Public Mental Health Across Cultural Contexts: An Essay on the Ethics of Primary Prevention of Depression, With a Focus on the Dakhla Oasis of Egypt

(Introduction to a chapter I wrote with Rachel Bingham. It will be part of the volume ‘Mental Health as Public Health: Interdisciplinary Perspectives on the Ethics of Prevention’, edited by Kelso Cratsley and Jennifer Radden.)

 

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For over a decade there has been an active and ambitious movement concerned with reducing the “global burden” of mental disorders in low- and middle-income countries.[1] Global Mental Health, as its proponents call it, aims to close the “treatment gap”, which is defined as the percentage of individuals with serious mental disorders who do not receive any mental health care. According to one estimate, this amounts to 75%, rising in sub-Saharan Africa to 90% (Patel and Prince 2010, p. 1976). In response to this, the movement recommends the “scaling up” of services in these communities in order to develop effective care and treatment for those who are most in need. This recommendation, the movement states, is founded on two things: (1) a wealth of evidence that medications and psychosocial interventions can reduce the disability accrued in virtue of mental disorder, and (2) closing the treatment gap restores the human rights of individuals, as described and recommended in the Convention on the Rights of Persons with Disabilities (Patel et al. 2011; Patel and Saxena 2014).

In addition to its concern with treatment, the movement has identified prevention among the “grand challenges” for mental and neurological disorders. It states, among its key goals, the need to identify the “root causes, risk and protective factors” for mental disorders such as “modifiable social and biological risk factors across the life course”. Using this knowledge, the goal is to “advance prevention and implementation of early interventions” by supporting “community environments that promote physical and mental well-being throughout life” and developing “an evidence-based set of primary prevention interventions” (Collins et al. 2011, p. 29). Similar objectives have been raised several years before by the World Health Organisation, who identified evidence-based prevention of mental disorders as a “public health priority” (WHO 2004, p. 15).

Soon after its inception, the movement of Global Mental Health met sustained and substantial critique.[2] Essentially, critics argue that psychiatry has significant problems in the very contexts where it originated and is not a success story that can be enthusiastically transported to the rest of the world.[3] The conceptual, scientific, and anthropological limitations of psychiatry are well known and critics appeal to them in making their case. Conceptually, psychiatry is unable to define ‘mental disorder’, with ongoing debates on the role of values versus facts in distinguishing disorder from its absence.[4] Scientifically, the lack of discrete biological causes, or biomarkers, for major psychiatric conditions has resulted in the reliance on phenomenological and symptomatic classifications. This has led to difficulties in defining with precision the boundaries between disorders, and accusations that psychiatric categories lack validity.[5] Anthropologically, while the categories themselves are associated with tangible and often severe distress and disability, they remain culturally constructed in that they reflect a ‘Western’ cultural psychology (including conceptions of the person and overall worldview).[6] Given this, critics see Global Mental Health as a top-down imposition of ‘Western’ norms of health and ideas of illness on the ‘Global South’, suppressing long-standing cultural ideas and healing practices that reflect entirely different worldviews. It obscures conditions of extreme poverty that exist throughout many non-Western countries, and which underpin the expressions of distress that Global Mental Health now wants to medicalise. On the whole, Global Mental Health, in the words of the critics, becomes a form of “medical imperialism” (Summerfield 2008, p. 992) that “reproduces (neo)colonial power relationships” (Mills and Davar 2016, p. 443).

We acknowledge the conceptual, scientific, and anthropological critiques of psychiatry and have written about them elsewhere.[7] At the same time we do not wish to speculate about and judge the intention of Global Mental Health, or whether it’s a ‘neo-colonial’ enterprise that serves the interests of pharmaceutical companies. Our concern is to proceed at face-value by examining a particular kind of interaction: on one hand, we have scientifically grounded public mental health prevention campaigns that seek to reduce the incidence of mental disorders in low- and middle-income countries; on the other hand, we have the cultural contexts in these countries where there already are entirely different frameworks for categorising, understanding, treating, and preventing various forms of distress and disability. What sort of ethical principles ought to regulate this interaction, where prevention of ‘mental disorders’ is at stake?

