Abstract
The Global Mental Health (GMH) movement has raised questions of the translatability of psychiatric concepts and the challenges of community engagement. In Tonga, the local psychiatrist Dr Puloka successfully established a publicly accessible psychiatry that has improved admission rates for serious mental illnesses and addressed some of the stigma attached to diagnosis. On the basis of historical analysis and ethnographic fieldwork with healers, doctors, and patients since 1998, this article offers an ethnographic contextualization of the development and reception of Puloka’s three key interventions during the 1990s: (a) collaboration with traditional healers; (b) translation of psychiatric diagnoses into local cultural concepts; and (c) encouraging freedom of movement and legal appeal to involuntary admission. Dr Puloka’s use of medical anthropological and transcultural psychiatry research informed a community-engaged brokerage between the implications of psychiatric nosologies and local needs that can address some of the challenges of the Global Mental Health movement.
Introduction
Discussion of the merits of the Global Mental Health (GMH) agenda is often polarized (Bemme & D’souza, 2014). Supporters emphasize the laudable goal of mental health care for all and argue GMH is driven by local needs and knowledge (Collins et al., 2011; Horton, 2007). Critics draw attention to the imperialistic undertones underlying the “Global” tag and the detrimental impacts of imposing Western illness categories on local experience (Fernando, 2012; Mills, 2014; Summerfield, 2008). In a critical analysis of “the obscure object of global health,” Fassin reiterates that in spite of globalization and the contemporary shift to framing health in global terms most health issues require policy interventions that are “national, even local” (Fassin, 2012, p. 96).
The challenges and politics of translating global policies and initiatives into local interventions are most clearly played out at the meeting point between health care providers and communities. Ethnographic studies of psychiatry have illuminated the politically and epistemologically loaded communication at this nexus (Estroff, 1985; Littlewood & Lipsedge, 1982; Luhrmann, 2000). Recent research has encouraged attention to the adaptations of psychiatry in new populations, and psychiatry’s need to “recreate and redefine concepts to fit with local cultural codes” (Behague, 2008, p. 143).
Tonga, a sovereign South Pacific nation of 176 islands with a population of approximately 103,000 people, provides an instructive case study of a local psychiatry that drew productively on medical anthropology and transcultural psychiatry research. Never formally colonized, the influence of British protectorate status from 1900–1971 was largely restricted to external affairs. A constitutional monarchy since 1875, Tonga advanced democratizing reforms in 2010, prompted by a long-standing prodemocracy movement (Besnier, 2011).
Research on colonial psychiatries has challenged the standard critique of the reductionism and depoliticization of suffering by colonial psychiatric practice that resonates strongly with critics of GMH. 1 For the most part, colonial psychiatrists were not engaged in projects of direct social control, and most usefully offered a scientific language to understand local behaviour (Leckie, 2010; Mahone & Vaughan, 2007). This language facilitated brokering across the boundaries between psychiatric and indigenous knowledge, which the “decolonizing” psychiatrist Thomas Lambo famously demonstrated in the 1950s in Nigeria. Lambo’s Aro Village Scheme provided “a holistic, community-based experience” where families lived with their mentally ill relatives in a village where traditional medical practitioners were incorporated (Heaton, 2013, p. 57).
By comparison the initiatives in the 1990s of Tonga’s psychiatrist, Dr Mapa Puloka, did not pursue an intermediary space for treatment between the mental hospital and a previous home. Rather, he strove for a more publically accessible hospital-based psychiatry emergent from dialogue with healers’ conceptualizations. He was integrative in conceptualizing and communicating psychiatric knowledge, but not in psychiatric practice. Dr Puloka recognized that a successful and publicly accessible Tongan psychiatry needed to broker local knowledge with global nosologies, and offer ideas of citizenship and improved patient communication to a nation edging towards democratic reform (M. H. Puloka, personal communication, May 6, 2011). Critical of biomedicine’s tendency to misunderstand local healing practices, he argued for an approach “in harmony with people’s current state of belief” that took account of the “special meaning” attributed to the efficacy of local healing (Puloka, 1998, p. 89). With the aim to encourage early diagnosis and address the stigma attached to attributions of mental illness, he attempted to transform psychiatric practice and revolutionize public knowledge of mental illness using radio, television, and newspaper media.
The way that Dr Puloka addressed the “treatment gap” 2 in the 1990s was distinct from the typical strategies in current GMH initiatives, which involve packages of care predominately focused on the recognition and management of mental disorders (Mari, Razzouk, Thara, Eaton, & Thornicroft, 2009). His initiatives were grounded in an ethnographic appreciation of mental illness, and were founded on collaboration and public engagement. To appreciate the context and contribution of his initiatives I introduce Tonga and then Tongan psychiatry, highlighting the important role of Christianity. I frame a dramatic increase in admissions in the late 1990s in relation to literature on the reception of media in Tonga, analyze it through considering the pragmatics of Tongan health seeking, and draw attention to the culturally loaded meeting point between religious ideas and Dr Puloka’s initiatives. The central part of this paper focuses on the reasons and inspirations for, and the reception of, Dr Puloka’s triple strategy: (a) Collaboration and workshops with traditional healers; (b) The translation of psychiatric diagnoses; and (c) Encouraging freedom of movement and legal appeal to involuntary admission. While each is introduced in relation to key theoretical challenges or critiques of GMH initiatives, I also analyse the reception of and response to these strategies in relation to particular professionals, patients, carers, and others. Most Tongans I spoke to, when explaining the behaviour of family and friends, did not generalize, preferring to focus on people’s personalities and life histories whilst acknowledging the limits of their knowledge. Attention to a diversity of viewpoints here serves to nuance the general argument of the value of anthropology, brokerage, and collaboration to reframe how GMH might reconcile local concepts and psychiatric knowledge in ways not overdetermined by the dialectic of biomedical imperialism versus cultural adaptation.
