Language, Measurement, and Structural Violence: Global Mental Health Case Studies from Haiti and the Dominican Republic
Hunter M. Keys and Bonnie N. Kaiser
In this chapter, we draw on applied research from Haiti and the Dominican Republic to analyze three core concepts in Global Mental Health (GMH): the issue of language and communication in mental health research and service delivery; the challenge of measuring mental illness in cross-cultural settings; and finally, the need to recognize and address structural violence as the strongest driver of GMH disparities.
We begin the chapter with a discussion of language and GMH communication. Drawing on our field research in both settings, we describe how awareness of certain idioms of distress can be useful in recognizing, communicating about, and ultimately treating mental illness in non-Western contexts. We then discuss the benefits and limitations of universalist and particularistic (or relativist) approaches to measurement of mental illness, as well as methodological challenges. We argue for adopting a hybrid approach that utilizes both adaptation of standard psychiatric screening tools and development of local scales based on idioms of distress. Such an approach avoids the pitfalls that arise from assumptions of universality, while facilitating clinical and public health communication. We conclude the chapter by situating mental health disparities within the broader matrix of structural violence.
H.M. Keys (и)
Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
Duke Global Health Institute, Duke University, Durham, NC, USA © The Author(s) 2017
R.G. White et al. (eds.), The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health, DOI 10.1057/978-1-137-39510-8_28
Structural violence theory, as articulated by Paul Farmer (1996) and others, provides a critical lens to better understand mental illness in these settings because it traces mental illness back to its root causes: unjust institutionalized processes that produce and perpetuate disadvantage.
Our case study examples come from a series of interdisciplinary team graduate student projects conducted in Haiti (2010, 2011) and the Dominican Republic (2011, 2012). Beginning several months before the January 12, 2010, earthquake, we had partnered with Project Medishare, a local Haitian non-governmental organization (NGO), to plan exploratory research to understand how mental illness is experienced, communicated, and treated in Haiti’s Central Plateau. This NGO was largely supported by Haitian national staff, ranging from community health workers to Haitian doctors and nurses who were obligated to complete a year of social service. Emory University had partnered with this NGO to provide funding and support short-term clinical services by visiting American students and professionals. In previous visits, student teams had noted that mental health needs seemed largely unaddressed or unexplored. The aftermath of the earthquake made this concern all the more pressing.
In the neighboring Dominican Republic, Emory University School of Nursing had partnered with a public, tertiary-care hospital in the Cibao Valley. There, the School of Nursing and Dominican partners conducted short-term mobile clinics in marginalized communities throughout the hospital’s catchment area. During one of these visits, a team noted that little was known regarding the population of Haitian migrants who used the public hospital or their communities. The research discussed in this chapter derives from these established partnerships between an American university and local NGOs and healthcare centers. The research questions themselves regarding mental illness were developed in collaboration with these various research partners, and our findings draw on qualitative and quantitative data collected in both settings.
First, we should recall that the field of ‘global health’ emerged out of academic and policy circles in Western, industrialized countries. The health and disadvantage faced by people in poorer, non-Western settings became a subject of inquiry, advocacy, and ‘intervention’. While this is a simplistic rendering, it points to the relationship between those who come from the industrialized ‘global North’ and arrive in settings of extreme poverty and hardship in the ‘global South’.
When researchers from more privileged backgrounds arrive in settings where ‘participants’ are far less privileged, there are clearly many ethical challenges. In this chapter, we try to forefront both these challenges and our attempts to overcome them. For example, in Haiti, everyone speaks Kreyol, a language that combines French words with syntax of multiple West African languages. French has long been the language of power in Haiti and remains the language of business and government, but it is only spoken by about 10% of the population. Though our research team included fluent French speakers, our training in Kreyol and close collaboration with translators were essential to communicate with both Haitian professionals and community members. Furthermore, there were issues surrounding appropriate language specifically to explain the purpose of our research and the nature of the research questions. In Haiti, there is no universally understood term for the domain of health known as ‘mental health’. Thus, even broaching the subject presents challenges in describing exactly what we as a research team were investigating.
Second, mental illness can be a highly stigmatizing form of suffering in many places, Haiti and the Dominican Republic included. Were we to inadvertently cast ourselves as ‘the outsiders wanting to learn about “crazy people” fOu)’, we could have unintentionally stigmatized community members we sought to interview or learn from. Furthermore, there was great potential for problems or misunderstandings to arise from power differentials between us as outsiders, the local professionals we worked alongside, and patients and community members. The history of both countries has long been marked by outside political influence, often exploitive; there is also a long history of intervention and humanitarian assistance, especially in Haiti. We had to remain sensitive to the ways in which our presence, attention, and involvement with some community members did or did not convey a sense of privilege not afforded to others. We had to clearly articulate what our purpose was, as well as what risks and benefit our research posed to community members. To do so, we worked closely with local partners and research assistants to conduct the research in an ethical, sensitive way. We had translators and cultural brokers in all interviews, and rather than conducting focus group discussions ourselves, we trained a local community healthcare coordinator to do so.