Unity within Diversity: Mental Health in the Global Century
EUGENE B BRODY
World Federation for Mental Health, Baltimore MD, USA
The Margaret Mead Memorial Lecture, Vancouver BC. Canada 2001
We stand at the threshold of a global century. Our small planet’s human population is truly interconnected by world-wide communications and a global economy. And we are at the historic high-water of human migration. Formerly distant peoples now breathe the same air, compete for the same resources, struggle to maintain their own cultures and strain to deal with their personal and family traumas in the midst of diversity and change.
Where, in this new century, is the role of the voluntary, international, non-governmental mental health association such as World Federation for Mental Health?
Let us remember that some elements of today’s context are not entirely new. In ancient Sumer, in the fourth millennium BC, long distance trade resulted in the core settlements of native landholders being surrounded by outsiders, people of different cultures who lived close to each other. That "poly-ethnic mingling" was what historian William McNeill called the "first multi-cultural reality" (McNeill, 1999).
Today’s intermingling reflects the speed and ease of long-distance transportation and communication, as well as the attempts of refugees and other migrants to escape war and poverty. It reflects, as well, the fact that there are many more of us than ever before – with no extra space to accommodate us.
We also have new aspirations. Radio messages and televised images attract economically deprived and politically oppressed peoples looking for better lives. UN sources indicate that more than 4 billion of the planet’s approximately 6 billion people live on the equivalent of less than 2 dollars a day. They are immigrating from developing to developed, from the global South to the North, at an unprecedented rate. The industrialised regions are being colonised from those areas, which are still developing, or simply stagnating. On one hand this can make the host populations more open to others, more interested in other races and cultures. On the other it can make them more defensive and vulnerable, not only to fear and hatred, but to disease. "If someone has tuberculosis in Sverdlovsk, Russia on one day, he may have it in New York City the next" (Novotny, 2000).
This new world is recognised in the theme of the 2001 World Congress for Mental Health – respecting diversity. I applaud its idealism, but remember that people divide themselves into warring factions on almost any basis: ethnicity, race, gender, sexual preference, religion, nationality, political parties. Dissidents versus conformists, heretics versus the orthodox, all try to destroy each other’s idols. They fight to the death, not only for space and resources, but about the integrity of beliefs, and threats to their identities.
The continuing conflict between diverse groups has stimulated the United Nations to call a "World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance". Its agenda included the treatment of immigrants and asylum seekers in developed countries, discrimination against gypsies in Europe, against people of African descent in Latin America, and contemporary slavery in Africa. There was also pressure, against the strong objection of the Indian government to include the Indian caste system. Caste has been legally outlawed. It may be estimated, from several sources, however, to still affect the lives of up to 200 million people.
The problems of racial-ethnic diversity and minority discrimination cannot be separated from those of economic diversity and oppression. Today at least 27 million people work under various forms of enforced servitude, apart from prostitution (NY Times, 9 Sept 2000). Slavery and its equivalents, including child labour, are most firmly entrenched in the less-industrialised world, in nations with oppressive traditions such as the devaluation of women and the caste system.
That is one reason why, aside from race and ethnicity, the UN is most concerned with the continuing subjugation of women as an international human rights and diversity issue. The triad of female illiteracy, high fertility rates and infant mortality is especially high when poverty is associated with culturally defended male privilege and a failure of men to communicate with the women whom they impregnate. To this is now added the risk of HIV infection. In cultures in which women are not only ignorant and illiterate but powerless, they cannot insist that their male partners wear condoms.
Economic globalisation brings problems as well as rewards. In 1999 UNICEF reported that with the transition to a market economy the status of women and girls in much of Eastern Europe and the former Soviet Union was deteriorating. With the collapse of state-supported employment and social services their life expectancy was shrinking, and smoking, alcoholism, prostitution and sexually transmitted diseases were increasing.
More recently UNICEF has turned its attention to curbing child marriage and its early pregnancies which complicate a life of subservience with serious health risks. A group of UN agencies including the World Bank has issued a joint statement on reducing maternal mortality in which two out of three key areas for action involve "empowering women to make choices in their reproductive lives" and their being "able to choose if and when to become pregnant".