Methodology
The following analysis is grounded in an initial 18 months of ethnographic fieldwork from 1998 to 2000 on biomedical and local treatment for mental illness and spirit possession. Six months of ethnographic research in the psychiatric unit on the main island of Tongatapu preceded an extensive survey of healers in Vava’u, the second most populated island group. Over 1 year, I assisted two of the most active “spirit” healers in their healing practice. With the assistance of Dr Puloka and public health nurses in Vava’u, I also traced past patients’ movements between psychiatric and traditional treatment. In subsequent research visits in 2004–2005, 2007, 2009, and 2011, I have continued to shadow Dr Puloka in his work and teaching, interview more psychiatric unit staff, and follow up on cases. My analysis of the reception of Dr Puloka’s public psychiatry is grounded in extensive ethnographic knowledge of specific individuals’ resort to traditional and hospital treatment and the attribution of efficacy and value to treatment more broadly. Ethical approval for this research was granted by University College London and by the Tongan Ministry of Health. Tongan guidelines on patient consent were met and informed consent was gained from all participants.
The establishment of psychiatry in Tonga
Tonga has been a Christian nation since King Tāufa‘āhau Tupou I used missionization to unite Tonga under his rule at the beginning of the 19th century. 3 Now the vast majority of the population are members of Free Wesleyan, Catholic, Church of Tonga, Evangelical, and Mormon congregations. The idea that nature is under divine control affirms the most stigmatizing causal attribution of mental illness: divine punishment or nemesis (mala’ia) for a crime against the church. It also explains the divine efficacy of plant-based remedies used by healers—often prominent members of church congregations—who explain the same behaviour in the nonstigmatizing terms of interaction with spirits. These explanations have continued to hold great appeal through the development of biomedical health services over the past century. In the early 1900s, the monarchy strongly supported the establishment of the Department of Health, the provision of free health care, and the building of the first major hospital. These developments, as “careful and purposeful selections of certain forms of ‘modernity’” (Young Leslie, 2005, p. 279), continued Tonga’s strategy of ensuring self-governance through establishing credibility as a nation. In fact, Dr Puloka publicly compared the introduction of scientifically validated knowledge on mental illness in Tonga to the European enlightenment (Puloka, 2004, p. 2). (Privately he was more modest and recognized that his aim was more rhetorical than realistic.)
The psychiatric unit in Tonga was established to address a long-standing deficiency in health provision that became both political and public in 1976 during the court case of a murder of a Peace Corps volunteer by a fellow volunteer (Weiss, 2004). Without a Tongan psychiatrist to contest the diagnosis of a psychiatrist from Hawaii, the accused was sent back to the United States, and there was considerable consternation over the fact that the accused had escaped justice. The need for a psychiatric unit was also supported by Henry Brian Megget Murphy, one of the key proponents of transcultural psychiatry at McGill University, who argued that many people suffering from chronic psychosis had never presented at the hospital. In extreme cases families would keep their disturbed relatives chained up in outhouses when symptomatic (Murphy & Taumoepeau, 1980). Murphy’s cowriter, New Zealand doctor Bridget Taumoepeau, was one of the founders of the psychiatric unit in Tonga.
Despite the presence of this specialized unit and long-term support from other countries (Australia, New Zealand, the United Kingdom, Japan, China, and the United States), the World Health Organization (WHO) and the Asian Development Bank, mental health policy in Tonga has been slow to develop. 4 WHO assistance 5 in the drafting the Mental Health Act 2001 accomplished little with regard to creating a national mental health policy in Tonga, as a result of both competing priorities—including domestic violence, drug abuse, and deportees—and the lack of a supportive political insider during key stages in policy change. Fadgen (2013) states “The sense was that mental health was neither being vigorously pursued by the MoH [Ministry of Health] nor insisted upon by Geneva as a matter requiring sustained attention beyond the particular agenda of any particular ministry of health” (p. 178).
Despite the lack of mental health policy, significant changes took place in the Tongan mental health sector during the 1990s and 2000s. Fadgen (2013) attributes most of this change to “practice-level policy innovations,” including community education, implemented primarily by a single influential psychiatrist. Specifically, he credits Dr Puloka with transforming Tongan psychiatry through a reconciliation of Tongan cultural conceptions with his understanding of international best practice (Fadgen, 2013, p. 164).
Dr Puloka frequently references witnessing the abuse of a mental patient in 1975 as the origin of his interest in psychiatry, affirming a cultural mandate for psychiatry that referenced personal involvement and conscience (M. H. Puloka, personal communication, February, 2005). At the age of 17, he went to a church service at the prison as part of voluntary work. A female patient from the asylum swore at one of the officers. Several prison officers then dragged her out of the church by the hair, while punching her repeatedly. Physical disciplining was still common 15 years later when he became Medical Officer in charge of the psychiatric unit. One of his first aims, to remove patients from the prison asylum and prison discipline, was realized with the building of a new security extension in the psychiatric unit in 1993.
