(Mary-Jo Del Vecchio Good)
WOMEN AND MENTAL HEALTH (1)
When the world of health policy and public health considers the health of women, one tendency is first and foremost to link the well-being of women to that of children and the family, and, legitimately, to the health of society overall. Although this perspective is well-founded given that the health of women is well documented to have a positive impact on the general health of all members of a society, too often a common focus among health policy decision makers is to emphasize maternal and child health. Women's health within the policy domain is often defined as reproductive health and identified with women's children's health. Family planning efforts, inspired by the theory that overpopulation is a major impediment to development, have dispensed contraceptives in the interests of reducing fertility, but often ignored women's needs for information about, and control over, reproductive processes. More recently, clinical trials of AZT during pregnancy have focused on reducing the transmission of HIV from infected mothers to their newborns, but financial constraints have limited efforts to provide AZT for mothers after pregnancy.(2)
Such efforts to improve the health of women's children through programs that affect women's health are laudable. Yet, in the past decade, as women have begun to exercise greater influence over health policy formation, questions about such trends have been raised. Initially, women asked "Where is the "M" in MCH programs?" (3) "What about programs designed to address women's needs as women as well as mothers?" Such questions challenge traditional health policies that focus primarily on MCH programs; the call for definitions of women's health which are broader than the reproductive and the maternal, incorporating mental and physical health across the life cycle, has been repeatedly expressed in recent years. As feminist theorists have recently argued, women's well-being is "not solely determined by biological factors and reproduction, but also by the effects of workload, nutrition, stress, war, migration." (4) Mainstreaming a gender perspective into the health sector requires a broad-based definition of health for women as well as men that addresses well-being across the life cycle and in domains of both physical and mental health. Mainstreaming a gender perspective needs to be coupled with mainstreaming mental health issues as well, because women disproportionately suffer from mental health disorders and are more frequently subject to social causes that lead to mental illness and psychosocial distress.
Epidemiologic and anthropological data point to different patterns and clusters of psychiatric disorders and psychological distress among women than among men. The origins of much of the pain and suffering particular to women can be traced to the social circumstances of many women's lives. Depression, hopelessness, exhaustion, anger and fear grow out of hunger, overwork, domestic and civil violence, entrapment and economic dependence. Understanding the sources of ill health for women means understanding how cultural and economic forces interact to undermine their social status. If the goal of improving women's well-being from childhood through old age is to be achieved, "healthy" policies aimed at improving the social status of women are needed along with the "health policies" targeting the entire spectrum of women's health needs. Such an emphasis calls for state gender ideologies that encourage investment in women's health in broad ways, from education to economic empowerment and through legal and political mechanisms that enhance the status of women. It also calls for a concerted effort to improve and enhance social and mental health services and the competence of professionals and programs in concert with the improvement of health services overall. Before we turn to examine policy implications in greater detail, I wish to provide a brief and partial profile of the cluster of problems in the domain of mental health that challenge policy makers committed to mainstreaming a gender perspective in health policy and state ideologies.
A Brief Profile of Psychiatric Disorder and Psychosocial Distress
Psychiatric Disorders
Comparative analysis of empirical studies of mental disorders reveals a consistency across diverse societies and social contexts: symptoms of depression and anxiety as well as unspecified psychiatric disorder and psychological distress are more prevalent among women, whereas substance disorders are more prevalent among men. The disability-adjusted life years data recently tabulated by the World Bank reflect these differences.(5) Depressive disorders account for close to 30 percent of the disability from neuropsychiatric disorders among women, but only 12.6 percent of that among men. Conversely, alcohol and drug dependence accounts for 31 percent of neuropsychiatric disability among men, but accounts for only 7 percent of the disability among women. These patterns for depression and general psychological distress and substance disorders are consistently documented in many quantitative studies carried out in societies across the world. (See Desjarlais et al. [1995], chapter 8, pp 179-206, for a review of research findings in numerous studies.([a]) Explanations proposed for gender differences in psychiatric morbidity in Asia, Africa, the Middle East and Latin America echo established associations among poverty, isolation and psychiatric morbidity for women in Western Europe and the United States (see Dennerstein et al. 1993). In a now classic study by Brown and Harris (1978), depression was found to be more prevalent among working-class than middle class women living in London. There is evidence that poor women experience more and more severe life events than does the general population (Brown et al. 1975; Makosky 1982); they are more likely to have to deal with chronic sources of social stress such as low quality housing and dangerous neighborhoods (Makosky 1982; Pearlin and Johnson 1977); they are at higher risk for becoming victims of violence (Belle 1990; Merry 1981); and they are especially vulnerable to encountering problems in parenting and child care (Belle et al. 1990). Poverty also erodes intimate and other personal relationships (Cherlin 1979; Wolf 1987). In fact, social networks can represent additional stress for poor women as well as sources of support (Belle 1990).) This gender difference has led some to contend that men tend to externalize their suffering through substance abuse and aggressive behavior, resulting in an under-reporting of psychological distress. Women, in turn, more often suffer distress in the form of depression, anxiety, "nerves," and the like.