But the search for identity through empowerment is common to all humans. It varies as people become targets of discrimination along with changing patterns of migration, needs for agricultural and factory labour, political or ethnic dominance, and the control of resources.
Erik Erikson made the point that a stable sense of identity depends upon achievement that has meaning within one’s own culture. Today, there are more questions than ever about just what culture or national tradition one belongs to. As long ago as 1930 sociologist E.V. Stonequist, in the United States, observed the problems of what he then called marginal people, mainly immigrants and their children and upwardly mobile members of native-born minority groups, especially Mexican and African-Americans. These were people, as he put it, with a foot in each of two cultures who did not feel themselves as thoroughly belonging to either. In the United States this thinking was also applied to first generation children of immigrant Jews from Eastern Europe. In India it has been applied to members of the untouchable caste who were upwardly mobile or passing as belonging to less restricted groups.
Europeans, today, are also in the throes of an identity crisis in which ethnic and economic factors are intertwined. Last year the urban centres of Europe received 500,000 illegal immigrants, up from an estimated 40,000 in 1993. The donor countries, largely Asian and African, are poor, and the immigrants are searching for economic as well as political security. Their high birth rates concern the local authorities. In Frankfurt am Main non-Germans now make up 30 percent of the population. In the year 2000 this historically Christian city included 80,000, mainly Turkish, Muslims and 27 mosques (Cohen, 2000). Germany’s particular crisis has been intensified by its heritage of Uberfremdungsangst –fear of "over-foreignisation" that might destroy its culture. In 1989 the city opened a "Multi-cultural Office" aimed at recognising its cultural diversity. But last year the office was placed within a new "Integration Department" aimed at enhancing at least some elements of cultural conformity.
Leicester, England is expected to become the first British city with a non-white majority (NY Times, 2 Feb 01). Its City Council has spoken of the "joy of being a truly diverse city". Its Asian population, beginning with refugees from Uganda, created its own white-collar employment and services. However, the more recently arrived Afro-Caribbean immigrants have ended up with blue-collar manual jobs. In 2001, blacks driving cars in Leicester have been 11 times more likely than non-blacks to be stopped and searched by the police and racial tensions have been expressed in widespread rioting.
Perhaps the most dramatic corollary of the new uncertainties is the suggestion of an epidemic of coronary heart disease in Eastern Europe associated with falling life expectancy. The European Science Foundation has launched a 4 year project to probe the apparent link between social change, disillusionment, depression and mortality in Russia, Estonia, Lithuania, Poland, Hungary and neighbouring countries. So far, not even the apparent differences in smoking can account for the rise in fatal heart disease. To quote a recent report, there is something "toxic" about a strong violation of expectations. People feel "less valued". Analogies are being drawn to bereavement. The co-director of a NATO workshop convened in Budapest last year said, "the key words are ‘giving up’"(Science, 9 June 2000, 228:1732-33).
World-wide, race, defined in terms of colour, has become "the prism through which all social issues are perceived" (Rodriguez, 2001). As early as 1903, W.E.B. DuBois, the first African-American to receive a Ph.D. from Harvard, wrote prophetically: "The problem of the twentieth century is the problem of the colour line". The UN planners of the Durban conference regard it as a major aspect of the division between the global South and North. Some recent observers (Sanchez, 1999) describe the rise of a socio-economically driven nativism directed by black Americans against recent Asian or Latino immigrants or American born people of colour who represent these newcomers. According to them, people perceived as immigrants, regardless of birthplace, provide "the perfect scapegoat" for an American population "frustrated by its own lack of economic progress in the society".
In Los Angeles and Miami African-Americans are angry as jobs, which were formerly theirs are being taken by Caribbean and Latin American émigrés.
But there are analogies in other countries that do not necessarily involve differences in appearance. Albanians and Kosovars, Croats and Bosnians, even Palestinians and Israelis are more physically similar than they are different. All differences are magnified by economic tensions and frustrated hopes.
Catholic-Protestant fighting in Northern Ireland has been most severe when times have been hard.
In France and Germany attacks against Algerian and Turkish immigrants are intensified in times of unemployment.
In every instance discrimination and racialised ethnic conflict are made worse by identity politics promoted by nationalistic parties and leaders looking for a cause to help them ride to power.