Contextualizing rising psychiatric admissions in the late 1990s
Admission statistics suggest a change in the accessibility and acceptability of the psychiatric unit at the end of the 1990s. In 1996, six years after Dr Puloka took over, six people were admitted with a diagnosis of schizophrenia; in 1997, 27; and in 1998, 35. Admissions for bipolar disorder rose from 11 in 1996 to 17 in 1997 and then 42 in 1998 (Minister of Health, 1998, p. 64). In what follows, I contextualize this increase in admissions, consider a number of possible explanations for the increase, and then illustrate how these explanations are contradicted by ethnographic evidence gathered in the present study.
In 1997, Dr Puloka began media initiatives focused on translating psychiatric diagnoses and explaining them in relation to contemporary social challenges. Prior to this, there was no media coverage of medical understandings of mental illness. Dr Puloka’s TV presentations 6 drew from the same content as his writings. Publication of his articles in Tonga’s two main newspapers meant that his work was widely accessible. 7 At first glance, increased public awareness of mental health signs and symptoms resulting from these initiatives appears to explain the dramatically raised admission rates in the psychiatric unit in the late 1990s. However, despite a considerable increase in consultation following broadcasts and publications, Puloka was cautious about explaining the increase exclusively in these terms (Vaiola Hospital Psychiatric Unit, 2004, p. 14).
In attempting to better understand public reception and action in response to Dr Puloka’s mental health radio and television broadcasts, some useful insights can be drawn from the literature on Tongans’ reception of Hollywood films. Hahn (1994) dismantled some of the assumptions of “media imperialism” in her exploration of “how Tongan audiences use cinema to reference and reinforce being Tongan” (p. 104). Rather than focusing on how the Tongan cinema experience could be explained by “poor viewing conditions and poor comprehension” she argued for a focus on “what aspects of Tongan culture they [Tongans] bring to the theatre” (Hahn, 1994, p. 109). Of most relevance to the present analysis is Hahn’s argument that the cinema experience was consistently interpreted by Tongans through the lens of Christian beliefs and churchgoing practices. In considering the effects of public mental health broadcasts, then, Hahn’s analysis suggests that there is a need to consider the interpretive frame Tongan’s brought to the viewing or listening experience—enduring Christian ideas of mental illness as punishment for past wrongdoing—and how these ideas related to the psychiatric concepts being presented.
In Tonga, mental illness and admission to the asylum have traditionally been associated with considerable shame that extended even beyond the family neglect or “unseemly behaviour” that led individuals to be incarcerated (Murphy & Taumoepeau, 1980, p. 474). Gossip about individuals with mental illness might allude to incest, illegal acts, or deliberate damage of church property. In one famous case mental illness was attributed to smoking tobacco wrapped in the page of a Bible (Poltorak, 2007). Families with suffering family members found it challenging, though not impossible, to address the implied slurs and impact on the social confidence of the family.
Prior to the mid-1990s families rarely brought their relatives to the hospital voluntarily unless there was a personal or familial connection to the psychiatrist, a factor that similarly facilitates consultation with healers through the typical health-seeking process of kole tokoni (asking for help) from someone identified through kin and church links (McGrath, 1999; Poltorak, 2010, 2013). In the process of seeking treatment, diagnostic considerations were secondary to establishing the entitlement and confidence to request help (Poltorak, 2013, p. 278). Potential stigma could be mitigated through healers’ communication and confirmation of spirit involvement.
In the following section, I draw on this understanding of Tongan health seeking and its value as a “public relations” strategy to demonstrate how the reasons most commonly cited for increased admissions fail to fully explain why patients began to approach the psychiatric unit more often.
Explanations for the increase in admissions
Ethnographic findings from the present study challenge some of the common explanations for the rise in psychiatric admissions observed in Tonga at the end of the 1990s. First, some examples of the use and understandings of psychotropic medications counter the argument that the increase in admissions can be attributed to public perceptions of psychiatry’s superior efficacy. In some cases, successful treatment with psychiatric medications served not to reinforce such perceptions, but rather to support nonbiomedical—and therefore nonstigmatizing—attributions of or treatments for mental illness. For example, one traditional healer added Haldol secretly to his traditional remedy (M. H. Puloka, personal communication, February, 2005). The increased efficacy of his treatment strengthened his nonstigmatizing diagnosis of spirit involvement. Even patients who had knowingly benefitted from psychotropic medications were likely to attribute their change of behaviour to nonbiomedical interventions, such as the benefits of forgiveness and reconciliation. In Vava’u, the only patient with mental illness that public health nurses actively encouraged me to interview was a woman cured of schizophrenia by a new evangelical church. The nurses emphasized the part of the cure that involved her husband seeking forgiveness for beating her when she was ill. In person, this individual denied she was completely recovered, but attributed her improvement to the laying on of hands of the charismatic minister, the casting out of evil spirits, and taking control of the dialogue with voices in her head. Another long-standing patient with bipolar disorder insisted that she gained more benefit from sleeping with the Bible under her pillow than from medications that gave her terrible side effects. Many patients saw healers concurrently or received help from relatives at the same time as taking psychotropics. They preferred to attribute efficacy to forms of healing that did not imply a shameful diagnosis of mental illness.