The meaning of prevention with which we are concerned in this chapter is primary, universal prevention, to be distinguished from mental health promotion, from secondary prevention, and from primary prevention that is of a selective or indicated nature. Primary prevention “aims to avert or avoid the incidence of new cases” and is therefore concerned with reducing risk factors for mental disorders (Radden 2018, p. 127, see also WHO 2004, p. 16). Secondary prevention, on the other hand, “occurs once diagnosable disease is present [and] might thus be seen as a form of treatment” (Radden 2018, p. 127). In contrast to prevention, mental health promotion “employs strategies for strengthening protective factors to enhance the social and emotional well-being and quality of life of the general population” (Peterson et al. 2014, p. 3). It is not directly concerned with risk factors for disorders but with positive mental health. With universal prevention the entire population is within view of the interventions, whereas with selective and indicated prevention, the target groups are, respectively, those “whose risk for developing the mental health disorder is significantly higher than average” and those who have “minimal but detectable signs or symptoms” (Evans et al. 2012, p .5). While there is overlap among these various efforts, we focus on primary, universal prevention. Our decision to do so stems from the fact that such interventions, in being wholly anticipatory and population wide put marked, and perhaps even unique, ethical pressure on the encounter between the cultural context (and existing ideas on risk and prevention of distress and disability) and the biomedical public mental health approach.

It is helpful for ethical analysis to begin with a sufficiently detailed understanding of the contexts and interactions that are the subject of analysis. With these details at hand, what matters in a particular interaction is brought to light and the ethical issues become easier to grasp. Accordingly, we begin in section 2 with an ethnographic account of the primary prevention of ‘depression’ in the Dakhla Oasis of Egypt from the perspective of the community. The Dakhla Oasis is a rural community where there is no psychiatric presence or modern biomedical concepts yet – like most communities around the world – there is no shortage of mental-health related distress and disability. It is a paradigmatic example of the kind of community where Global Mental Health would want to action its campaigns. In section 3 we move on to the perspective of a Public Health Team concerned with preventing depression in light of scientific and evidence-based risk factors and preventive strategies. Section 4 outlines the conflict between the perspective of the Team and that of the community. Given this conflict, sections 5 and 6 discuss the ethical issues that arise in the case of two levels of intervention: family and social relationships, and individual interventions.

Notes:

[1] See Horton (2007), Prince et al. (2007), and Saxena et al. (2007).

[2] Most recently there was vocal opposition to a ‘Global Ministerial Mental Health Summit’ that was held on the 9th and 10th of October 2018 in London. The National Survivor and User Network (U.K.) sent an open letter to the organisers of the summit, objecting to the premise, approach, and intention of Global Mental Health.

[3] See Summerfield (2008, 2012, 2013), Mills and Davar (2016), Fernando (2011), and Whitley (2015).

[4] For debates on the definition of the concept of mental disorder consult Boorse (2011), Bolton (2008, 2013), Varga (2015), and Kingma (2013).

[5] For discussions of the (in)validity of psychiatric categories see Kinderman et al. (2013), Horwitz and Wakefield (2007), and Timimi (2014). Often, the problem is framed by asking whether mental disorders are natural kinds (see Jablensky 2016, Kendell and Jablensky 2003, Zachar 2015, and Simon 2011).

[6] See, for example, Fabrega (1989), Littlewood (1990), and Rashed (2013a).

[7] For example: Rashed and Bingham (2014), Rashed (2013b), and Bingham and Banner (2014).

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More Things in Heaven and Earth

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For a few months in 2009 and 2010 I was a resident of Mut, a small town in the Dakhla Oasis in the Western desert of Egypt. My aim was to become acquainted with the social institution of spirit possession, and with sorcery and Qur’anic healing (while keeping an eye on how all of this intersects with ‘mental disorder’ and ‘madness’). I learnt many things, among which was the normalness with which spirit possession was apprehended in the community: people invoked spirits to explain a slight misfortune as much as a life- changing event; to make sense of what we would refer to as ‘schizophrenia’, and to make sense of a passing dysphoria. It was part of everyday life. The way in which spirit possession cut across these diverse areas of life got me thinking about the broader role it plays in preserving meaning when things go wrong. To help me think these issues through I brought in the concepts of ‘intentionality’ and ‘personhood’. The result is my essay More Things in Heaven and Earth: Spirit Possession, Mental Disorder, and Intentionality (2018, open access at the Journal of Medical Humanities).

