26 March 2021

Seeking Commonality of Mental Suffering in a Divided World

DECOLMAD is very excited to host a blog piece by Dr Harry Yi-Jui Wu, Associate Professor in the Cross College Elite Program and Department of Medical Humanities and Social Medicine at National Cheng-Kung University in Taiwan, who introduces his new book - Mad by the Millions: Mental Disorders and the Early Years of the World Health Organization (MIT, 2021).

By Harry Yi-Jui Wu, National Cheng-Kung University of Taiwan   

Entering the new millennium, the world is still far from unity after three waves of globalization and two world wars since the 19th century. A disunified world is best demonstrated by the global inequality of COVID-19 testing, treatment, and vaccine roll-out. During the pandemic, social unrests resulting from political oppression have been growing in Hong Kong, Belarus, Thailand, and Myanmar. Societies are torn apart by various ideologies in the “United” Kingdom and the “United” States. Studies have shown that despite the advancement of psychiatric sciences, people have not become happier. Most of the sufferings now can point to obvious sources of stress. These stresses can only be mitigated in structural ways. Unfortunately, medical science can only diagnose and prescribe medicine or talk therapy.

The collective suffering experienced now ironically resembles the pain the world underwent after World War II. In 1948, Alan Gregg of Rockefeller Foundation said, “The greatest unpleasant surprise of the war for medical men was the importance of psychiatry and psychology,” marking the watershed for mental health to be integrated to public health.[1] Facing the devastation of Nazi genocide in Europe and atomic bombs in Asia on top of the war itself, psychiatrists were at a great loss yet remained hopeful. To find a common solution to mental distresses, scientists first asked: is there a universality regarding psychiatric disorders? My book documents and analyzes the context in which the question was asked and the science behind mental health experts’ effort to answer the question. According to Eric Hobsbawm, the time frame was situated at the “age of extremes”. However, the big question also emerged against the short-lived ideology of “scientific internationalism,” during which psychiatrists tried their best to alleviate the situation by collaborating on a scientific project.

The “commonality” of mental suffering was both a wild guess and a serious scientific enquiry. While scientists speculated so, they also attempted to prove it. Before World War II, psychiatric sciences developed in the “Global South” could not be disassociated from the expansion of empires and colonialism. In most history of medicine accounts, colonial psychiatrists were known for creating theories of “the native mind,” reflecting their racialized ideologies not exactly supported by organized scientific research. Instead, colonial administrations exercised various forms of social engineering work with ill-trained and under-resourced medical practitioners. On the contrary, experts in the World Health Organization (WHO) attempted to free human beings from mental sufferings by conducting survey studies worldwide. Mirroring the concept of scientific internationalism, the spirit of WHO’s project embodied “world citizenship,” a term introduced by its first Director-General, Brock Chisholm. Its flagship project also nailed a golden spike in the history of psychiatry, suggesting that the science of mental health entered the era of decolonization.

Chisholm saw a “free floating anxiety” as part of everyone’s life after the war.[2] He proposed a rather post-modernist concept that all human beings should form a single race to pursue collaborative works among nations. It was against this backdrop WHO, created under the United Nations system, became the ideal place to conduct research to answer the query of universality. Situated in the politically neutral Geneva, it also enjoyed the best position at the time to outsource and coordinate scientists worldwide. However, before the first “manageable” project was proposed, the organization suffered from lack of financial support, work force, and research methods. The organization also had to operate under the shadow of Cold War, during which the entire Communist China was ludicrously prevented from participating in the project. With Taiwan, the Free China represented the biggest area of “underdeveloped” post-war state in East Asia. For Brock Chisholm, the fact that Taiwan represented the entirety of China was “an absurdity which is outstanding even in this era of absurdities.”[3] The complex structure of WHO implies that the organization did not represent “one world” from the very beginning when it was established.