Another possible explanation for the increase in admissions is that there was an actual or perceived increase in mental illness in the population—again, ethnographic findings did not support this explanation. Those who endorsed a societal increase in mental illness referenced cultural malaise reflected in increased un-Christian behaviour and increased visibility of some patients, more than any scientifically validated survey. I recall hints of this morally loaded explanation when I first met a nurse employed by the government as a Mental Health Welfare Officer (MHWO) in 1998. She described how some of her youngest teenage patients had personality disorders caused or made worse by glue and pen sniffing. She then detailed how much more access teenagers now had to beer, marijuana, glue, and petrol to sniff and how TVs were in nearly every home (P. Lolohea, personal communication, April 24, 1998).
Indeed, a number of researchers, historians, and commentators have concurred on the importance of the 1990s as a period of significant transition in Tonga, one describing it as the “most profound turning point in its 3000-year history” (I. C. Campbell, 1992, p. 228). A concern with moral decline was common in this “transition culture” (van der Grijp, 1993). Traditional brother/sister avoidance and respect for the nobles declined as freedom of movement increased. A deteriorating economy and raised public debt contributed to increased internal (rural to urban) and overseas migration. Adjustment processes of migration have been suggested to be contributory to proportionally higher rates of mental illness of Tongans in New Zealand (Vaka, 2014). Increased psychosocial stress in adapting family structures coupled with physical discipline and violence have been argued to be precipitating factors of mental illness in Tonga (Puloka, 1999).
However, the MHWO’s account of what patients liked most about the psychiatric unit—”The most, volleyball. Then the once monthly bus trips. Singing and dancing. Eating. Barbecues. Mango drink. Pretty much everything”—strongly suggested that morally loaded macrosocial explanations for increased incidence were not central among the reasons particular people approached, resisted, or even wished to remain in the psychiatric unit.
Dr Puloka’s strategies and success in promoting access to mental health care
An ethnographically sensitive and sufficiently general explanation for increased admissions must take into account the absence in the 1990s of a valued public or political discourse critical of medical practice. Public criticism of medical treatment was devalued in Tonga due to the achieved chiefly status that doctors occupied in relation to patients. Nevertheless, dissatisfaction was manifest in low expectation of successful medical treatment, an acceptance of death as the natural consequence of sickness, and desire for treatment overseas. The extent of community collaboration, aim for accessibility, and increased dialogue with patients underlying all of Dr Puloka’s strategies meant that the psychiatric unit was distinguished by comparison with a general dissatisfaction with hospital services. Only people occupying the position of critical outsider, such as patients who had been treated overseas and visiting psychiatrists were overtly critical of the psychiatric unit. Rarely, however, did their frustrations approach or justify a position of antipsychiatry. 8 The limited public criticism of psychiatry was not only the result of Dr Puloka’s respect for families’ mental illness treatment strategies, the absence of state or government use of psychiatry to silence or address dissent, and the very low financial support by comparison to other countries that had limited psychiatry’s reach. 9 There were simply no vocal former patients or practitioners extolling alternatives or criticizing psychiatric practice in the public domain.
Having provided this context, I now turn to Dr Puloka’s strategies to increase access to mental health services in Tonga, which I consider both in relation to key challenges and critiques of the GMH movement and in relation to ethnographic data gathered from a diversity of informants. His first strategy acknowledged that healers were usually the first port of call not only for most behaviour resembling mental illness but also illness more broadly (Parsons, 1983).
Collaboration and workshops with traditional healers
According to one critique of GMH (C. Campbell & Burgess, 2012), the need for expanded engagement with local communities and “respectful global–local alliances” contradicts the GMH movement’s aim of “scaling up mental health services” and mental health advocacy. The assumption of passive communities waiting for external experts to solve their problems undervalues communities’ ability to assess and integrate into their daily lives what biomedicine has to offer. In Tonga, healers present the most vocal and accessible sources of community perceptions of health and illness. Their popularity reflects their understandings of public perceptions.
Potential integration of healers into health services in Tonga was challenged by healers’ lack of confidence in biomedical notions of disease and suspicion towards the motives of the Ministry of Health. Healers typically treat symptoms, affirming linguists’ arguments that Polynesian languages do not reference “disease” (Capstick, Norris, Sopoaga, & Tobata, 2009); there is an implied impermanence in descriptions of illness suggested by the distinction between the most commonly used word for sickness (puke) and the rarely used combination of terms used to describe a long sickness (puke ma’u pe). Tongan and Polynesian models of health are better refracted through ideas of identity and relationship (McMullin, 2005). Tongan spirit healers treat inappropriate interactions between spirits (tēvolo) and humans that are typically short-term (Jilek, 1988).
In Tonga, it has been argued that the challenge of community engagement would best be met by researching and valuing healers’ knowledge (Parsons, 1983). There were, however, few precedents for psychiatrist and traditional healer collaborations in the Pacific or in the literature to draw on. Wolfgang Jilek’s encouragement of such collaborations in Tonga followed the 1978 Alma Ata declaration (WHO, 1978) calling for greater recognition of, and integration with, traditional healers (WHO, 2002). 10 After a consultancy to the Tongan Ministry of Health in 1987 he argued that patients “suffering from what appears to be schizophrenic process psychosis, can show significant improvement with culture-congenial psycho-phyto-physiotherapy” (Jilek, 1988, p. 173).