Social Origins of Distress
Ethnographic research and case descriptions enrich the quantitative findings of these prevalence studies of psychiatric morbidity, elaborating on the social context of depression, dependency and hopelessness and on the gendered dimension of these epidemiological clusters of social and psychological distress. Clusters appear as post-traumatic stress disorder and dissociative disorders, depression and sociopathy, and other mental illnesses which are highly correlated with societal breakdowns and social problems, such as civil strife, domestic violence, street violence, community disintegration, substance abuse, and family breakdown.(6) Numerous case studies illustrate the configuration of such social psychological clusters. Das, for example, recounts events in the life of an Indian woman following the loss of her husband and three sons in an ethnically charged riot, showing how her husband's family's subtle communication of the responsibility for the disaster converged with her own guilt to culminate in despair and eventual suicide.(7) Links between economic hardship, child death, emotional deprivation, and psychological distress in women have also been documented in many anthropological studies, including recent work carried out in Brazil, Mexico and Pakistan.(8)
Anthropology also offers an alternative approach to understanding the experience and expression of emotional distress. Complementing an epidemiological or clinical perspective with an ethnographic one, we find psychological pain realized not necessarily as "depression" or "anxiety" but in local idioms of distress -- "nerves," "attacks," "heaviness of the heart" and intrusions by unwanted "spirits" -- in studies carried out through South and North America, the Mediterranean region, Africa and Asia, and in Middle Eastern societies. Higher prevalence of such disorders is consistently found for females. Careful attention to social and cultural meanings associated with complaints of "nerves" often points to power conflicts, abuse and oppression in families and communities. Such findings appear in studies done in settings as diverse as Somalia, Iran, Malaysia, and among Central Americans who are refugees who fled civil strife and societal breakdown and currently live in the United States.(9)
Poverty, domestic isolation, powerlessness (resulting, for example, from low levels of education and economic dependence), and patriarchal oppression are all associated with higher prevalence of psychiatric morbidity in women. In short, a considerable body of evidence points to the social origins of psychological distress for women. In the chapters on "Women" and on "Violence" for World Mental Health (1995), we also examined issues of hunger, poverty and overwork, sexual and reproductive violence, domestic, civil and state violence, and the potential noxious effects of certain state economic policies, such as structural adjustment programs and monetary crises, on the mental health and general well-being of the majority of women. (See World Mental Health 1995 for data summaries.) The conclusions from these reviews are indeed distressing. Malnutrition in many parts of the world is found more frequently among girls than boys, manifesting sex bias also found in traditional patterns of infanticide and newly practiced sex choices of fetuses, through selective abortion.
In the world of work, we find employment may bring self-esteem and independence; however, low paid or unpaid labor may contribute to oppression rather than independence. Many women work a "double day" maintaining households, raising children, carrying out economically productive activities in marketing and agriculture and in household-based industries. Numerous studies document that women "work" more hours than do their husbands given their widely diverse economic and household responsibilities. Overwork may lead to exhaustion and stress. In addition, global and local traffic in women for commercial sex as well as household servitude entraps women, leading to high rates of mental illness. Sexual and reproductive violence, as well as rape during war, ethnic violence and civil strife, target women disproportionately. Severe and on-going domestic violence has been documented in almost every country in the past decade; the World Bank (1993) estimates the consequences of familial and communal abuse account for approximately five percent of the global burden of disease for women during the reproductive years. Such abuse is often associated with depression, dissociative disorders, and suicide.
