Global health security has been concerned predominantly with organizing transnational collective action to prevent the risks of bioterrorism and infectious disease outbreaks, such as the Ebola crisis of 2014-2016.1 One confounding omission in global health security has been mental health. The Global Health Security Agenda (GHSA), currently a partnership of more than 60 sovereign states plus the World Health Organization (WHO), other international institutions, nongovernmental organizations, and private companies, is committed to “a world safe and secure from infectious disease threats.” Of its 8 Action Packages, from antimicrobial resistance to biosecurity to zoonotic disease, none pertains directly to mental health. The WHO’s Global Preparedness Monitoring Board, which gauges global preparedness not just for outbreaks but also health emergencies, makes no meaningful reference to mental health in its first annual report, released in September 2019.2 None of the 6 indicators on the Global Health Security index, developed by the Johns Hopkins Center for Health Security, the Nuclear Threat Initiative, and The Economist Intelligence Unit, even mentions mental health.
This omission of mental health from the heart of global health security is perplexing considering that the global burden of mental disorders is estimated to account for 21.2% to 32.4% of years lived with disability and 7.1% to 13.0% of disability-adjusted life-years.3 Large-scale mental health crises can be precipitated by security-threatening triggering events, such as pandemics, war, and political turmoil, that result in disruptive socioeconomic and demographic transitions, if not forced migration and displacement.4 Financial crises, which destabilize public service budgets and compromise education and health care institutions, are also known to be closely related to mental health insecurity.5 The effects of the 2007-2008 global financial meltdown, including the European debt crisis that began in 2009, were strongly correlated with significant increases in 1-month prevalence rates of major depression in Greece, the epicenter of the latter, from 3.3% in 2008 to 8.2% in 2011.6
The ongoing COVID-19 pandemic has inflicted emotional isolation, insecurity, and stigma onto individuals all over the world and undermined the mental well-being of entire communities through aggravating factors, such as inequitable distribution of necessities, inadequate medical resources, and significant economic loss.7 These stressors may bring forth the next global mental health crisis, which is arguably as detrimental to health security as communicable diseases in the long run.8 To exclude mental health from all major global health security initiatives, as is the case now, is to treat as acceptable a rampant lack of preparedness for such a crisis.
A mental health renewal of our current understanding of global health security, itself rooted in the concept of human security, is urgently needed. The identification and mitigation of political and socioeconomic conditions that are detrimental to public mental health are no less important than the enhancement of biodefense and population health interventions for the control of communicable diseases in defense of human security, the global importance of which is underscored by United Nations General Assembly Resolution 66/290. The primary concern of human as opposed to state security is to enlarge the genuine freedoms relied on by individuals in order to live fulfilling lives.9 To defend human security from a mental health perspective is thus an imperative of the key principles of international human rights, such as the right to mental health, set out in the International Covenant on Economic, Social, and Cultural Rights, and the spectrum of rights of persons with mental disabilities guaranteed by the Convention on the Rights of Persons with Disabilities.
To give adequate recognition to what may be called global mental health security, international and national capacities to respond to large mental health crises need to be radically strengthened. The GHSA should extend its coverage to mental health, with the aim of developing a tool, such as the Joint External Evaluation, that will aid in the review of a country’s capacity to respond to public mental health crises.10 Such a tool should involve a component of national self-assessment and another of external evaluation by public mental health experts. The GHSA should facilitate the creation of time-limited task forces that can immediately respond to any developing mental health crises. The WHO should amend the International Health Regulations (2005) to rectify the conspicuous absence of any reference to mental health. Preventive and control responses to global mental health threats must be adopted. It is bemusing that this recommendation has not been made at all in the WHO’s Comprehensive Mental Health Action Plan 2013-2020, which is set to be extended to 2030. And the Global Preparedness Monitoring Board should actively raise awareness among governments on the importance of mental health emergency preparedness.
Individual nations need to abandon their misunderstanding of mental health being unimportant to their citizens’ security and development. Consequently, they should build a stronger capacity in the prevention, detection, and response to potential mental health epidemics. Prevention will require a larger investment relative to current health expenditure in the training of mental health care professionals, the enhancing of the quality of mental health services that are comprehensively accessible, and the provision of timely humanitarian psychological aid in the event of crises or emergencies with demonstrable consequences for public mental health. Detection will demand countries to invest time and resources in acquiring a comprehensive, evidence-based understanding of public mental health and how this may be affected by a range of political and socioeconomic conditions or events. Once a mental health crisis has erupted, multistage and multidimensional interventions may be required to respond to individuals already affected and to prevent others, especially vulnerable populations, from succumbing to the crisis. Specialized agencies that coordinate public mental health preparedness and emergency responses should be established by law.
Worldwide mental health epidemics cannot be restrained by geographical borders. To recognize mental health as a global health security problem is to acknowledge the fact that communities and states cannot be truly secure and flourishing if a sizeable number of individuals cannot capitalize on their abilities, cope with normal stresses, work productively, and contribute to society, to paraphrase the standard WHO definition of mental health.
Corresponding Author: Eric C. Ip, DPhil, MBioethics, MSt, LLM, LLB, BSocSc, The University of Hong Kong, Faculty of Law, Floor 10, Cheng Yu Tung Tower, Centennial Campus, Pokfulam Road, Hong Kong, Non-US 852 (firstname.lastname@example.org).
Correction: This article was corrected on June 22, 2020, to correct author Daisy Cheung’s academic degree from BC to BCL.
Conflict of Interest Disclosures: None reported.
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