WHO-sponsored workshops in 1996 and 1998 with traditional healers revealed a diversity of approaches and remedies, some of which implied syncretism with the form and occasionally content of biomedical treatment (Poltorak, 2010; Williams, 1999). Pauline Lolohea, the MHWO mentioned above was instrumental in using the workshops to build links with the community. Moved by pity, she had joined the psychiatric unit in 1989 from the general ward with a desire to practice long-term care. As the longest serving member of staff, who had also benefitted from training overseas, she was well qualified to comment on the transformation of the psychiatric unit: “Previously a placement in the Psychiatric ward was considered as a punishment. However, nurses are now taking more of an interest thanks to Mapa’s [Dr Puloka’s] presentations” (P. Lolohea, personal communication, April 24, 1998).
The importance of Lolohea’s involvement is well captured in the 6-year professional friendship she developed with a very active local healer. Their mutual trust meant the healer attended two workshops and referred patients to the unit. In the late 1990s the MHWO dedicated 2 days a week to visiting on average 8–10 patients a day. She always took the opportunity to visit healers to encourage them to refer patients with more enduring or serious conditions. Her community involvement strongly contributed to the confidence patients and families had in their ability to ask the unit for help. This was confirmed when funding constraints led to the decrease in availability of transport; as a result of less frequent village visits, the number of patients recommended by healers dropped, and the severity of symptoms of patients at first admission increased. According to Dr Puloka, the funding constraints followed senior doctors’ disapproval of his support of traditional healers. Dr Puloka had no choice but to replace effective care in the community with a cheaper media strategy that addressed a wider public.
Translation of psychiatric diagnoses
The translation of psychiatric diagnoses into terms that have cultural salience to local populations is a key challenge of GMH initiatives. Dr Puloka’s aims in the 1990s are well encapsulated by the two (of a total of 25) challenges that the GMH movement more recently identified as cultural: “Reduce the duration of untreated illness by developing culturally sensitive early interventions across settings” and “Develop culturally informed methods to eliminate the stigma, discrimination and social exclusion of patients and families across cultural settings” (Collins et al., 2011, pp. 8–9). Anthropological research informed, and fellow Tongan scholars supported Dr Puloka’s transformation of the term ‘āvanga that described relationship with spirits or infatuation to a basis for psychiatric diagnostic translations. Churchward’s (1959) dictionary confirmed healers’ nonpathologizing use of the term while defining the possibility of biological causality: “(1) sickness caused (or believed to be caused) by a fa’ahikehe or tēvolo” (p. 555).
The most strident argument for making a term for symptoms stand for a medical condition came from Professor Futa Helu, a Tongan scholar and founder of ‘Atenisi (Athens), the first privately funded university in the South Pacific autonomous of government and church. In a 1984 paper, he argued that spirit-caused behaviours were in fact “mental illnesses” and “manifestations of emotional conflict between basic drives and urges and a rigid social environment” (Helu, 1999, p. 37). Helu’s argument intended to politicize distress as part of a much wider project of critical education in Tonga. He presented new terms and arguments for the nascent prodemocracy movement (‘Atenisi University, 1989; Janman, 2011). Helu’s explanation of spirit-caused sickness resonated with anthropological research arguing that Samoans’ reference to ghosts constituted a covert institution (Shore, 1978). As a surrogate form of regulatory conflict resolution, it provided psychological and symbolic relief while maintaining the status quo. Health professionals’ observations of healers using the “metaphor” of spirits to cover up embarrassing events of abuse and inappropriate or illicit relationships supported this argument. Anthropologists of Tonga agreed and disagreed with Helu’s (1999) position that traditional treatment served to depoliticize distress. Gordon, for example, argued “that ‘avanga’s potent marginality provides a tool for social critique on a potentially wide scale” (1996, p. 73). McGrath’s accommodation to both positions—”talk of tēvolo” simultaneously sustained and resisted the existing unequal social order”—suggested that more ethnographic exploration of particular cases was necessary (McGrath, 2003, p. 44). Of most use to Dr Puloka was Cowling’s translation of ‘āvanga motu’a as “chronic mental illness” and her suggestion that although it typically described a long-established relationship with spirits, it could signify schizophrenia (Cowling, 1990, p. 73).