It took the United Nation's "Decade for Women" to begin to make women's productive, as well as reproductive, roles visible to the world. Many development policies, and most recently in Asia, monetary policies to ease the debts of the rich and the consequent monetary crises, have hit women in traditional marketing, agricultural, and even in governmental and commercial sectors hard. Yet, the global consciousness-raising of the United Nations has spawned a number of programs that enable women to be productive, to control their own labor, the means of production and their earnings. Programs that are attuned to women's voices, needs, and hopes for the future for themselves and their families, and that contribute to women's control over economic and social/political resources have a direct and beneficial effect on women's mental health. They also have indirect effects, buffering women from oppressive conditions that place them at risk for mental illness and providing them the means to escape situations of violence, economic and sexual slavery and abuse.
Such a description of the social origins underlying psychiatric disorders can be disheartening. However, the resilience of individuals and the ability of governments and community organizations to develop policies and programs to address both the needs of the psychiatrically ill and the social origins of psychological and psychosocial distress offer not only hope but examples as well. What can be done? What has been accomplished thus far? What creative efforts may serve as models and inspiration for future action?
State Gender Ideologies and Healthy Policies:
Mainstreaming Gender Perspectives in Mental Health PolicyGendered Voices
Just as important as an understanding of the social origins of women's ill health is a recognition of what can be done and is being done to improve women's status and well-being. The development of policies and programs consistent with broader definitions of health require listening to the women whom such programs are designed to serve and giving voice to their concerns, at all stages of planning, implementation and management. Listening to women who will use and staff programs maximizes the likelihood that services provided will fit well in local settings, and as a result be acceptable and used. The myth that poor women cannot or will not speak for themselves must be dispelled.
Much local listening work -- that is, going into communities and talking with women about how they live and what their health and in particular mental health needs are -- remains to be done. In the meantime, we may listen to the work of many NGOs and women's groups that have mounted programs to defend and promote the overall well-being of women, such as recent efforts being undertaken by Indonesian women's organizations to address the mental health consequences of the sexual violence perpetrated against Chinese Indonesian women during the May 1998 riots. NGOs and women's organizations are also seeking ways to give voice to ordinary women's concerns about feeding their families and caring for the sick in this stressful period created by the monetary crisis.
Building on local movements and enhancing grass-roots strengths offer pathways through which the status of women and women's health may be improved. Numerous local initiatives abound, from adult literacy programs in India to grass roots movements throughout the world's local communities of women, to resist oppression and to organize and reshape community health programs.(10)
The voices of the contributors to the 1991 National Council for International Health's Conference on Women's Health(11) represent a broad perspective as well. Conference recommendations are directed toward women's overall empowerment; these include 1 establishing baselines for women's health and well-being and measuring progress; 2 developing ways of monitoring the impact of structural adjustment programs on women's welfare, and establishing programs to mitigate their adverse effects; 3 enforcing or enacting legislation to improve women's status; 4 addressing women's need for equitable employment and economic development; and 5 expanding education for women and girls.
Efforts at both the international and local levels are crucial, but to be maximally effective the two must connect. This may take several forms. One is the "listening" exercise mentioned above; exogenous donor agencies seeking to promote health and "development" should do so not only having listened but having given voice to the participants and intended beneficiaries of programs. For women, this means being partners in the process of mainstreaming gender perspectives in health policy and development programs. International support for local initiatives is another connecting mechanism. A third is learning from and using local programs as models or creative inspiration for the designing of new initiatives.
Healthy Policies and Mental Health Policies
Health policies can be distinguished from "healthy" policies at the level of the state.(12)Healthy policies are those government programs that, while not specifically aimed at fighting illness and disease, nonetheless have positive consequences for health. Healthy policies for women are supported by state gender ideologies that enhance the cultural, political and legal status of women by legitimizing equitable public investment in and protection of females as well as males. Countries with equitable gender ideologies are far more likely to educate females at approximately the same rate as males and to provide women legal protection, political rights and economic opportunities, than are countries that do not promote such equity. Although furthering gender equity in state ideologies requires the mobilization of political will and political action, as well as attention to women's voices and participation, the impact on women's well-being, and therefore the well-being of society, has been shown to be considerable.
