How mental health lost the war on disease
The BBC reported a “crisis in mental health provision” last month, after an NHS trust was told no mental health beds were available anywhere in the UK.
In response, one MP said: “It is simply unimaginable that in the event of a heart attack someone would be left with no A&E bed available anywhere in the country. Why is this accepted for those with a mental rather than physical health crisis?”
One might also ask why, if mental illnesses account for 28% of morbidity, the NHS spends only 13% of its budget on mental health services.
Joshua Hutton, a PhD candidate working in Sussex’s Science Policy Research Unit, argues that this inequality can partly be explained by the way we talk about health issues. He tells me the language we use to frame policy problems is important because it can impinge on the response. He argues that health policy has been led astray by the language of war (think: “fighting” cancer). While war logic appeals to our adversarial side, Josh believes its use in health policy discourse has contributed to the chronic underfunding of mental health research, and also to the disparity of esteem between mental and physical health.
In Josh’s opinion, it is only natural that war logic should have gotten mixed up with health: “War and health have been meshed together forever. Some of the initial advances in health in the 20th century benefited mostly the war effort. Advances in influenza surveillance were made because Spanish flu was affecting the First World War massively—in certain years of WW1, Spanish influenza deaths outnumbered battlefield causalities. Penicillin was a huge innovation initially because it stopped people from dying of battlefield wounds.”
War requires distinctness. Without this, whom are we fighting? Josh tells me that, historically, thoughts on health have met this criterion: “Illness has tended to be framed as something external. You have the practice of leeching, where you have to leech the ailment out of the body, because it’s something that’s gotten in; you have faith healing, where a demon has to be purged from the body. Even with the advent of germ theory, again, it’s an externality.” In every case, the lexis of war can be coherently applied, because there is a clear divide between them and us.
But mental illness is not so easily framed as a foe. Josh says: “With mental health it is very different. You have something which is intrinsic to the working of the mind, which almost becomes part of your identity; you don’t really have something external to fight. Policymakers always talk about combating disease, or combating obesity, or combating diabetes, whereas mental health doesn’t really get talked about that way. The distinction would be hard vs. soft. It’s tangible vs. very intangible.”
Consequently, mental health is deprived of the fanfare that the war drums excite: “In the case of disease outbreaks, they’ll say x or y disease is a threat to national security, and that allows for much more attention and financing of that particular issue. And what you get is more policies being put to that particular issue and you end up with a lot more money being flooded into it.”
It’s easy for humans to think in terms of self and other. The War on Cancer, for example, beginning with Nixon’s signing of the National Cancer Act of 1971, capitalised on the visceral and ancient appeal of banding together to destroy a common enemy; Samaritans’ ads, on the other hand, are broody and macabre, usually starring a haggard, unshaven face—sadly, this just does not rouse us in quite the same way.
All of this helps to explain why a measly 6% of the UK’s health research budget is spent on mental health—in spite of the fact that one in four people experience mental health problems. The framing of health policy as a war has skewed the distribution of resources, and opened a vast chasm between the mental and the physical.
In turn, this dearth of research has “created a lack of understanding in both policy and in some scientific circles, and that lack of understanding has reinforced a lack of political will.”
As Josh tells it, policymakers rely on experts to inform them of the causal chain that leads from good health to bad: “With physical conditions, health experts have a very good grasp. We know the causative agent behind, say, ebola, we know we can make a vaccine against it, we know how to treat the symptomatic elements of the disease that eventually kills people.
“Whereas with mental health issues, many of the causal processes are not well understood. We know some of the molecular predispositions towards bipolar disorder and depression, because we know how the drugs that treat it work. But experts are not able to clearly, and in a way that policymakers would understand, define the way in which mental illness is caused. That means there is no causal process to interrupt.”
He explains this is why policymakers bludgeon the sugar industry in national obesity campaigns, without paying any attention to the socioeconomic and psychological factors that motivate binge eating.
But, I complain, there are many evidence-based treatments for mental health problems. Perhaps a lack of knowledge of the causal processes might explain the lack of national campaigns, but can it really explain simple discrimination—whereby those suffering from mental rather than physical emergencies are denied an NHS bed?
Josh responds: “The overall privileging of physical over mental health issues on a macro-scale informs the micro-decisions that get made. There is a socially constructed disparity between physical and mental illness, in that society puts more of a premium on securing physical health than it does on securing mental health, because of that intrinsic logic that a population as a whole can fight against something external, whereas the population as a whole cannot fight against something that’s internal.”
However, he gladly concedes that “there are a lot more facets to this issue, and there are a lot of people who can give you more specifics on the micro-level, and on the psychological and neurological levels. What I’m talking about is the intrinsic thought processes and the ways in which political structures reinforce a particular way of thinking, which can in some cases lead to particular decisions being made on a micro-level.”
Finally, Josh puts on his accountant’s hat and answers what the proper ratio of mental-to-physical health spending should be: “I think that there has to be equal relative funding, or at least more equal relative funding.”
Equal relative funding means a percentage of funding equal to the percentage of caseloads. Therefore, since mental illnesses accounts for 28% of morbidity, mental health should, according to Josh, get 28% of the NHS’ funding—instead of the 13% it receives today.
But “it’s not just about finance.” Josh says we need to change the way we think about mental health: “mental health needs to be considered as a more integral part of health as a whole, instead of just an add-on.”
Image: Official US Navy Imagery