Inspired by traditional healers’ distinctions between different kinds of ‘āvanga, Dr Puloka took ‘āvanga as a base term and added a second term, gleaned from dictionaries, to define schizophrenia as ‘Avanga-Motu’a and bipolar mood disorder as ‘Avanga-Femaleleaki (Puloka, 1998). Used singly, motu’a can refer to an old or elderly person. Following ‘āvanga, it describes a condition that is old or fully developed. Femaleleaki evokes a leaning or swaying from side to side (Churchward, 1959). In 1997, schizophrenia and bipolar mood disorder made up 32% and 20% of all formal admissions to the psychiatric unit. Contra Jilek, Puloka had treated enough patients with schizophrenia and bipolar disorder to recognize that traditional treatment offered management and reduction of potential stigma but little chance of remission (M. H. Puloka, personal communication, April 21, 2011). Dr Puloka’s explanations of the symptoms and origins of, and treatments and prognosis for different mental illnesses appeared in the newspaper Taimi ‘o Tonga (Tonga Times) from May 1997 to May 1998. After a period of frequent radio broadcasts he appeared on TV from 1998 to 2003. He explicitly engaged with Tongan perceptions of mental illness: Some Tongans describe ‘āvanga motua as a form of lunacy (or faha, sesele, vale) in which the ailment is not caused by a spirit, but is a curse (mala or talatuki) or divine punishment upon a particular family and its descendants for ancestral wrongdoing. Thus the ailment is considered to be hereditary and not responsive to traditional treatment: it may need “higher heavenly intervention” for its cure … Avanga motua has been conceptualised within the framework of Western psychiatry as schizophrenia. (Puloka, 1997, p. 91)
Accessibility, humour, and novelty
Puloka’s translations became familiar to people because of media attention and because most were based on terms in popular use. In 2004 I asked Dr Puloka if people were already familiar with some of his ideas. He responded: “Yes, for the last five years, yes. They start talking about a politician and they ask me what kind of ‘āvanga is that politician” (M. H. Puloka, November 29, 2004). An employee of the Supreme Court, with experience caring for mentally ill relatives, argued that the possibility of misuse weakened the credibility of Dr Puloka’s translations: Some people are laughing at his translations. He should have discussed the names in a group, like we do in court. Terms that are ridiculous don’t stick. An example of this is Banke loupati for bankrupt, it just didn’t stick. There is much to recommend in discussion. People say as a joke go to Mapa, to imply you are a little crazy in a similar way they would joke about going to Viliami Talo, the surgeon for elephantiasis. (Supreme Court’s employee)
Humour and familiarity were the two common themes I identified in the many conversations I had about the reception of Dr Puloka’s radio and TV appearances. His slightly eccentric and funny persona meant people felt comfortable referring to him as Mapa. After a presentation at ‘Atenisi University in 2004 two attendees explained that it was peculiar to hear scientific concepts in Tongan and the metaphorical allusions, implied by some of the old Tongan words he used, were hilarious. Soon after I asked if he expected laughter at his first presentations: Some of the time. Whenever I lecture I like to put in some humor just to make them wake up. Also humor facilitates understanding. It hits home faster and I understand some, I won’t say most, is related to sexual things. We [Tongans] of course are very Freudian, that’s what I am doing now, collecting a lot of things to do with sex. Names of places, myths, something in legend—most of them related to sex. (M. H. Puloka, personal communication, November 29, 2004)
The wider appeal and acceptance of his hybrid terms was precisely because they could be misused to comment humorously on people evidently worthy of teasing or critique. The assumption that greater public understanding of the biological foundations of psychiatric diagnosis will reduce stigma has been found to be flawed, even in industrialized nations (Schomerus et al., 2012). In Tonga, psychiatric explanations for mental illness had the potential to strengthen prevailing ideas of mental illness as punishment for past wrongdoing while also affirming ideas of independent and autonomous citizenry. More important to the more immediate goal of early diagnosis for psychosis was Dr Puloka’s use of novelty to attract patients to the ward through remaining memorable and accessible. In my discussions in Vava’u on families’ choice of healer, the second most commonly mentioned reason to go to a healer after the fact of being connected in some way or close in residence, was the novelty of their treatment.
Beyond the humor and novelty of his terms for mental conditions, the broader content of Dr Puloka’s media communications also had value for some, albeit very particular audiences. More high-functioning patients with bipolar disorder, some associated with or supportive of ‘Atenisi University, embraced their diagnosis, the enlightenment connotations of Puloka’s project and associations with prominent scholars or artists who had shared their condition. They were in a minority of patients. The majority, Dr Puloka argued, lacked insight into their conditions.
Freedom of movement and legal appeal to involuntary admission
In their key statement in Nature, the global consortium of researchers, advocates, and clinicians constituting the GMH movement, ignore possible public resistance to psychiatric ideas and interventions and the potential political implications of psychiatric ideas serving a GMH agenda (Collins et al., 2011). Conversely, it tends to be assumed by critics of psychiatry’s expansion that the damage of medicalization to local cultural practices emerges after people approach psychiatric services. The notion that psychiatry can make a positive contribution to political change is typically regarded as suspect.
Puloka’s liberalization of the process of psychiatric admission was key to maintaining the positive association psychiatry had gained in affirming citizen rights. He offered greater freedom of movement through the psychiatric unit and encouraged the use of clear and publicly transparent legal procedures for nonvoluntary admission. The complexity and diversity of the relationship between sufferers and their families had been simplified by the widespread argument of public health doctors and nurses that everyone avoided the psychiatric unit because of potential shame. In 1994 Dr Puloka’s “open door policy” established the category of RDP (revolving door patient) to encourage previous patients to voluntarily “drop in” or seek respite care without formal admission. 11 From 1994 to 1995 the number of patients defined in this category rose from 13 to 97 (Vaiola Hospital Psychiatric Unit, 1998). Some psychiatric unit staff attributed the increase to patients valuing the escape from conflictual and demanding relationships at home. The “open door policy” was thus potentially preventative of future relapse. It also demonstrated that in many cases families had more to lose in terms of stigma than their suffering relatives.
By contrast, involuntary admission for 7 days, a period not exceeding 28 days, and a period not exceeding 2 years required orders carried out under Sections 9, 10, and 11 respectively of the 1992 Mental Health Act. 12 These required the orders of an MHWO, medical officer (psychiatry), or psychiatrist in the case of a Section 9 admission, a magistrate for Section 10, and the Supreme Court for a Section 11. Dr Puloka’s encouragement of patients to appeal in writing against Sections 10 and 11 involuntary admissions established due process and legal redress.
