The concept of mental health and mental illness, like biomedicine, is still a relatively new concept in Fiji. As a Western, allopathic psychological model, very few people in Fiji are trained in appropriately and sensitively treat mental illness, and, thusly, the resources available to individuals who suffer from mental illness are fairly limited. In addition, very little research has been conducted within the country to assess the success of the training given to health care professionals, the indigenous attitudes toward mental illness, and the experienceof Fijians who are diagnosed with a mental illness or a mental disorder. Most of the services available to address issues of mental health are still very new, understaffed, in a stage of nascent development and largely inaccessible to those outside of Suva or Lautoka (the major cities in Viti Levu). St. Giles hospital is the only mental health facility in the whole country that cares for and treats patients with a variety of mental illnesses; it provides occupational therapy, day care facilities, forensic assessments, counseling services, community psychiatric nursing, electro-convulsive therapy and pharmaceuticals. The support systems for those who may be suffering from mental illness or distress—such as the Hope Center in Lautoka, the Community Recovery Outreach Program (CROP), Lifeline Fiji, Youth Champs 4 Mental Health, the Psychiatric Survivors Association, the Fiji Alliance for Mental Health, Empower Pacific Counselling Services, and the Hope Health Centre—are all contactable by phone, even though many Fijians still do not possess telephone land lines or mobiles/cell phones, so their ability to aid and counsel the majority of the Fijian population is narrow and imperfect.
This restricted level of access is only further complicated by the lack of education or awareness many Fijians possess about mental illness or mental health. Just as doctors and nurses in Fiji must attempt to reconcile indigenous models of the body and traditional aetiologies with biomedical frameworks, those that work in the mental health sector must attempt to explain, often in the most simplified scientific terms they can find, what mental illness is, a task difficult in almost any language. As a developing country, the Fijian education system may not provide information on the biological and genetic components that contribute to mental illness, insight which would afford Fijians with the baseline knowledge to understand the manifestation and effects of mental illness. Even if psychology is taught in schools, many adolescents tend drop out of school early and may never have been exposed to terms like “neurology,” “dopamine,” or “neural transmitters.” For communities that have never been introduced to concepts like brain chemistry and psychology, how do you effectively communicate the complicated array of factors that contribute to mental illness that many neurologists still puzzle over? Finding the proper explanatory models, metaphors and analogies is a huge challenge for health care workers, especially when you consider the consequences of language and how important medical discourse is to a patient’s understanding and approach to illness. Mental health is also affected by “social, cultural, economic, political and environmental factors such as national policies, social protection, living standards, working conditions, and community social supports. Exposure to adversity at a young age is an established preventable risk factor for mental disorders [and] Depending on the local context, certain individuals and groups in society may be placed at a significantly higher risk of experiencing mental health problems” Mental Health Action Plan 2013-2020,” World Health Organization: 9). This interaction between biology, genetics, environment and culture requires an integrated, multisectoral approach to addressing mental illness, especially in the wake of Fiji’s NCD (non-communicable diseases) crisis.
The World Health Organization recently released a Mental Health Action Plan to address the growing concern of mental illness globally, especially in countries that lack comprehensive and institutionalized health care programs. Within Fiji, mental illness is characterized by ignorance or stigma due to indigenous interpretations of madness or family embarrassment. The nurses that are assigned to treat patients with mental illnesses, at least in Tailevu, seem to lack a basic knowledge of mental illnesses, what causes them, and how to sensitively treat patients, even though the topic is taught in nursing school. Nurses will glibly swap stories about their “mental cases,” and refer to patients who have a history of not taking their medications as “defaulters,” as if a TB patient who doesn’t take their meds and an individual with depression who refuses medication are equivalent. The term “defaulting” is usually used to refer to patients who have communicable diseases, and, thusly, risk infecting others when they aren’t “medically compliant.” The terms “default” and “compliance” are also morally fraught and often connote condemnation or shame upon the patients. This shame is routinely used as a tool to compel compliance, reifying stigma in an already stigmatized community, even when a patient simply can’t take their medication for social, structural or economic reasons. But individuals who suffer from mental illness are not contagious and, for many, the choice to forgo medication does not endanger those around them. Very little is still known about how different medications affect the brain and the body, especially among adolescents. Many treatments for mental illness have several serious negative side-effects that may only worsen the patient’s condition. Some patients may also be on several medications at once, promulgating negative neurological and physical interactions between the chemicals. When nurses refer to their “mental cases,” they often lump together very different forms of mental illness, from epilepsy to schizophrenia. Many, when asked what the patient has been diagnosed with, though they’ve been assigned to their case, don’t know and will cover up their lack of knowledge by saying, “But they’re not violent,” as if all mental illnesses predispose people to violence. Indeed, in a study on “Mental Health Workers’ Attitudes Toward Mental Illness in Fiji” by Foster et al. (Australian Journal of Advanced Nursing, Vol. 25, No. 3), they found that 91.3% of the health workers they interviewed in Fiji agreed with the statement that “Psychiatric drugs are used to control disruptive behavior,” revealing a flawed and negative attitude about the nature of psychaitric medications and the conditions they treat.