Health policies that incorporate mental health into public health and address women's needs and concerns from childhood to old age can be developed in numerous ways to further mainstreaming of gender perspectives. Ethical considerations and competence of practitioners are central to the formulation of integrated health programs capable of redressing the trauma of rape, the stigma of sexual or domestic violence, the depression of isolation or gender oppression, and the anxiety of scarcity. One of the more troubling mental health consequences of general health status of communities is the effect on mothers of high infant and child mortality rates and high HIV infection rates affecting multiple family members across generations. Highly skilled clinicians as well as broader programs are necessary to address the deeply troubling experiences women encounter when faced with decisions about how to make use of scarce family resources or how to plan for the care of children who may be orphaned because of familial HIV.
Although the social roots of many of these problems mean that they cannot be simply patched over with medical care, to ignore the potential role of the health care system to attend to needy women would imply that a society does not want to invest its resources in women's health. Institutions of health education, such as medical schools and training programs for health workers, need to be evaluated and barriers to treating mental illness and the consequences of violence addressed. Communication among health workers, physicians, and women patients (and often men as well) is notoriously authoritarian in many places in the world, regardless of the sex of the physician or health worker, making a patient's disclosure of psychological distress or consequences of sexual violence difficult, at times stigmatized. Evaluation of training and enhancing the competence of primary care physicians and health workers to treat the consequences of domestic violence, sexual abuse and psychological distress and mental disorders may occur in tandem with a review of what women ideally want from health care givers.
International and state sponsored health policies must also face the challenge of formulating moral but "culturally sensitive" responses to practices hazardous to the emotional and physical health of women and girls (such as female circumcision, female infanticide, gender-specific abortion, and feeding practices that discriminate against girl children.) Such dilemmas can be partially resolved by offering support to local public health movements and grass-roots efforts.
Health policies and accompanying programs of health research may become leverage to mobilize political will and participation, and to promote change in policies controlled by other sectors of government. Continued documentation of the powerful relationship between the health of the whole society and female education is but one example. Evidence is overwhelming that the education of females is the single most important factor in improving the health of infants and children, and of men. It is even a factor in reducing alcohol consumption by husbands (which, in turn, reduces male abusive behavior).(13) Similar analyses of links between legal inequities (such as gender discrimination in family and criminal law) and sexual and domestic violence and their health consequences for women and their families would provide another. A third example is to emphasize the link between health and access to and control of economic resources and opportunities.
Health policies and "healthy" policies may both be fostered by and provide ways to encourage equitable state gender ideologies that bring about the mainstreaming of a gender perspective into the health sector. There are also several specific initiatives in the domain of mental health that call for concerted attention from the research community, international agencies, and local governments. The following recommendations do not propose formulas for the development of specific solutions, but suggest ways that recognize the complexities of creating mental health policies, and ultimately, mainstreaming a gender perspective in the health sector that recognizes the concerns of the very people most affected by the problems in question.
Recommendations for Specific Initiatives in Mental Health Services and Training (14)
- Upgrade the quality of mental health services
Mental health services have a crucial role to play in alleviating suffering associated with psychiatric illnesses, emotional distress, psychological disorders, and behavioral pathology. Abused women, troubled children, those traumatized by political violence, those who have attempted suicide or are addicted to alcohol or narcotics, and especially those who suffer acute or chronic mental illnesses can be helped substantially by competent mental health care. We have seen how women suffer disproportionately from mental illnesses such as depression and anxiety, and dissociative disorders associated with sexual abuse, and yet these are the illnesses that competent clinicians may best help. With recent advances in psychiatric medications and specialized forms of psychosocial interventions, the potential for benefit is greater than at any time in history.
