Abstract
Many governments around the world have made political commitments to ‘parity of esteem’ between mental and physical health. Challenges remain, particularly in how this talk of parity relates to equity in resources for provision and research in mental and physical health (Ashton, 2017). Sen (2013) speaks of ‘equality of what’, and we can also ask ‘equity of what’. In line with policymakers and clinicians, patients and the public enthusiastically support the idea of equity between mental and physical health. Contained in this equity are multitudes of possible pathways to mental–physical health equity. Fundamental to inequity between mental and physical health is the disparity in regard given to causes and moderators of mental ill health, compared to physical health. That is, a recognition that smoking or poor diet, which are predominantly risk factors for poor physical health, are of equal relevance to risk factors for mental health, such as trauma, substance use, and socioeconomic disadvantage. Paralleling the increasing visibility of mental health on the world stage has been the emergence of violence as a global policy issue. In 2004, World Health Organization (WHO) helped to establish the violence prevention alliance, aiming to address violence and improve services for victims. WHO defines violence as the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.
This definition gives rise to the classification of violence into self-directed, interpersonal and collective forms of violence. Each of these forms is further classified, with interpersonal violence subdivided into family and intimate partner violence, and community violence, and collective violence classified into social, political and economic violence. The rise of coordinated efforts to address violence, and increased visibility of mental health in global policy, is not coincidence – violence is important, both as a risk factor for mental ill health in individuals and as a society-level problem which shapes society’s capacity to respond to challenges of identifying, assessing and mitigating the impact of mental and behavioural disorders. Eco-social models of incidence, care and provision have been advanced for both mental ill health (Mair et al., 2010) and violence (Garcia-Moreno et al., 2005). In this regard, government policies relating to public institutions such as health care, education, criminal justice, and social care, form an important but usually under-considered influence on health. Mental health is relevant for understanding and developing public policy on violence, including violent crime, and could be used to develop more effective policy and interventions to improve public safety. More explicit framing of geopolitical influences in violence and mental ill health could be beneficial in understanding and responding to the burden of mental ill health globally.
Public health involves theoretically guided, multidisciplinary, empirical, and practically focused approaches to the prevention, treatment and alleviation of ill health and its impact on populations. So public mental health is about the research, policy and practice that influences mental health at a population-level. Because of the increasingly recognised importance of social determinants of all health, and the crucial role played by fundamental and proximal causes of health inequalities, there are strong arguments for the inclusion of mental health in all policies. Many existing calls for action have referred to domestic policy, that is, policies that do not explicitly refer to people, states and processes outside the state in question. In line with geopolitical understandings of the distribution of mental health in populations, violence-related policies, including decisions to engage in regional conflict, may influence mental health of populations (Siriwardhana et al., 2014). Economic and social causes have long been considered fundamental drivers of ill health (Link & Phelan, 1995), including mental ill health. Political drivers are also important, and through democratic enfranchisement, modifiable through political action and campaigning. Fundamental to accepting violence as a public health problem is the need for political recognition that all violence is equally harmful, and therefore that the safety of people should not be downplayed in favour of economic and sociocultural imperatives.
Public health approaches can help increase our understanding of the ways in which violence, and policies which respond to violence, have unequal societal impact across population strata. For example, the experience of physical victimisation is more common in those with low income (Brennan et al., 2010), and mental ill health is associated consistently with greater victimisation, including in higher income settings with the most comprehensive and well-resourced mental health provision (Bhavsar et al., 2018; Maniglio, 2009). This can combat the way in which people with mental illness tend to be excluded from policy thinking, contributing to inequalities, for example in physical health (Millard & Wessely, 2014). We have previously argued for increased awareness of mental health impacts and excluded populations including those affected by SMI, in the development and implementation of foreign policy, and this requires further work (Persaud et al., 2018). In particular, we have emphasised the need to address geopolitical factors, including regional conflict, disaster, corruption and democratic and political upheaval (including Brexit) as determinants of mental health, and therefore, the relevance of mental health in the development of policy strategies for the welfare of citizens. Some, but not all of these factors are also incorporated into prominent multilevel frameworks seeking to explain interpersonal violence (Garcia-Moreno et al., 2005). Populism is a political approach aiming to appeal to ordinary voters who feel their concerns are disregarded by established elite groups. Populism has also been identified with a distinctly masculine political approach, and with a dismantling of so-called political correctness and ‘wokeness’, processes which themselves are generally considered to have favoured, or which reflect, increasing gender equity (openDemocracy, 2020). Given close relationships between patriarchy, misogyny, toxic masculinity, and violence against women, the possible impact of political populism on the mental health of women in particular requires closer attention.
In this regard, the occurrence and impact of violence in society is influenced by public policies, including laws defining violent crime (and ordering it in severity), sentencing, noncarceral interventions, and what acts society chooses to collect data on/make visible (Walby et al., 2015). For example, firearms cause high levels and impact of interpersonal violence, and therefore are central to public mental health, but there is very little recognition of the impact of firearms policy on mental health in the population. Greater attention to the recording and surveillance of the psychological impacts of gun violence will benefit future policy responses to firearms violence. Systematic collection of data on all violence stands to support improvement efforts (Hensengerth, 2011), but requires political will, informed by a focus on mental health equity. This should incorporate a place-based approach that centres unsafe areas, in line with accepted eco-social models. Even within existing practices of data collection of violence across the world, there is strong evidence for correlation between violence and structural characteristics, including income inequality, ecological indices of alcohol consumption and population density, implying the relevance of policy for violence control and prevention. Although violence is highly complex, the correct monitoring and data collection on physical and sexual injuries, and their wider emotional, social and health impact, must be considered as a fundamental starting point for improving violence prevention efforts in low and middle income countries (LAMIs), and in shaping future mental health approaches and priorities.
