Offline: The fetishisation of “global”

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Last week, the UK Government, WHO, and OECD came together to host the first Global Ministerial Mental Health Summit. The gathering, under the banner of “Equality for mental health in the 21st century”, felt a genuinely momentous event. Matt Hancock, Britain's Conservative Secretary of State for Health and Social Care, spoke about “a bold and ambitious statement of intent”. Mental health was “a defining challenge of our age”. As machines take over what, in the past, have been considered cognitive tasks, human beings will be left to rely ever more on their emotional skills and abilities. Mental health will therefore be central to a country's future economic wellbeing. Simon Stevens, Chief Executive of the National Health Service, called mental health “an unfinished revolution”. An array of health ministers from Europe, Africa, and Asia pledged their support for this new global health initiative. The Netherlands Government announced that it would hold the second Global Summit in Amsterdam in October, 2019—the theme, emergency settings. The Lancet Commission on Global Mental Health and Sustainable Development, co-chaired by Vikram Patel and Shekhar Saxena, was launched at the Summit. The Commission builds on a 2007 Lancet Series on Global Mental Health, also led by Vikram and Shekhar, which made the case for greater investments in mental health services. That Series led to the creation of a Movement for Global Mental Health. A decade of campaigning has made mental health a core priority for the international health community. The Lancet Commission's goal is to accelerate action on mental health. But it does so not by repeating old messages. Instead, the Commission aims for a radical reappraisal of mental health. It situates mental health as foundational for sustainable development. It defines mental health as a continuum rather than a binary. As Vikram Patel noted, when we talk about mental health, “we are talking about ourselves”. The Commission sought to contextualise mental health as a product of the political, economic, social, and environmental circumstances of communities. And the Commission argued that mental health is “a fundamental human right”. Charlene Sunkel, who leads the Movement for Global Mental Health, called for the Commission to be used as a tool for advocacy. Grace Gatera, a member of Young Leaders for the Lancet Commission, described her two attempts at suicide, “to escape the darkness”. “Young people are suffering”, she said. “Young people are now.” The Commission looks forward to a time when discrimination against those with mental health conditions will end, when political leaders recognise and act on the mental health needs of their peoples, and when communities are empowered to demand the attention and services they need. But I left the Summit with nagging doubts. Doubts not about the importance of mental health to sustainable development, nor about the ambitious messages of the Lancet Commission. But doubts about the fetishisation of the “global”. Global summits. Global campaigns. Global actions. What is this idea of the “global”? Irene Agyepong, director of health services for Accra, Ghana, gave the annual Academy of Medical Sciences/Lancet International Health Lecture 2 days before the Summit. She asked whether universal health coverage (UHC), the global health community's latest priority, would be a “breakthrough or great white elephant?” By white elephant, she meant, “a curse if the resources to maintain a commitment of such magnitude were not forthcoming”. Her experience was that abstract global calls often ignore local country contexts. “History matters”, she argued. She told the story of Ghana's quest for UHC—colonisation, independence, self-rule, four Republics interspersed by military coups, the emergence of multiparty democracy, and the eventual creation of the Ghana Health Service and National Health Insurance. The trajectory towards UHC cannot be taken for granted, she warned. If grand global goals are to be realised, country demand, ownership, leadership, institutions, ideas, interests, and resources are essential. The principle global goal should be to catalyse human capacity building in countries. Global commitments mean little unless they take account of the domestic challenges faced by country policy makers. Above all, she urged global health leaders to “resist the gold rush lure of fix-all, global technological magic bullets”. A bracing admonition.