The patients themselves may also lack a thorough understanding of their own conditions. If the health care professionals that treat the patients aren’t able to explain their condition in a culturally salient narrative, then indigenous explanatory models are likely to be employed in lieu of medical ones. Many traditional aetiologies are utilized to explain psychotic breaks, stress or mental illness. I had a conversation with a representative from St. Giles who mentioned that witchcraft and spirits are often still blamed for mental illness. One of the patients who came in during a Korovou Mental Health Clinic (held once every three months), was diagnosed with schizophrenia at 19. Since then, she’s been in and out of St. Giles five times, and though she’s been medicated ever since her diagnosis, had never heard the term “schizophrenia” to explain her illness. The woman, now in her late forties, believed that she was suffering from a curse a “bad man” had laid upon her, which was why she was not always regular with her medications. It is also believed that if a family builds a house on land that does not belong to their clan or mataqali, the ancestors or Vu of that land may bring about madness or misfortune in the new residents. If an individual becomes wealthy or economically successful, they may incur the envy of their neighbours, who may then entreat witchcraft to lay a hex on their neighbour to punish them for their accomplishments. The St. Giles representative also noted that some people believe that if you are particularly bright or smart in school, you’re more likely to develop a mental illness. She elaborated that mental stress is still a relatively new and foreign concept to Fijians, and that part of their job at St. Giles is to explain the relationship between stress, social and environmental factors, and mental illnesses like mood disorders. Patients and family members who utilize indigenous explanatory frameworks are therefore likely to seek out religious leaders, traditional healers or spiritualists for treatment before seeking out help within a biomedical establishment. Many of the cases St. Giles see, therefore, have far progressed psychosis and rapidly declining mental health making them out of touch with the real world when they’re admitted.
Schizophrenia accounts for 70% of the patients St. Giles see and treat. The next most common complaint is mood disorders. The St. Giles representative indicated that globalization and Western media influence may play a role in the increase of mood disorders in the country. She noted that whereas several years ago they’d only have one case of depression a month, they are not receiving anywhere from four to six new cases with mood disorders a week. Dr. Anne Becker, a medical anthropologist out of Harvard, has been conducting research on the increase of eating disorders and binge-eating in Fiji as it correlates with increased exposure to Western media and Western models of the “ideal” body (“Binge Eating and Binge Eating Disorder in a Small-Scale, Indigenous Society: The View From Fiji,” 2003). Although certain conditions like depression and bipolar are caused by a chemical imbalance in the brain, there has also been preliminary research investigating whether Western psychological models of the mind and mental health are necessarily applicable to people in other cultures. Ethan Watters, for example, wrote Crazy Like Us: The Globalization of the American Psyche to complicate our understanding of Western pyschology and its usefulness or salience in other parts of the world. The book researched the new epidemic of eating disorders in China; the treatment of schizophrenia in Zanzibar; and the treatment of PTSD in Sri Lanka. One chapter explores Western pharmaceutical companies’ attempts to market depression drugs in Japan, a country where there was no cultural concept or equivalent for depression as it is understood in America, even though they have one of the highest rates of suicide in the world. He writes, “Americans experience the self as isolated within the individual mind. The Japanese, on the other hand, conceive of a self that is less individuated and more interconnected and dependent on social and environmental contexts. Feelings that Americans associate with depression have, in Japan, been wrapped up in cultural narratives that altered their meaning and the subjective experience for the individual.” (211). Advertisers had to fabricate a culturally salient new framework with which to comprehend sadness in Japan; the Western media literally had to indoctrinate the Japanese into believing that they suffer from depression in order to sell their drugs and make a profit.