Data on human violence are highly asymmetrical in their coverage and do not obey neat definitional boundaries. Clear, legalistic definitions tend to obscure important forms of conflict, particularly that occurring between groups, and make certain types of violence less visible. Violence understood at the group level can take a variety of forms, as described by Zwi and Ugalde (1991), who argue for specific approaches to mitigating health impacts of structural, repressive, reactive and combative violence. State violence, and the associated instrumentation of torture, rape and child cruelty in wartime, may be driven by economic instability, ethno-cultural rivalries, intolerance and racism. However, although epidemiological studies show that different forms and levels of violence (e.g., interpersonal and state-level violence) are interconnected, focusing on regional conflict as a ‘fundamental explanation’ for increased levels of interpersonal (including sexual) violence can limit the attribution of accountability to individual perpetrators – the perpetration of sexual violence in a war setting must be seen as equivalent to that perpetrated in any other circumstance. Understanding the full scale of the mental health impact of the reported persecution of Rohingya people in Myanmar (Mahmood et al., 2017) and of the systematic re-education of Uyghurs in Xinxiang, would seem to be important, but requires concerted diplomatic and political action. It is well known that Russia lost 10% of its population in World War II, Korea lost 10% of its population during the Korean War, and Vietnam lost 13% of its population in the Vietnam War. Conflict interferes with public health through infrastructural damage, challenges to delivery of basic services (e.g., water, transportation and energy), and to provision of human personnel (including health care professionals). War tends to call for redirection of resources from health care and related avenues, into the conduct of warfare and allied efforts. Conflicts generate movement of refugees, driving psychiatric morbidity. War affects the mental health of children, including of those deployed as combatants (Forrest et al., 2018). The expanding role of civil war, civil unrest, targeting of noncombatants, and the increasing importance of nonstate actors in global armed conflict challenges the drive for better data collection.
There are implications of this violence-informed approach to public mental health for existing interventions. Investing in, and understanding what goes on in mental health care, is crucial to a public health approach to violence, because although population impact is generally small, there is evidence that violence perpetrated by people with severe mental disorders is modifiable (Fazel & Grann, 2006). Adequately capturing and assessing this risk is fundamental to generating optimal impact on violence affecting the population and requires coordinated policy. This includes policing and criminal justice policy, and acknowledgement of the impact of sentencing, rehabilitation and deterrence models, on the size and scope of incarceration, and repercussions on the mental health and substance use behaviours of men (in particular). On the contrary, public policies that overlook people affected by mental illness are unethical, ineffective and unsustainable. Therefore, this is another arena where public policy might impact the development of mental ill health. Advocacy for improved education, knowledge, skills and awareness of mental health must accommodate the role of violence in shaping mental health, its coping and care. Aside from the well-hewn cycles of violence, and cycles of disadvantage, we may also optimistically conceptualise cycles of intervention, wherein systems change, for example, politically or culturally could bring about an array of benefits for different forms of violence. (Public) Health workers must be educated on the impact of regional/state violence on health. Where relevant (and informed by public health surveillance) training should focus on signs and symptoms of torture exposure, guidance on what is acceptable and unacceptable during times of conflict, the assessment and treatment of victims and locally specific guidance on care provision in conflict conditions, as well as the relevance of mediation and reconciliation. Coordinated action and intervention, for example, from education, human resources, public housing, media, business, medicine and criminal justice, requires enthusiasm and political will, but also scientific understanding of levers for change and clear specification of problems to be addressed. Different systems of coordination and models for intervention might be produced for understanding how to expand the scope of data collection on childhood abuse, compared to reducing the long-term impact of firearms injuries, for example. Theories must also accommodate local contexts – including the disparate and historicised factors which shape political agency/motivation, for example, in low-income settings where survival and legitimacy of political regimes has traditionally been considered (Grindle & Thomas, 1991).
Men and women must advocate for the proper representation of women in power, politics and in all sectors, including those with a direct involvement in the public health approach to violence (Heise et al., 1994). Media reporting which recognises the importance and gravity of violence against women, both in reference to victims and perpetrators, could drive structural change, challenging notions that family is private, beyond the control of the state, and beyond the purview of health care. In fact, a focus on optimally identifying and assessing risks to health and well being of women, including domestic violence, could be a key strategy in reflecting a shift towards greater transparency and public safety. From a public health perspective, systems evaluation is highly relevant; however, there are obvious human rights and ethical imperative to reform, strengthen and, in some cases, establish laws criminalising violence, including sexual violence against women. Attention to gender equity in the measurement and response to violence could have benefits for gender rights and mental health and broader public safety.
Existing eco-social theoretical frameworks for violence may overlook the relevance of mental health, the collection of data and the unequal impact of violence, particular for women and children.
Working with affected communities to inform research and policy development in mental health prevention/improvement requires a focus not only on the views of people with mental illness but also those exposed to violence. After Sen, one might ask what is the value of equity of mental with physical health in a world where violence carries on, unmeasured, poorly understood and falling unequally within society.