Yet mental health services in most societies are inadequate. Well-trained practitioners are scarce, drugs and psychosocial interventions are unavailable or of poor quality, and even where expertise and resources exist, they seldom reach into the communities where the needs are greatest. The human rights of the mentally ill are often severely compromised, and mental health care is too often associated with abusive social control. Financial investment is required for sustainable programs, and creativity is needed to build programs that join local resources with professional knowledge.
Mainstreaming a gender perspective in the mental health sector -- through educating women at all levels of society about the possibilities of mental health interventions and the potential for services and programs -- is central to the success of mental health program development. The development of community based programs may build upon the engagement of many women to their local communities and their commitment to community and family health. Formal mental health services, including rational drug policies for psychotropic medications and the reliable provision of adequate supplies at reasonable costs (selected generic antidepressants, antipsychotic and anticonvulsant drugs), must be complemented by non-medical support groups, consumer groups and healing institutions that provide crucial care in many communities.
- Encourage systematic efforts to upgrade the amount and quality of mental health training for workers at all levels, from medical students to graduate physicians, from nurses to community health workers.
Essential to mental health programs is a small cadre of well-trained mental health professionals: psychiatrists, psychologists, social workers and psychiatric nurses. They are the ones who must lead efforts to establish priorities of mental health in medical education and health policy. Training primary care physicians, nurses and health workers in the recognition and appropriate referral and/or treatment of mental illness is central to expanding community services to meet needs. Specific training in diagnosis and management of psychiatric conditions is required to improve the quality of mental health services offered in primary care. And since community practitioners often depend almost exclusively on agents of pharmaceutical companies for new information on medications, initiatives in continuing education are needed to provide more basic training in the safe and effective use of psychotropic medications.
With appropriate training and supervision, nonphysician primary health workers can learn to diagnose, treat, and organize follow-up programs for a substantial fraction of cases of depression, anxiety and epilepsy, and can, with appropriate supervision, manage patients with chronic schizophrenia in the community if their social welfare is provided. WHO has developed training programs and shown they can be effectively employed in societies as diverse as India, the Philippines, and Tanzania. In societies in which nonphysicians provide a substantial portion of primary care, specialized training activities are a cost-effective means of improving and extending mental health services.
Mainstreaming a gender perspective may build on the interests of many women professionals who have entered the field of mental health care as psychiatrists, psychiatric nurses, counselors and social workers.
- Promote efforts to improve state gender policies, toward interdicting violence against women, and toward empowering women economically, and to make women central in policy planning and implementation of mental health services. Research should evaluate the mental health consequences of these programs for women, for children, and for men.
As we have noted above, investing in the health, education, and well-being of women is of high priority for improving the mental health of populations in low and middle income countries. The World Bank's 1993 World Development Report clearly demonstrates that educating women to primary school level is the single most important determinant of both their own and their children's health. World Mental Health (1995) indicates women's education is an equally valuable investment for the mental health of women, men and children. Such education also renders women less likely to tolerate domestic violence and abuse, or the spending of substantial portions of the family income on drinking or gambling by their spouses. Educated women are also more likely to be receptive to and engaged, as equal partners, in public health programs.
Women throughout the world constitute the vast majority of caretakers of first and last resort for chronically disabled family members, including mentally retarded children, demented elderly, and adults suffering a major mental illness. Minimally, it is in a community's long-term social interest to assist with this burden through formal health services. In addition, because women are critical to the success of health policies, their participation in formulating mental health policies should be encouraged, with governments, international organizations and NGOs defining avenues for women to exercise leadership roles. Policies may be evaluated by women's groups not only in terms of how they support women's mental health but also in terms of the quality of services offered to women, children and men.
- Encourage initiatives to attend to the causes and consequences of collective and interpersonal violence.
Collective and interpersonal violence is one of the most pressing problems in the world today. Wars, prolonged conflicts, ethnic strife, and political repression lead to deep trauma and psychological problems that persist beyond the period of conflict and violence. While only profound changes in international and national politics will reduce armed conflicts, peace and security initiatives should be strongly encouraged. In addition, mental health concerns should be more widely understood in peace and security programs. For ethnic conflict, for instance, mental health issues -- from the effect of racism on ethnic identity to the vicious cycles of revenge -- should become the target of new policies, such as education in schools. Transnational initiatives to treat trauma may assist in modest but effective ways as well to quickly respond to and aid victims of collective violence. Intervention programs of therapy and triage, which have been shown to have beneficial effects, need to be supported internationally as well as locally given costs and limited services in many parts of the world. Women's organizations have taken major roles in leading such efforts in the past and can be models for future efforts as well.