One such letter was written by a young Tongan man brought up in the United States and treated in U.S. psychiatric institutions, who I have given the pseudonym Ray. His case raised challenging questions regarding compulsory treatment, mental health law, local interpretation of human rights, and the Tongan psychiatric unit’s capacity to treat diasporic patients with different cultural backgrounds and pharmacological and institutional expectations. The letter described, and others confirmed, how Ray’s mother had delivered him to his Tongan father and stopped his medications with the hope that being in Tonga and traditional healing would cure him. In less than a week, the police locked him up for being a public nuisance before bringing him to the psychiatric unit. He appeared in the Supreme Court on the 13th of May, 1998 in front of an Australian judge. His Tongan lawyer contested Dr Puloka’s application for a Section 11. Dr Puloka both attempted to have Ray involuntarily admitted and encouraged him to appeal the admission. The judge made reference to the case being used to establish new procedure, and supported the earlier Section 10 magistrate’s decision to retain him. In court Ray did not speak. Outside the courthouse he was remarkably appreciative of Dr Puloka’s previous advice. As he paced and stepped up and down, a side effect of haloperidol, he addressed him as “the man” and said: “If you love someone you must let them go. If you keep me for another 28 days after this one, you don’t love me.” He then shared his love for his father, who had maintained a low profile and had not communicated with him during the proceedings. Pulling back his hair, Ray then showed me a bump on his head where a guard hit him, loudly complaining that other guards did not share the food gifted from the Free Wesleyan Church Conference, particularly the roast piglet. His reference to two important cultural values in Tonga—love and sharing food—did not sway Dr Puloka’s clear response that many of the misunderstandings between him and the psychiatric assistants remained cultural ones. He was also accustomed to other types of care and treatment which Dr Puloka acknowledged would be a lot better for him. “The Tongan patients get used to the rhythm very quickly,” he explained. Dr Puloka suggested he write a letter to the embassy to request repatriation or mention it to the judge. His statement “We can’t afford to give you community care here,” referenced the unavailability of transport for community visits due to budgetary restrictions.
Twelve days later I was surprised to encounter Ray eating a mango ice cream with his father in the centre of Nuku’alofa. He explained he had been released the day before and invited me to join him to celebrate. That night he was arrested for assault in a well-known night club and put into prison. Dr Puloka later revealed his decision to release him into the care of his father because he was too much of a distraction for the other patients. In Ray’s case, he stated, the prison had better facilities to house him in advance of expatriation to Hawaii or the US, where he would get better and more specialized care.
The case demonstrates that the psychiatric unit was ill-equipped to deal with such cases as inpatients or outpatients. In the absence of a mental health policy that anticipated more challenging diasporic or deportee patients, the only solution was to improvise and in the process ultimately not provide the necessary care for Ray to not reoffend.
Despite being one of the most vocally critical patients I came across, and most able on the basis of his experience in the US to criticize psychiatric practice in Tonga, he was also one of the least credible at the institutional level. As long as he was perceived as a nuisance, by comparison to the benign eccentric behaviour of other mentally ill patients in public, criticism could only fall on Dr Puloka for not keeping him in the unit longer or on his mother for sending him to Tonga. Under law, the psychiatric unit had retained the power to release patients without court proceedings. 13 This was an important recourse for patients who did not want to leave, given the attraction of a restful space away from the challenges of their families with fun activities and frequent meals. Ultimately Ray’s desire to be released was answered, though his father, without support, could not prevent him from reoffending. Ray and other patients’ movement through the psychiatric, police, and legal institutions did however contribute to institutional knowledge and public awareness of the key role of open courts to section on the basis of psychiatric evidence provided by Dr Puloka (M. H. Puloka, personal communication, February, 2005). The encouragement of patients’ appeals established due process, greater transparency, and visibility of involuntary admission that opened psychiatric practice to wider scrutiny while also granting it credibility for valuing citizen rights. There is a particular irony in Ray’s case. In the process of indirectly supporting his wish for release, while using his case to establish processes affirming citizen rights in Tonga, his human right to not be incarcerated in prison for mental illness was not respected, contrary to most international guidance.
From 1992 to 1995 the total numbers of forensic cases under Section 10 in the Magistrates Court and under Section 11 in the Supreme Court were 21 and 21 respectively (Vaiola Hospital Psychiatric Unit, 1995). In 1997 the numbers of all inpatient admissions that required court proceedings were: Section 9 (power of the psychiatrist), 28; Section 10 (Magistrate Court), 58; and Section 11 (Supreme Court), 9 (Vaiola Hospital Psychiatric Unit, 1998)—a total of 95. By contrast, the number of patients who chose to admit themselves as RDPs, was 97 (Vaiola Hospital Psychiatric Unit, 1998). At the midpoint of the period of dramatic increase in admission from 1996 to 1998, slightly more patients wanted to be in the psychiatric unit than those who had been sectioned through legal process. The psychiatric unit had developed a reputation for accessibility and care valued by an increased proportion of patients and their families.
