The Lancet Psychiatry's recent Position Paper on how mental health care should change as a consequence of the COVID-19 pandemic was welcomed by many, but others expressed disquiet at its lack of authors from low-income and middle-income countries. “Far too long, global mental health has been an exclusive group of scholars from selected countries and @TheLancetPsych is enabling it by giving them the platform and not even caring about the missing voices”, tweeted Maji Hailemariam of Michigan State University. “How is this even possible in 2020? What's wrong with HIC academics?” asked Soumitra Pathare of the ILS Centre for Mental Health Law and Policy. The paper itself does not specifically address the mental health of individuals in low-income and middle-income countries. Any fault rests with us, and not with the authors; as editors we could have done more to clarify the remit and purpose of this publication, as well as to highlight the excellent work being done on COVID-19 and mental health in low-income and middle-income countries. This work has been discussed in our weekly webinars with United for Global Mental Health, and has been published in the Comment and Correspondence sections of the journal. We anticipate that it will feature further in all parts of The Lancet Psychiatry.
However, there is a greater issue at stake. It is a concern that “global mental health” contains assumptions about knowledge and expertise that are inimical to the very populations it purportedly sets out to help. Without sufficient forethought, global mental health may become a globalised iteration of psychiatry's potential to reinforce existing power structures and hierarchies. Furthermore, in the broader world of global health, the COVID-19 pandemic has exposed professional prejudice to the harshest of light. As Sarah Dalglish of the Johns Hopkins School of Public Health and University College London put it in a letter to The Lancet in April, 2020, “Global health will never be the same after COVID-19—it cannot be. The pandemic has given the lie to the notion that expertise is concentrated in, or at least best channelled by, legacy powers and historically rich states.”
The first phase of global mental health is ending, catalysed by the social and cultural shifts, including renewed calls for equity and justice, that have accompanied the COVID-19 pandemic. The global situation has drawn attention not only to the failings of high-income states, and the resourcefulness of low-income and middle-income countries, but to the diverse experiences of populations within those settings. Two processes are thus taking place. First, the recognition that expertise comes from individuals and communities in specific social, cultural, and economic environments, rather than the world being a blank slate on which supposedly value-neutral, technocratic solutions can be imposed. Second, the development of a model of the world that goes beyond simple—and implicitly hierarchical—classification of countries by income. This model looks instead for mutual learning between communities at a more complex level. For example, recent work on suicide prevention in Northern Ireland might be of interest and use to other countries post-conflict; Dixon Chibanda's Friendship Bench scheme, meanwhile, may benefit other communities regardless of their nation's economic status.
The Lancet Psychiatry's role at this end—and new beginning—of global mental health remains the same, but we will adapt our methods. We aim to publish material that is valuable to mental health practitioners, policy makers, advocates, and individuals with lived experience. We already publish the gender and countries of our peer reviewers annually, and welcome comparison with other journals in the field. We will continue to proactively seek out authors and peer reviewers from diverse global settings, a process facilitated by our ongoing Editorial Development Board scheme. We are concerned by reports of early-career authors and authors from low-income and middle-income settings being insufficiently credited or not credited at all on research papers, and will increase our scrutiny of authorship contribution forms and statements. Inclusion must take the form of respectful collaboration, and credit should reflect the work and expertise of individuals. We will also ask our contributors to consider the settings for which their recommendations regarding policy and practice are appropriate. As editors we will ensure this is clear in the resulting publications. We are keen to hear further suggestions from our readers. No single paper can hope to capture the richness of the new global mental health in its entirety. Perhaps no journal can. We can only attempt to, as Maji Hailemariam exhorted us, “#DoBetter”.
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