No more Knock Down Ginger

When I was a kid in South East London, there was no Internet and no video games. There were just two black and white television channels. Commencing the day after President Kennedy was assassinated, we had Dr Who on a Saturday evening, but both channels went off for an hour on Sunday evening. The Sixties were fantastic for young adults, but if you were a child, there was not much to do except wander the streets and hang around on bombsites.

Forced to make our own entertainment, we used to play Knock Down Ginger. In other parts of the UK the game had (and probably has) other names such as Knock and Run, or Knock and Gnash. The rules can be read here. I have come to feel guilty over my invention of a variant called “the Granny Run”. There was a row of old peoples’ ground floor flats near where we lived, and you could press the doorbell on each one as you ran past. Then you could hide by the bins and watch as the old people opened their doors and expressed irritation to each other.

The suggestion that the UK should disinvest from international aid feels like a game of geopolitical Knock Down Ginger to me. We British have gone around the world leaving a highly variable legacy behind us, and now it seems that we would like to act as if global problems are nothing to do with us. Like the Granny Run, this is not honourable. Unlike the Granny Run, it is also hard-to-implement and self-defeating.

Within the political Right, there is a body of opinion that is fiercely opposed to overseas aid. Priti Patel, the new (-ish) Secretary of State for International Development, is of this persuasion. She has long believed in ‘trade not aid’. In 2013, she argued that the department that she now leads should be abolished or at least focus on business links with low- and middle-income countries.

For hundreds of years, international trade has been important to the world economy. The British Empire was created specifically to assist trade. It developed out of the East India Company, which at one time controlled a half of all the world’s trade. There is nothing intrinsically wrong with international trade, except for the grotesque inequities that are sustained by a global economy that systemically favours the rich above the poor. One of the purposes of aid is to address the problems that are caused by this.

Seventy years of perpetual conflict and war are unwelcome consequences of global inequities, although life is not so neat that the world is divided into unequivocal good and bad guys. The British economy ‘benefits’ from warfare in a variety of ways, not least through the manufacture of armaments, but there is huge public discomfort when conflict makes itself felt through the arrival of refugees or terrorist atrocities. Although the new political philosophy of Brexitism appears to hanker for isolation and trade without movement, these are impossible objectives. If we want to go back to a time prior to the mingling of people, which means before the Crusades or perhaps before the Roman Empire, we have to expect an economy of pre 11th century dimensions. By modern standards this would be extremely small. It is not going to happen.

There are strong moral arguments for a more equal and just world, but self-interest is also a major factor. A less unequal world would be more stable. Health is globally interconnected. The 2014-2016 Ebola epidemic demonstrated that poor sanitation in West Africa has the potential to have a direct impact on public health in the UK. It is a truism to say that reduction in disease burden can only be achieved through public health measures. In the 21st century, public health has to be understood in a global context.

Public mental health is a core element of social psychiatry, and there is considerable interest in it within the profession. Nonetheless, it has yet to really take off or capture the imagination of policy makers, despite the Chief Medical Officer for England’s report in 2013. In part, this may be because current Government economic policy is pulling in the wrong direction somewhat.

Public education is worthwhile, but there is very little evidence that it can achieve very much on its own. The key factors affecting people’s health, mental and physical, are income inequality and social adversity. Debt is a major cause of mental ill health and suicide. Two years ago, I was the co-author of a book setting out the evidence that supports the case for great equality as a means to reduce the burden of mental illness within the population. The evidence is particularly strong for schizophrenia, but it applies to some extent to most mental illnesses. This may sound both idealistic and uncomfortably political, but the evidence is there for all to see. It is increasingly difficult to address inequality in one country. We need to work towards more equality everywhere, because inequality in China or India is bound to affect the UK before very long. I do not suggest that we can proceed to utopian objectives, but clarity about the desirable destination means that we can hope to move things in that general direction, no matter how slowly.

In previous blogs I have described the collaboration between the Centre for Mental Health and Society and colleagues in Mysore, working on a suicide prevention programme. The work is still in progress. This month we are pulling together a grant application for a larger project involving more partners in the UK, and a second country in south Asia. The collaboration is not just about suicide prevention. It also aims to build clinical and research infrastructure in south Asia. The UK partners in this work gain much more from the collaboration than simply accumulating points to be counted towards the next Research Excellence Framework exercise. We have gained skills and expertise, exposure to new ideas, and experience of making things work in an environment where this is intrinsically complicated. We have learnt a lot.

In the current national atmosphere of xenophobia, British psychiatry needs to nurture its links with colleagues in other countries and with supra-national organisations. The profession is truly multinational, and this is a strength. When the profession comes under attack (as opposed to justified criticism) our international links are helpful. International psychiatry can help when psychiatrists in one country develop an ethical problem. The Royal College of Psychiatrists worked with international colleagues within the World Psychiatric Association to challenge political abuse of psychiatry in the USSR. This was surprisingly effective. If Donald Trump becomes President, US psychiatrists may well need some support from the rest of us. If Trump means what he says about extending torture, ignoring human rights and over-riding the US Constitution, they may well face similar dilemmas to those faced by Soviet psychiatrists in the 1970s and 80s.

There are many more good reasons to nurture international links between psychiatrists, such as:

  • Big Pharma. Can’t live with them, can’t live without them. International psychiatry is large and strong enough to be able to resist Pharma’s excesses without throwing the therapeutic baby out with the big business bath water. We are not there yet, but this is achievable.
  • International psychiatry has been steadily working to learn the most appropriate responses to war, disaster and displacement. In case anyone thinks that Britain does not need help with this, I was working in central Liverpool in 1989, at the time of the Hillsborough disaster. Psychological de-briefers were sent to make contact with everyone who was present in the Leppings Lane end. I saw the consequences right up until I moved to a job in Wales in 2004. The evidence from many international disasters is one of the reasons why such an inappropriate response would be less likely today.
  • Notwithstanding Jeremy Hunt’s suggestion that he might want doctors born overseas to go away in due course, I cannot foresee a time when UK psychiatry will have a predominantly British-born workforce. One of the glories of British medicine in general and British psychiatry in particular is its cosmopolitan, international character. It is right and proper that we should have professional, research and educational links to these doctors’ countries of origin as it maintains the flow of fresh ideas back and forth across national and continental boundaries.

So no more Knock Down Ginger. A Little Englander psychiatry would truly be an enervated enfeebled ghost.