In their contribution to our annual Worldwide Intergenerational Fairness Blog Week, community psychologists and mental health researchers from Chile, María José Campero Rauld and Antonia Rosati Bustamante outline the state of mental health in Chile before and throughout the COVID–19 crisis, which they argue is better described as a “syndemic” than a pandemic. They also call for better interventions which treat mental health as a human development concern, taking into account the social determinants of mental health, particularly focusing the relationship between mental ill-health and poverty.
Signs left-to-right: Sing 1: “You didn’t worry about mental health, welcome to collective catharsis. Is not depression, is inequity”. Sign 2: “Less Ravotril, more Justice”. Sign 3: “We are not hysteric, we are historic”.
The “jaguar” of Latin America. This is how Chile has long been considered, being described as an example of how economic liberalisation had enabled GDP growth and poverty reduction. Nevertheless, underneath what the Chilean president named as the “Latin American Oasis”, was a pressing discontent and the eruption of a 30-year-long malaise.
Why? The reality of having one of the highest indices of inequalities in the world, injustice, and precariousness. This explosion was part of a bigger, worldwide wave of discontent where inequalities are in the “eye of the hurricane”. Chile went from being a “neoliberal paradise” to representing the best illustration of the “trickle-down” illusion.
Thus, Chile confronted the Covid-19 pandemic whilst in a state of social ebullience. The complex interactions between these different crises (social, epidemiological, economical) transforms this scenario from a pandemic into a syndemic. In this context, multiple factors interact synergistically to contribute to the etiology and persistence of mental health problems, exacerbating vulnerabilities, and reproducing health disparities.
Mental health as a two-folded right
In the middle of this storm, Chile seems to be neglecting a dangerous reality: the relationship between poverty and mental health problems. At the international level, some researchers have looked deeper into this relationship, not only confirming it, but more so by describing it as a vicious cycle.
This cycle refers to how poverty can cause mental health problems, but also how mental health problems (when unattended) can cause people to either fall into poverty or become unable to overcome it. This is why it is so important to remember that “the right to mental health” is an inclusive, two folded right, it includes equitable access to both: mental health care and the conditions underlying its social determinants.
Accordingly, avoiding the danger of poverty psychiatrization, researchers and activists have called for a new era for global mental health. They call for social interventions that engage with systemic vulnerabilities rather than a narrow focus on individual mental health. However, this global call still has not reached Chilean public policy agenda.
The country is still part of the 40% of countries in the world that do not have a Mental Health Law, which is further aggravated by low public spending on mental health. This is problematic considering the high prevalence of mental health problems: high levels of depression; high rates of alcohol and other substance abuse; and a high rate of depressive disorders in adolescents.
However, these rates are unevenly distributed. For example, there are more than 240,000 people with mental, psychiatric and/or intellectual disabilities, of which 40% are in a situation of monetary and/or multidimensional poverty. More so, regarding depression, this relation shows greater presence in women.
Mental health during the COVID-19 crisis
In addition to the pre-existing issues, let us add the negative consequences that viral outbreaks and economic contraction have on mental health symptoms. Trying to address this problem, the Chilean government quickly created “SaludableMente”: an online platform that gathers scattered resources and delivers online mental health care.
This is needed, indeed, but is not enough. More so, most of the actions carried out by the government have been concentrated in remote and virtual care. Thus, digital barriers have been a critical problem for the poorest sectors. Similarly, the World Health Organization suggested a series of measures that include staying in contact by phone and internet, maintaining physical activity and a healthy life.
Again, is this something that everyone can do? The adoption of a healthy lifestyle (balanced diet, physical exercise, abstinence from smoking, etc.) is associated with socioeconomic and educational conditions that are not resolved by the mere promotion of individual responsibilities. These are examples of the “missing half of the equation”: addressing the social and economic conditions that contribute to poor mental health.
Is there any good news? Yes. The public in Chile is starting to hear about this. The Covid-19 crisis unveiled the effects that inequality and poverty have on mental health. Media and academic reviews are starting to highlight this.
There is no doubt that these are challenging times for mental health, and more importantly, there are underserved sectors that need urgent attention: people living in poverty living with mental health problems.
Building better policy for current and future generations
First, we need to incorporate valuable knowledge, and practices, that flourished during these multiple crises. Among these: reactivation of the social fabric is crucial to respond to local needs in times of crisis. In Chile, spontaneous and resilient practices emerged during the social ebullience, strengthening neighbourhood associations.
At the same time this is vital for mental health improvement considering the weakening of communities and social ties are related to higher rates of mental health problems. Accordingly, in the face of social conflict, health crisis and economic recession, social policies aimed at strengthening social cohesion are essential to mitigate negative effects on mental health.
Second, we should listen to what is already known but, while “obvious”, has been ignored so far: mental health cannot be thought of, or acted upon, if it is not in the light of its social determination. For that, we need strong, integral and sustainable intersectoral action. Developed countries already have forwarded this idea. For example, we need to question how mental health is being understood and included as a concern in poverty alleviation policies. What are the challenges? What are the opportunities?
Spirit of the age
Overall: mental health should be at the centre of human development concerns. The WHO’s Director-General has already stated, “There can be no health or sustainable development without mental health”. What are we waiting for? Chilean current constitutional process presents a HUGE opportunity in this regard.
One could say the “spirit of the age” in Chile can be summarised in three words: syndemic, revolution and mental health. Let’s avoid inertia, let’s walk towards innovation and start acting upon the social determinants of mental health by securing enabling environments that promote a life of dignity and wellbeing at all settings, throughout the life course.
For us, and for future generations.
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