Curtailing and preventing interpersonal and domestic violence (often generated by community violence and breakdown) requires the mainstreaming of a gender perspective to formulate policies both in health care services and in the legal system. Although medical care for physical wounds and mental health care for psychological wounds may mitigate long term suffering, deterrence and ultimately prevention require laws that make domestic violence against women (and children) a crime.
- Direct efforts specific to primary prevention of mental disorders, and behavioral, psychosocial and neurological disorders.
Such efforts would survey the scientific knowledge base, examine primary prevention activities around the world, address the cross-cultural relevance of prevention programs, and define training needs and related activities. Successful prevention programs call for the integration of biological and psychosocial factors, and the active promotion of proven preventive programs. Models taking account of the co-morbidity of many disorders, the clusters of psychiatric disorders and psychosocial distress, must be developed in order to encourage interventions to support individuals who are afflicted with mental illness. In addition, prevention programs require an understanding of indigenous protective factors, such as the activities of caretakers of those who are ill and those local practices that enhance the mental and physical health and well-being of individuals and of communities. Listening to women, professional and lay, should help in identifying these factors.
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FOOTNOTES:
1 This working paper focuses on one of the many components of the well-being of women: women's mental health. it draws on the World mental Health project carried out by the Department of Social Medicine at Harvard medical School, in particular on Chapter 8 "Women" which I co-authored with my colleague, Norma Ware, and which incorporated contributions from many colleagues from around the world, including Violet Kimani of Kenya, and Elizabeth Miller and Ruth Fischbach of Harvard Medical School. See Robert Desjarlaid, Leon Eisenberg, Byron Good, and Arthur kleinman, World Mental Health: Problems and Priorities in Low Income Countries (1995). Chapter 8 "Women" (by Norma Ware and Mary-Jo DelVecchio Good) and Chapter 11 "A Call for Action." See also Updates on Global Mental and Social Health, Summer 1997 2:1.2 Angell 1997; Msamanga and Fawzi 1997; Lurie and Wolfe 1997; Whalen et al. 1997.
3 Rosenfield and Maine 1985.
4Van der Kwaak et al. 1991:2.
5 World Bank 1993.
6 Updates on Global Mental and Social Health, Summer 1997.
7 Das 1994.
8 Finkler 1985; Malik et al 192; Naeem, 1992; Nations and Rebhun 1988; Scheper-Hughes 1987, 1992, 1995.
9 Davis and Low 1989; Jenkins 1991; Farias 1991; Good and Good 1982; Boddy 1989; Lewis 1986; Ong 1987.
10 See Desjarlais et al. (1995) p. 202 for many examples of such local efforts carried out by women to address the social origins of mental distress and illness. See also Cohen 1997.
11 Koblinsky et al. 1993; Jacobson 1993
12 Julio Frenk, personal communication
13 World Bank 1993.
14 This section is summarized from Desjarlais et al. 1995, chapter 11.
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a Explanations proposed for gender differences in psychiatric morbidity in Asia, Africa, the Middle East and Latin America echo established associations among poverty, isolation and psychiatric morbidity for women in Western Europe and the United States (see Dennerstein et al. 1993). In a now classic study by Brown and Harris (1978), depression was found to be more prevalent among working-class than middle class women living in London. There is evidence that poor women experience more and more severe life events than does the general population (Brown et al. 1975; Makosky 1982); they are more likely to have to deal with chronic sources of social stress such as low quality housing and dangerous neighborhoods (Makosky 1982; Pearlin and Johnson 1977); they are at higher risk for becoming victims of violence (Belle 1990; Merry 1981); and they are especially vulnerable to encountering problems in parenting and child care (Belle et al. 1990). Poverty also erodes intimate and other personal relationships (Cherlin 1979; Wolf 1987). In fact, social networks can represent additional stress for poor women as well as sources of support (Belle 1990).