In this editorial for BMJ Global Mental Health, Cristian Montenegro and Francisco Ortega aim to "unsettle and expand the relatively circumscribed place given to culture and context in global mental health." And they do so brillantly, pointing out that the impementation of global ideas can push out the local realities and local strengths to deal with specific contexts. "Think Global, Act Local" does not always work in mental health implementation models. "It is important for global (mental) health to recognise that culture and context are internally contested, and that their meaning and relevance are rooted in local history and identity. Critical concerns about exporting knowledge and practices need to be supplemented with a careful examination of the internal complexity of culture and context and how they are made visible and negotiated alongside global and local policy ambitions.". Indeed!
There is little to add to all the things said about 2020. Perhaps just to note that it did not go unnoticed. It was a year that we lived more consciously than ever. From day to day, from curfew to new Corona statistics, from lockdowns to travel restrictions, moving from one ‘bubble’ to the next. We noticed differences more than ever: between groups of people who were strict and others not so strict with the rules; countries that called themselves democratic saw 'authoritarian' others with sometimes better results in controlling the pandemic; we noticed differences in eating habits, mass behaviour, greeting rituals and so on. What was unbearable interference in the private sphere for some was a natural trust in government for others. What was real fear for some was seen as overprotection by others; what was taken for care-homes turned into prisons for some of the senior citizens. One thing struck us at C4C – biased as we are of course: these were all examples of how culture shapes our lives, and even the way we die.
We feel encouraged by the initiatives in neighbourhoods and communities all over the world where people used old traditions and invented new ones to help each other. We see that new understanding is replacing old judgment: in working out how to deal with fear and isolation, how to care for the vulnerable, how to organise society in a more equal way. We keep looking for these examples and we keep using them in our interventions as we have done in 2020. You will hear more about this in our upcoming annual report.
We thank you wholeheartedly for the support you gave us, and we hope to be able to do more and show you more in the coming year. We wish you happiness and transcultural adventures for 2021!
Stay safe & stay tuned,
Bibiane and Willem
C4C participated in the final conference of COA (COA is short for Centraal Orgaan opvang asielzoekers, in English: the Central Agency for the Reception of Asylum Seekers – on the project “Participation Eritreans: taking cultural differences into account”. Willem van de Put presented on the ‘refugee experience’. Wonderful day – and beautiful drawings! On the page of the project Participation of Eritreans on www.coa.nl you will find, among other things, links to the animation videos Eritreans in the Netherlands; the information range guidance Eritrean licensees and the online version of the book Eritrea and Eritrean refugees that the COA has published. There are also other project products to be found, such as the photo dictionary 'Look, here! ' and the brochure Western life is fast – handles for the guidance of Eritreans.
In Brussels, many migrant women without legal status have no or limited access to health care and other basic services. Their access to descent care is mainly hampered by a lack of information, limited fnancial resources and poor experiences in the past. Three non-governmental organisations joint eforts to help migrant women without legal status to come out of their isolation. Action research during the implementation process was conducted in order to know which elements contributed
to increased feelings of trust and reinforced autonomy among the target group and more willingness to support migrants among a larger population. Our major conclusion is that mental health and well-being is largely defned by (the quality of) social relations and interactions – an aspect that is too often forgotten as a result of the medicalization of mental health related problems.
The debate on Corona and the measures taken by governments is spinning out of control. We are concerned about how the increase of emotions – understandable as they are in the midst of this crisis – becomes a real barrier for the discussion that we really need right now.
The question about how one values life, and lives, seems to be the elephant in the room in our ways to cope with the pandemic. At the same time ethical decisions have to be taken that can no longer wait. They range from entry criteria to IC departments to a reconsideration of international relations. This sounds a little pathetic perhaps, but too often issues are labelled as too complex or too sensitive and then left alone – a luxury that I believe we have permitted ourselves far too long. We can no longer avoid tough choices by pointing at a ‘slippery slope’ that leads to the abyss – we are on the slope, and the abyss is in sight. But that is no reason to panic – which seems exactly what we are doing – in most of the high income countries.
Right at the beginning of the Covid-era we understood that this virus may be the first of a series of outbreaks that signal the underlying problems of climate change, loss of biodiversity, and globalization. We know that epidemics always deepen fault lines in inequity in the world. I am still trying to grasp why we then soon forgot all these syndemic complexities to fight ‘the last war’ once again: “let’s all unite to kill the virus”!
It is time to face ‘ethical values’ and be practical, because ethics is nothing if not practical. Part of this is to ask (and answer!) whose ethical values or which values need to be preserved – in other words, who are the people we care about most, and who are the we in this sentence? People who have had good lives? That may be those who have been so lucky to come closest to the four foundational requirements for health, summarized by Richard Horton in last weeks’ Lancet as peace and security; equality and equity; a balanced and sustainable ecosystem; and ‘just governance.
Let’s face that these four foundational requirements are aspirations towards a life without suffering (a fundamental ‘design’ error of our secular age – but this is not the place for philosophical musings about our human fate to understand why Sisyphus is, after all, a happy man.) Let’s then check the other end of aspiration, the ‘is’ rather than the ‘ought’, and realize the daily reality of obscene inequity and vulgar abuse of millions and millions of people around the globe.
Against this background we need to figure out how we (and again, who is we?) will chose between the interests within one group (e.g. people with access to high quality health care, divided by age, comorbidity, or number of quality life years expectations), and how we chose between different groups (e.g. the people in the first group compared with those living with life expectations so low that getting Covid is almost an indicator of success?).
Let’s then ask what would exactly be unethical (and from whose point of view), if we use the resources now used for implementing and controlling rigid measures, plus the substantial 'opportunity costs' of freezing education and culture and economy and so on, to provide tailor-made protection for the most vulnerable groups.
- To begin with the easiest part, the choices within privileged rich countries, we can start by granting the elderly who want a loving environment and refuse to be imprisoned and isolated for their own good, the freedom to do so and the offer them the needed help to realize that. Those that want protection should be served to the maximum to realize their choice.
- We give up enforcing behaviour change (for young people, but also to reboot the cultural sector) that is unrealistic, damaging and unsustainable for any prolonged time.
- We stop focusing on the IC-occupation as the determining factor. We accept that there is a maximum of IC capacity and a maximum budget. When these are reached, we will apply rules that we make as a society (not any subgroup) to decide who will be admitted (and therefore who will be not). A draft is made in Holland, where a triage system could control the patient flow by step-by-step considerations of priority, in this order: patients who are expected to require a relatively short ICU admission; patients who are active in care and have had risky contact with patients; patients from a younger generation (0-20 years, 20-40 years, 40-60 years, 60-80 years and 80+ years); and if all these conditions are inconclusive, a draw will decide.
Much more difficult is moral behaviour towards all the people that have never had access to decent health care. Who may be the first to get caught by any new virus, because it will come from their threatened ecosystems. Who have never had the luxury of moral philosophy because they were too busy holding on to the slippery slope itself to avoid falling in the abyss.
I'm sure these decisions will hurt, and will hurt many of us. But we have seen them coming for a long time, and we now need to become moral philosophers fast.
Willem van de Put