The essay is a philosophical exploration of a range of concepts and how they relate to each other. It appeals sparingly, though decisively, to the ethnography that I had conducted at Dakhla. If you want to know more about the place and the community you can check these blog-posts:

The Dakhla Diaries (1) : Fast to Charing-X, Slow to Hell

The Dakhla Oasis: Stories from the ‘field’ (0)

The Dakhla Diaries (3): Wedding Invitation

Old Mut, Dakhla

The Dakhla Oasis: Stories from the ‘field’ (I)

And this is a piece I published in the newspaper Al-Ahram Weekly (2009) voicing my view on some of the practices that I had observed: To Untie or Knot

 

To Judge or not to Judge: Confrontations with Rabt in the Dakhla Oasis

My destination was Mūt, the ‘urban’ centre of the Dakhla oasis. As I disembarked the ‘Upper Egypt Travel’ flea-ridden, cramped bus into the deserted streets of an August siesta, I was struck by the enormity of the mission that lay ahead: investigating Madness in the Western desert of Egypt, the practical part of my doctoral thesis. I wouldn’t say I wasn’t prepared; I had done my literature reviews, I had a good idea of the representations people employ to make sense of psychological and behavioural deviance, and I knew of the ubiquity of Jinn possession and magic, not only in the Western desert but all over Egypt. My initial fears of the impossibility of genuine access to the community turned out to be unfounded: within a few days I had already started my initiation in to the Dakhlan world-view. One thing I wasn’t prepared for was the extent my rational and moral sensibilities required stretching to accommodate what I was about to confront. It is one thing to understand why a people do what they do, but it’s quite another to take a moral stance towards their beliefs and practices. But here I was, wearing the Anthropologist’s hat, constantly reminding myself that I am here to understand and not to judge, yet frequently fighting the urge to throw it off and soothe my moral outrage.

It was at moments like this when I would reminisce on the tarnished history of anthropology. It is no secret that the systematic study of alien cultures started life as the intellectual arm of the late-imperialist enterprise. Back in those days (think late 19th, early 20th century) the world was simple and you were either civilised (meaning Euro-American) or not. Within the world-view prevalent at the time, the belief systems, practices, and more generally the way of life of the communities studied were judged against the intellectually, morally, and technologically advanced Europe and obviously found wanting, inferior. Magic was at best seen a symbolic practice, and at worst a form of proto-technology, a primitive attempt to control events in the world, something science is much, much better at. Outside anthropology, sentiments of superiority found expression in the myth of the Arian race and the Eugenics movement.

But things have changed: now a day it is common place for academics and thinkers to pride themselves in cultural relativism: “we live in different moral and cognitive worlds”, and to shy away from judgments based on a theory of linear progress. Relativism, it seems, became a moral imperative, a doctrine that no serious thinker or good man could risk writing off. An intended implication of relativism was to eliminate the possibility of hierarchical judgment, mainly by highlighting the coherence and meaningfulness of beliefs and practices when seen in the context of an overarching world-view. While it may seem obvious that sacrificial offerings to the gods of rain are an inferior method of begetting rain than modern rain-making technologies such as cloud seeding, the case remains that sacrificial practices cannot be assessed on the basis of a secular, technology-based world-view; this would completely miss the point of the practice, which in this case involves a confirmation and re-creation of the essential affinity of the individual with society and of both with a god imbued nature, precisely the stuff that a secular, technology-based world-view has eschewed.

So it was with an open-mind and a gentle-heart that I approached what I heard and saw. A week in to my stay in Mūt I made the acquaintance of a feisty thirty-four year old who practically accosted me off the coffee-shop near the old city. Old Mūt, by now mostly deserted, is a cornucopia of interlocking dwellings and shaded avenues built of mud-bricks on top of a low hill and was once completely surrounded by a wall with a gate that was locked at night. Some two decades ago the residents of the old city began to descend to the flatlands below and a surge of concrete and steel construction began that still shows no signs of abating. All over town you see one and two-floor buildings with concrete pillars sticking out of the roofs and bare steel rods dangling upwards, the whole construction eerily resembling a helpless upturned insect. But the beauty of Mūt is at its most magnificent just after sunrise, and just outside town, when the pastel coloured fields and the bordering sand dunes are bathed in golden light.

I spent many evenings with my feisty friend in the vicinity of the old city. He told me about the healers and magicians in town, introduced me to the local mad-men, shared with me insider-knowledge of the local prostitutes, and briefed me on the extent of Jinn possession. Naturally muscular and fairly handsome, he had tiny intelligent eyes that betrayed a degree of mischief, his whole demeanour and attitude seemingly non-conformist. Among all the people I later met he was the most critical of his brethren’s gullibility; their unwavering belief in magic and their tendency to invoke possession as an explanation for most ills. So it came as a surprise, several weeks later, when he told me that he has sought one of the local healers to help him with a domestic problem. For a week his wife had not been her usual self; she was pushing him away in bed, demanding to leave home, neglecting her duties, and displaying uncharacteristic episodes of anger and unexplainable tempers. This, he explained, is Rabt, and a healer must be sought to undo it. Up to this point my acquaintance with Rabt was seriously limited; I might have heard the term before, but it struck no chords. It was this phenomenon, however, that seriously challenged my relativistic tendencies.

