health agencies to integrate mental health into a broader long-term development agenda. But solutions must be rooted in local institutions and indigenous cultures as well. Mental health must be confronted by local initiatives that empower the most impacted communities.
Systematic imprisonment of the mentally ill has also plagued Indonesia, where, despite the abolition of such practices in the 1970s, some 18,000 have faced forced confinement in recent years, tied down to their beds, warehoused in animal pens, and branded with public shame. However, under public pressure, the Indonesian government has begun to reform, vowing to provide more psychiatric-treatment resources.
As one of West Africa’s most stable democracies, Ghana could be another place where the health-care system may be reaching a turning point. Though there is a massive deficit in mental-health services, with only about 14 practicing psychiatrists for a population of 26 million, its parliament passed a landmark mental-health law in 2012 that included provisions for voluntary, community-based services, along with human-rights protections for people affected by mental-health issues. But it will take funding and political momentum to implement this framework in practice.
Human Rights Watch has launched a media campaign to end shackling with a coalition of Ghana-based and international mental-health advocacy groups, urging the government to fully fund community-based treatment alternatives. “We hope to scale up this campaign, but are focusing on Ghana because there’s a real opportunity to bring about change here,” says Shantha Barriga, HRW director of disability rights, via e-mail from Brussels, noting that “The government recognizes the shackling as a human rights abuse—and there is space to put pressure on them to fund and raise awareness about community mental health services, so people don’t resort to shackling.” A parallel campaign in Somaliland is also underway.
The mental-health crisis intersects with other public-health epidemics in societies with weak social-service infrastructures. Many who suffer from mental illness have done so since childhood and have never been properly diagnosed, and their lives are relegated either to criminalization or violent victimization. According to the World Health Organization, the epidemics of major depression and schizophrenia raise a person’s risk of early death by 40 to 60 percent, due to related health problems like cancer, diabetes, heart disease, or HIV infection. Socially, mental-health problems disrupt everyday life through lost productivity at work, exclusion from schooling, and family violence.
Death by suicide is one of the most common escape routes for youth, along with coping through abuse of alcohol or drugs. The millions of youth and families growing up in conflict zones suffer mass trauma, displacement, and intense poverty, resulting in generation-wide mental-health epidemics that can impede young people’s opportunity to contribute to the recovery of their communities post-conflict.
Although mental health is part of the United Nations global development agenda, it remains little more than a bullet point in poorer health-care systems, which struggle to manage basic physiological care, such as preventing infectious disease or reducing infant mortality. Yet mental health is an integral component of public health, since disease, poverty, and abuse fall disproportionately on the psychologically vulnerable.
In 2013, through a process that engaged 135 member states, the WHO issued a seven-year action plan that includes expansion of community-based care along with culturally oriented research on mental illness in diverse social contexts in order to evolve from a Western-centric treatment model to more culturally competent therapy methods.
That some people remain shackled, that prisons remain America’s largest mental-health system, and that children penned in squalid refugee camps are growing up steeped in unspeakable trauma are facts attesting to a universal health crisis. But some suffer more than others, because their poverty and remoteness make them easier to silence and ignore. Denying empathy to them is ultimately society’s collective self-harm.