Again, we ask, where might the work of an NGO, an international, non-governmental federation such as World Federation for Mental Health, be useful in this situation?
In the century just past, after the devastation of two global wars, the founders of World Federation for Mental Health, most notably Canada’s Brock Chisholm, soon to be the first Director General of the new UN’s World Health Organisation, and his friend, the American psychoanalyst, Harry Stack Sullivan, did identify a unifying ideal. That ideal is a world community in which local loyalties are compatible with a wider allegiance to humankind as a whole. After World War II it was implicit in the UN charter of 1945 and in the post-war conferences of UNESCO, the first specialised agency of the new intergovernmental system.
The seminal UNESCO conference was entitled, Educating Children for World Mindedness. Sullivan who was a participant was especially taken with the idea of "world-mindedness". He and Chisholm brought this vision to Margaret Mead, Britain’s John R. Rees and the international group of colleagues who together helped found the Federation.
Perhaps it is time in this global era for the leadership of the World Federation for Mental Health to turn its attention once more to our original mission and identity (see Brody, 1998). These are embodied in the Federation’s 1948 founding document, Mental Health and World Citizenship (Flugel et al, 1948). It expressed its own unifying ideal – one echoed in the theme of respecting diversity. It called for "a responsible allegiance to humankind as a whole, a world community built on free consent, on respect for individual and cultural differences". It also called for the promotion of mental health for "all of the world’s peoples". By advocating equal treatment for all, including women, refugees and ethnic, national and racial minorities, as well as those defined as mentally ill, the Federation at its very inception declared itself on the side of social justice. It challenged the customary values and practices of traditional and authoritarian societies.
Rees, the first President and Director – predecessor of today’s Secretary General – became a passionate advocate of "world-mindedness". He called the founding document the Federation’s "bible". It provided, in his view, the expansion of the traditional concerns of mental health associations, which were essential to the vision of a new organisation. The founders were determined to go beyond psychiatric concerns with mental illness to advocacy for social justice, for positive health and well being, for self-determination and equal opportunity. They wanted a new global organisation, which concerned with global health, would be more than an international union of mental health associations.
Today, more than fifty years later, this appeal is more relevant than ever. It truly belongs to the 21st century with its coming together of formerly separated and homogeneous peoples and its new recognition of the human rights of minorities including women and children.
In emphasising this message we honour the memory of Margaret Mead, perhaps the world's best known cultural anthropologist.
Mead, who became the first woman World Federation president in 1956, was a firm believer in international co-operation to preserve world peace, in the human capacity to form relationships across potentially divisive barriers, and in the power of individual creativity and non-institutional leadership to improve the quality of life for all of the world’s peoples. She believed in the efficacy of education and learning, and in the initiatives of concerned citizens, to effect change. As she stated in 1948, "In every civilisation human beings can learn by applying their intelligence to themselves and their institutions."
She particularly valued the voluntary sector to which the Federation belongs. Unlike the governmental and corporate sectors it is not obligated to accumulate political, military or economic power. This gives it immense potential as an agent of social change that can influence public attitudes and governmental policies. We can engage in advocacy, mutual outreach and support across political, socio-economic and cultural boundaries so long as we remain free of corporate, governmental, and, indeed, intergovernmental constraints.
Mead and the other founders of World Federation for Mental Health, just as we today, understood that an effective agent of social change must tread a fine line between a conviction about the universality of human rights and respect for the cultural standards of particular societies. They agreed that the World Federation should not be to plant replicas of Western mental health services in the less industrialised world, and that one culture’s prescriptions for health promotion are not always exportable to others. But they also understood that traditional value and belief systems need not be sacrosanct. In many parts of the world traditional values and structures continue the oppression of social minorities including women.
Mead was especially sensitive to culturally defended privileges based on gender. In many societies these still deny women the opportunities for careers alternative to motherhood, to control their own bodies, achieve safe sexual maturity, and even safe motherhood. This was on her mind in 1961 when I first introduced her to a class of medical students. The class, in that non-politically correct era, was called, "Man and his Environment". I asked how she wanted me to introduce her. "Just tell them", she said, "that I’m descended from a long-line of women".