In an interview with NPR’s “Talk of the Nation” on his book, Watters said, “I think we do have to understand how these scientific notions cross over into cultural notions of the mind. And I think the only way we can really do that is by looking cross-culturally and understanding that there are other ways to think about the human self. There are other ways to think about the human psyche. And before we tromp into other cultures and try to change them and try to get them to think like us, we should appreciate those differences because they’re really the only mirror we have,” imploring the audience to consider that by exporting Western models of the mind, we are unintentionally perpetrating a form of psychological imperialism. There is still little known about other conditions called “culture bound syndromes,” like susto, which seem to appear only within certain cultural contexts. In fact, medical anthropologists like Margaret Lock have been problematizing biomedical approaches to illness through the theoretical framework of local biologies. Margaret Lock looked at experiences of menopause among women in Japan to scrutinize variations in the ways in which menopause is subjectively experienced, noticing that the physical symptoms of Japanese women differed from those of their American counterparts. She concludes “Menopause, Local Biologies, and Cultures of Aging” (The American Journal of Human Biology, 2001), by stating, “The danger, of course, is that the “Western” body remains unproblematized […] it is appropriate to think of biology and culture as in a continuous feed- back relationship of ongoing exchange, in which both are subject to variation” (503), indicating that bodies nurtured and grown in different cultural context may experience different somatic representations of sickness. The concept of local biologies could, therefore, be applied to the manifestation of mental health and mental illness as well. Not only may we be exporting Western ideas of the mind, but we may also be simultaneously providing a set of symptoms that typically characterize a particular mental disorder that those diagnosed must then fit into. Some believe that the biomedical model of the brain will help to reduce stigma against those suffering from mental illness, but, in reality, quite the opposite might be true. Foster et al. indicated in their study, “contrary to the assumption of de-stigmatization programs, genetic and biological causal beliefs were related to more negative attitudes toward those with mental illness” (73). Watters echoes this trend in his discussion on “Talk of the Nation”: “I mean, we have this assumption that if we can get the world to think like us in terms of the biomedical conception of mental illness, that it’s like a disease like another, that it will reduce stigma. And unfortunately what the studies have found is as this idea gets adopted around the world – and it has been gotten adopted around the world – that oftentimes the very reverse occurs, that people want more distance from the mentally ill. They assume that they’re more dangerous. They want less to do with them.” So perhaps the task to overcome stigma and discrimination lies not in discussions about brain chemistry and biology, but rather the supportive cultural narratives a society already possesses that promote understanding, empathy and support.
The health care workers in Fiji tasked with addressing issues of mental health employ a holistic approach to their outreach and awareness programs. They recognize how important family and local support are to an individual’s health and success. They speak in villages and settlements around the country to increase awareness, while fostering sympathetic understanding, open communication and support so that those with mental illnesses aren’t discriminated against and have the compassion and care of their communities they need to stay healthy. FSNet, another mental health organization in the country, distribute booklets called “The Carer’s Hope for Recovery,” which stresses the carer’s responsibility to be an ally in mental illness and outlines some advice of how to care for those with mental illnesses. The staff at St. Giles, however, only numbers twelve, so their ability to reach all the communities around Viti and Vanua Levu is fairly limited. They’ve been utilizing the media to increase outreach efforts, but television is effective for only a confined target population, as many of the more remote and impoverished villages don’t have television and only sporadic electricity. The demographics that actually do see the television spots, in urbanized areas like Suva or Labasa, are the ones that are closest in proximity to the mental health facilities and thus more likely to have already been exposed to information about mental illness. Legally, the Mental Health Decree of 2010 is supposed to protect the rights of those with mental illness and prevent discrimination. The rights of caretakers or caregivers are also outlined in the Mental Health decree, but it’s unclear how people are informed of their rights if they don’t have access to the Internet and aren’t made aware of the legislation passed down by the government.
The state of mental health services in Fiji is still as poorly understood as the condition of mental health itself. Many individuals suffer in the shadows in a state of emotional and psychological confusion without knowing where to turn for help or support, let alone equipped with the language to describe their condition. Further research on the indigenous understandings of mental health need to be undertaken, particularly in regard to belief in the role of spirits and ancestors in one’s life. Some of these traditional beliefs have become submerged or considered ilicit due to the Christian missionary work, which labeled indigenous belief systems as “devil worship.” These indigenous beliefs do not necessarily preclude biomedical explanations being used in conjunction to explain mental illness. As many medical anthropologists have illustrated, people are self-reflexive beings that understand the influence of their own culture and have the capacity to combine multiple explanatory models to create syncretic systems that make the most sense to them. In Fijian culture, the head is considered the part of the body associated with knowledge and wisdom, and it is therefore taboo to touch the head or hair of another person. Even the emotional states we have in English don’t directly translate or correlate to Fijian equivalents, suggesting the concepts like depression may be further complicated by language barriers as well. A more thorough understanding of the training in mental health that nurses and doctors are given should also take place. We need to understood how health professionals are taught about mental health and mental illness and what sort of sensitivity training they receive. Nurses that make house visits to administer medication are also supposed to offer therapy, even if they’ve never been trained in different therapeutic techniques. If Fiji is to effectively address its NCD crisis, an institutional as well as a social movement needs to begin from the ground up, utilizing grassroots activism, culturally available narratives and scripts, and community/village health workers to create a society conducive to mental health and stability.