Discussion: Brokerage, Tongan identity, and stigma
In 2004, I asked Dr Puloka about some of the challenges of translating psychiatric knowledge based on the autonomy of the person into a Tongan context where culturally valued personhood is constituted in relationship (Morton, 1996). His tangential response addressed my then still unexamined assumption that an expanded psychiatric service was at odds with the continued practice of local modalities of care by claiming a cultural mandate for his initiatives: “I think tauhi vaha’a is one of the most important things here. Our consciousness and awareness of tauhi vaha’a. It affects every Tongan. Western society is much more individualistic, looking for self-esteem, identity” (M. H. Puloka, personal communication, November, 2004). Tauhi vaha’a or “maintaining harmony of the ‘space’ between oneself and others” (Thaman, 1988, p. 120; Ka’ili, 2005), derived from tauhi (nurturing), va (space between), and ha’a (lineage), was central to the political success of his interventions. This Tongan form of brokering is one of the key Tongan values defined as central to a Tongan identity, and is one of the key “special meanings” he attributes to traditional medicine (Poltorak, 2010). It suggests Dr Puloka’s success in raising admission figures strongly relates to his establishing social credibility for his interventions, attempting to maintain “a harmonious space” between his patients, mental health workers, family, Tongan health institutions, regional organizations, global initiatives, the churches, and media organizations. That his social credibility was occasionally tested by his personal life only affirmed that he had an experiential knowledge and familiarity with the lives of the mentally ill he was seeking to improve. As a result of Dr Puloka’s work, patients and families were more able than before to address the stigma of their conditions through a similar brokerage. The greater accessibility of the psychiatric unit and the use of medication meant that patients were less likely to be in public when symptomatic. Widely known cases of patients with bipolar disorder have tended to associate mania—not depression—with being symptomatic and influenced the public perception that most episodes of mental illness would happen in the public domain. In the absence of unusual behaviour, more people were likely to agree that the religious cause for an individual’s behaviour had been removed.
The social worker in the psychiatric unit underscored how Dr Puloka uniquely combined the qualities of a healer with the structural position of a doctor: Healers give a better explanation and they treat you well. With doctors you wait and then you get Panadol. Doctors have a different attitude. If they have personal problems they bring them to the hospital. Some turn up at 10:30 and go home early. Mapa is very different, he talks to the patients. (2004, research interview)
Conclusion
This ethnographic analysis of Dr Puloka’s interventions underscores the importance of culture brokerage for GMH initiatives. Puloka instituted a “respectful global–local alliance” (C. Campbell & Burgess, 2012) that led to translation and integration of novel psychiatric ideas into everyday discourse and to increased awareness of what the psychiatric unit could offer. His resort to anthropological and transcultural psychiatric research confirmed the value of conducting ethnographic studies prior to tackling mental health burdens (Desjarlais, Eisenberg, Good, & Kleinman, 1995).
Puloka’s translations of psychiatric concepts showed how the accessibility and political implications of terms may trump the aspiration to improve biomedical health literacy. The effort to build on “local institutions, traditions and values” (Desjarlais et al., 1995, p. 281) to improve access, needs to be complemented by political astuteness. The Tongan experience suggests that global mental health initiatives need to pay as much attention to how key individuals can build an enduring cultural and political mandate for psychiatry as they do to addressing the “treatment gap.”
Dr Puloka’s success suggests that critiques of the misapplication of medical categories may understate the potential depoliticization of distress by some traditional therapies and the local utility and transformational potential of psychiatric terminology. Dr Puloka is both psychiatrist and culture broker, who in translating psychiatric explanations is also helping Tongans balance cultural integrity with the contemporary challenges of an increasingly globalized political economic system. He is also located in a position of brokerage between the heterogeneity of local strategies of dealing with mental illness and the global recommendations and universalizing claims of institutions such as the WHO and systems of categorization such as the DSM-IV. The absence of critique of psychiatry suggests that, at least in Tonga, improving access to mental health services is not contingent on the harmful misapplication of biomedical diagnostic categories.
Finally, the most serious critique of the GMH movement is that its initiatives will distract attention from the social inequalities underlying the uneven distribution of mental illness (C. Campbell & Burgess, 2012). Dr Puloka focused attention on the Tongan social determinants of mental illness, rather than on social inequalities, through his engagement with spirit-based explanations for mental illness. I have argued that his interventions both supported and critiqued the depoliticization of distress present in traditional treatment for spirit possession. To do so, he relied on local, transcultural psychiatry and medical anthropology research, and an institutional freedom to develop translations of concepts that built on healers’ conceptualizations. His openness to engaging with the “special meaning” of traditional medicine was key to building a psychiatric service on community collaboration and dialogue. As a broker, he walked an ethnographically grounded middle way between local and disciplinarily polarized debates on the merits of the increased expansion of psychiatry. In this role, he is an inspiration for efforts to develop more accessible and successful local mental health strategies.
Footnotes
Acknowledgements
I am very grateful for the support of Mapa Puloka, Palu Laumape, Mele Lupe Fohe, and Pauline Lolohea from the Psychiatric Unit, Vaiola Hospital and from the many healers, patients, and health workers in Tongatapu and Vava’u. In New Zealand, I am indebted to the psychiatrist Siale Foliaki for hospitality and long insightful dialogues on the differences and similarities between psychiatric practice in Tonga and New Zealand. I thank Vincanne Adams and James Rodgers for extremely valuable guidance on a first draft. My colleagues in the School of Anthropology and Conservation gave perceptive feedback on a second draft. Mary de Silva, Alex Cohen, and Sara Cooper at the London School of Hygiene and Tropical Medicine (LSHTM) gave detailed comments that helped frame the argument in relation to the Global Mental Health Movement. Participation in a conference panel at the International Union of Anthropological and Ethnological Sciences (IUAES) conference in Manchester in August 2013, organized by David Orr and Sumeet Jain, was vital to the development and publication of this paper. I thank them and the anonymous reviewers for their extensive comments that helped craft this final version.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The ESRC (Economic and Social Research Council) of the UK funded doctoral (1998–2002) and postdoctoral research (2004–2005). The University of Kent supported a return visit in 2011 under their small grants scheme.