She also felt strongly that a planet-wide organisation, such as the World Federation for Mental Health, including people of many beliefs, ethnic heritages, nationalities and occupations, should place inter-cultural understanding high on its list of priorities. Along with Rees and Brock Chisholm who, in 1946 chose the name for the organisation, she believed that the Federation would be a more effective voice for peace and social justice if the membership included social scientists, educators and others concerned with the health of society as well as individuals. They would help provide a valid basis for its advocacy, and help translate data into public policy.
Chisholm’s definition of health as well-being, which remains in the Preamble to the WHO constitution, is central to the Federation’s advocacy. It recognised this in 1982 when it first brought survivors of mental illness and mental hospitalisation into active participation in the Federation. This belated move, accelerating in recent years, forced it to think more seriously about stereotypes and stigma directed to a range of minorities including people defined as mentally ill. It has also forced us to think seriously about the paradox of coerced treatment, the ideas, essential in multi-cultural settings, that there is no such thing as absolute health, and that there are times when the individual dignity essential to well-being outweighs medically defined health. If we follow the perspective of the founders, the World Federation for Mental Health should not try to duplicate the international efforts of psychiatric associations promoting Western diagnostic categories with their automatic recommendations for pharmacological treatment. Nor, is there today, any need for another organisation duplicating the work of psychiatric and national mental health associations. There is no incentive for individuals to belong to what could become, merely, an international union of national mental health associations or an adjunct of the World Psychiatric Association.
Our challenge today, as we set our course for the new global century, is to, once again, rethink our mission and the agenda necessary to achieve it. I submit that we can again find guidance in our founding document, and the ideals of Margaret Mead and those others who came together to found a totally new kind of world organisation.
Yes, we have pursued some of the crucial issues with which our founders were concerned. The Federation has been involved with the human rights of refugees and other migrants, the traumatic aftermath of complex humanitarian disasters, responsible parenthood, elevating the status of women, and promoting their reproductive freedom. We have even gone beyond the founders in promoting measures to prevent illness and disability, in the fight against stigma and to protect the rights of survivors of psychiatric illness and hospitalisation. But we have been only minimally involved in combating prejudice and ethnocentric discrimination directed against minorities, both native and newly arriving strangers into formerly homogeneous populations. We have been silent regarding the international human rights aspects of the gay rights revolution. The homophobic attacks against members of the gay and lesbian community have much in common with the xenophobic attacks against migrants and ethnic minorities. We have been silent about the mental health problems accompanying economic globalisation, the great issues of child labour, and enforced servitude of all kinds.
Most important, in recent years the Federation has not utilised its full moral force as an agent for social change, reinforcing the work of its far-flung committees and collaborators. Margaret Mead and her associates believed that the task of an organisation of this kind should be to develop advocacy positions for the major social issues that bear on mental health. We can provide a unique platform, concerned with the social systems, which produce less than optimal health. We can be an international centre of advocacy for peace, justice and the human rights challenges of every day life.
As Mead reminded us: a few people, bound together by intelligence and vision, acting with courage and determination, can change the world.
It was ever thus.
Brody, E. B., 1998, The Search for Mental Health. A History and Memoir of WFMH, 1948-1997. Williams & Wilkins, Baltimore.
Cohen, R., 2000, Germany’s financial heart is open but wary. New York Times, December 30, pp A1, A5
Flugel, J.C., et al, eds., 1948, International Congress on Mental Health, London 1948. H.K Lewis & Co Ltd, London
McNeill, W. H., 1999, Multiculturalism in history. An imperative of civilization. Orbis: A Journal of World Affairs. 43: 541-551.
Novotny, T., 2000, Quoted in Johns Hopkins Public Health, Fall, p. 44.
Roderiguez, G., 2000, Mexican-Americans. Forging a New Vision of America’s Melting Pot. Sunday New York Times, pp. 4-5.
Sanchez, G. J., 1999, Face the nation: Race, immigration and the rise of nativism in late twentieth century America. In The Handbook of International Migration. The American Experience (C. Hirschman, P. Kasinitz, and DeWind, .eds.).. Russell Sage Foundation, New York. pp 370-382