Should Doctors Prescribe Cleaner Air? Better Housing? A Dance Class?

A new book highlights the difficulty of treating mental health issues without addressing simple facts of poverty and injustice in people’s lives.

Dr. Barry Zuckerman and his colleagues at Boston Medical Center were tired of fighting battles they couldn’t win. No amount of quality care could help their pediatric asthma patients over the long term if those children were being discharged to homes with mold and vermin. Zuckerman needed a new specialist on his team: a lawyer. In 1993, Zuckerman started what later became known as a medical-legal partnership. In an MLP, attorneys work alongside health care providers to address the social and legal issues that stand in the way of a patient’s well-being by, for example, writing letters to landlords to address substandard living conditions, or helping patients access assistance such as food stamps or Medicaid.

The model emphasizes that health care providers need to do more than examine patients in a clinic to treat them effectively. Studies of MLPs have found they lower hospitalization rates, reduce asthma flare-ups, and generally improve well-being. Today, over 450 health organizations, across 49 states and D.C., have an MLP. Lawyers in MLPs not only tackle individual cases but often train physicians in advocacy so they can influence legislation and policy to make structural changes in their communities.

Yet such practices are still relatively rare. And in the decades since Zuckerman began Boston Medical Center’s MLP, Americans’ well-being has by many metrics deteriorated. The prevalence of chronic disease is on the rise. For those without a college education, average life expectancy is falling. And more and more people are diagnosed (or self-diagnosed) with poor mental health, to the point that some experts warn of a mental illness “epidemic.”

Why is our society getting sicker? In Empire of Madness: Reimagining Western Mental Health Care for Everyone, Khameer Kidia argues that an unjust world is an unhealthy world—that sickness, and in particular mental illness, can result from the gross misallocation of resources stemming from colonialism, capitalism, and the ongoing predations of rich countries and corporations. Kidia, an internist at Brigham and Women’s Hospital in Boston, reassures readers that his focus on structural and historical contributions to ill health are not intended to discredit modern medicine. “Fear not: I’m a physician, not a scientologist,” he writes in the introduction.

In questioning the standard paradigm of mental illness, Kidia joins a line of physicians such as Bessel van der Kolk, Gabor Maté, and Rupa Marya, as well as social psychologist Jonathan Haidt, whose inquiries into the sources of mental distress push beyond standard biomedical approaches to emphasize how factors such as trauma, cultural environment, and social media affect well-being. But Kidia writes from a unique position: He splits his time between practicing medicine in Boston and overseeing a mental health nonprofit in Zimbabwe, where he was born and raised. As he moves between countries, both insider and outsider at any given moment, he grows more and more attuned to the culturally specific nature of healing, and critical of interventions that don’t account for the simple facts of poverty and injustice in people’s lives.

Kidia calls at the outset of his book for “the end of psychiatry,” at least as a practice that limits itself to “a tiny toolbox”—a neurochemical model of mental distress overly reliant on diagnoses and drugs. Many instances of mental distress are not so much disorders as a “rational reaction to colonialism and capitalism,” he writes. “My patients are not suffering from depression; they’re suffering from oppression.” To treat such symptoms requires reckoning with the root causes: the legacies of colonialism, capitalism’s intense pressure to produce and consume, and systems that leave so many people’s basic needs unmet even as billionaires proliferate. “For the oppressed,” he adds, “psychiatry does not heal so much as mollify.”

Kidia begins with his mother’s nervous breakdowns, periods of what her doctors describe as “paralytic mental distress” lasting weeks or months, which she had experienced since she was a teenager and one of just a few girls of color at an elite boarding school in what was then Rhodesia. His mother has never received an official diagnosis for these episodes, and, Kidia later discovers, “nervous breakdown” is not itself an official diagnosis, even though it is her preferred term and his—with its connotation of a break,........

© New Republic