Rabt is common all over Egypt, and particularly so in Dakhla. Literally ‘to be tied’, it is invoked to account for a range of problems from flaccid penises on wedding nights to marital discord and spinsterhood. Rabt is a form of magic, and therefore involves an envious or evil person taking the trouble to visit a magician with the goal of hurting or embarrassing some foe or nemesis. Like all magic, the harmful effects are mediated through a Jinni, or simply a direct consequence of the script embedded in the ‘Amal (think of it as an amulet that harms rather than protects). The Jinni may wreak havoc in a variety of ways: it may enter the body and settle inside the corpora of the penis preventing erection on the wedding night, it may aggravate the person’s Qarin (some sort of spirit double) resulting in bad tempers and mood swings (a.k.a marital discord), it may infatuate the person rendering them immune to human attraction and possibly leading to spinsterhood. In short Rabt works through a conglomerate of effects on its victims, ranging from the crudely physical to the psycho-emotional.

In my moral commitment to neutrality, I tried to understand Rabt in the context of the values and social constraints of this community. Isn’t Rabt an ingenious explanation for containing the painful irony of a flaccid penis on a wedding night that follows at least a decade of sexual expectation? Isn’t the externalisation of causation much more effective at protecting the married couple and their families from the disastrous possibility of male impotence, at least temporarily? And isn’t it much better to blame the evil actions of others for inter-relationship problems than to consider the actual relationship, its faults and merits, a consideration that may lead to divorce, an evil we must try to avoid? Yes, I thought to myself, Rabt makes sense, a lot of sense, if only we are charitable enough to see it within the wider context of a society trying to maintain the status co, to keep things as they are, and in the process to avoid facing the darker inevitabilities of life: some women and men will never marry, may not even want to marry, and some relationships just don’t work and must be brought to an end. Rabt then is a major device of mystification, side-stepping the working through that I am personally inclined to see as essential to managing relationships and life-situations in general. And herein lays the problem.

I can no longer keep on the Anthropologist’s hat; I have understood but that doesn’t seem to make me less inclined to judge. I have no trouble (or maybe some) stretching my rational sensibilities and accepting folk theories of spirits entering and exiting bodies and settling in penises, in fact I find them somewhat endearing. My problem is with a framework that functions to limit human potential, to nip change in the bud, and to subvert freedom by allowing no space for individual expression. This seems to me a powerful ideological onslaught targeting the individual. Its an onslaught that tries to deny my prerogative to express my wishes and desires, to be able to express my discontent at a lousy relationship through my tempers and moods, and not to have my mental states subverted of all possible referents, save for one that functions to keep me where I am: in a lousy relationship. Yet it is an onslaught maintained by each and every person who subscribes to it. My friend, who was not devoid of intelligence or critical tendencies, could not see in his wife’s revolt anything more than the doings of a malicious person. This is not to say he wasn’t aware their relationship was far from ideal. It was clear from our extended conversations that their personalities frequently clashed: him a strong-headed authoritarian, her a spoilt only-child who usually had it her way. But such is the power of subversive representations: they do not leave us with the truth, and instead appease our fears and serve collective rather than individual interests.

I still like my friend. I enjoy his energy and his impressive capacity at transforming a potentially boring coffee-shop in to a locus of contention, mainly by cheekily infuriating everyone and arguing over every little thing: without him the place would be far too serious. But I just can’t shake the thought that we are different, and fundamentally so. Whereas I carry through life privileging experience and change over social stasis, he is happy to fall back on constraining traditional representations when ever the potential for change shows itself. And while I can understand the power of society over the hapless individual, I cannot bring myself to regard this haplessness as absolute. I am therefore entitled to conceive an order of things, an order where Rabt is morally inferior.

To judge is to be human, and it is a myth of academic anthropological discourse that we must eschew judgement from our interpretive, descriptive account of how things are. To be sure we need to understand before we hasten to make judgments, but in the absence of a moral and rational ordering of things, the whole research endeavour will suffer from a sterility that renders it merely a topic of scholarly debate, with little relevance to the important, constructive vision of how the confrontation of world-views can lead to a critical assessment of both.

Mohammed Abouelleil Rashed 2009