In this book, using International Pilot Study of Schizophrenia (IPSS) and the re-writing process of International Classification of Diseases as a lens, I detailed how the ideology of scientific internationalism, WHO institutional structure, peripheral inputs of experts from developing countries, and the progression of various technologies together facilitated the first international social psychiatry project. In the 1960s, the development of information technology was critical in advancing the capacity of scientists to analyze the vast amount of symptom data collected in field research centers across continents. However, the downside of relying on technology is that scientists had to iron out cultural variations of symptom manifestations and ignore narrative forms of mental suffering that carry meanings with them. This story perhaps is useful for historians of science and clinicians to consider the mounting promise of big data and artificial intelligence regarding their potential benefit and impairment.

The most relevant part of this book for contemporary mental health professionals is the discussion on the historical roots of the current call of global mental health from the immediate post-World War II period.[4] When scholars talk about “global psychiatrization” and “psychiatric colonization”[5] to question the social and cultural justice underlying global mental health, my story reminds readers that the “hegemonic power” of globalized psychiatric tools (including epidemiology and diagnostics) actually originated from scientists’ effort to alleviate mental suffering. However, we must be mindful that even in the same project, “experts” who came from different belief systems and training backgrounds might have represented various worldviews. I attempt to discuss the interconnection of the globalization process of mental disorders with complex storylines. Scientists were originally calling for a bottom-up approach to mental disorders. However, they failed to consider the accountability of such an approach in the complex and constantly changing world.

The book begins with the opening scene of Hiroshima mon Amour, the French new wave movie made in 1959 that questioned the commensurability of mental trauma of World War II between two individuals coming from very different cultural backgrounds. Despite the powerful tools of psychiatric science we now have, same problem is encountered today. In the beginning of 2020, in response to the most recent public health emergencies like the bushfires in Australia and COVID-19, an editorial in The Lancet Psychiatry stated that when implementing disaster measures, “we should be cautious in reducing trauma to a simple matter of exposure and response prevention, and instead take a more complex view of trauma that incorporates pre-existing and comorbid mental health problems.”[6] These problems are the worsening inequalities in terms of availability and accessibility of health services best exemplified by unequal scales of suffering in different parts of the world during the most dreadful pandemic in the 21st Century.

Lastly, when I write about experts, I also mention an anecdote of Tsung-yi Lin, the lead of IPSS, who was a victim of White Terror in Taiwan governed by the Chinese Nationalist Party (Kuomintang). Despite the availability of psychiatric diagnosis of trauma, he could not find a word to “diagnose” or explain the mental suffering among those who were still exposed to protracted political oppression when he returned to the country he came from after three decades in exile. In the face of authoritarianism and split societies in various parts of the world, this serves as a reminder that incompetent psychiatric sciences, which supposedly alleviate distress, directly relate to oppression. My remark in the last page of the book, “We are still sailing with a world map of knowledge that has never been accurately drawn,”[7] points to the pressing research agenda in contemporary psychiatry yet to be completed.

[1] Yi Jui-Wu, Harry. Mad by the Millions. MIT Press, 2021, p. 32.

[2] Mad by the Millions, p. 32.

[3] Farley, John. Brock Chisholm, the World Health Organization, and the Cold War. Vancouver, UBC Press, 2008, p. 90.

[4] Lovell, Anne M., Read, Urusula M. & Lang, Claudia. “Genealogies and Anthropologies of Global Mental Health.” Cult Med Psychiatry 43519–547 2019, https://doi.org/10.1007/s11013-019-09660-7.

[5] Mills, China. “Global Psychiatrization and Psychic Colonization: The Coloniality of Global Mental Health.” In Morrow, M. and Halinka Malcoe, L. (Eds.), Critical Inquiries for Social Justice in Mental Health, Toronto, University of Toronto Press, 2017, pp. 87-109.

[6] The Lancet Psychiatry. “Send in the therapists?” The lancet. Psychiatry Vol. 7,4 2020, p. 291. doi:10.1016/S2215-0366(20)30102-4

[7] Mad by the Millions, p. 173.