Race, Racism and Discrimination in minority health -where next According to the census in 2011, of the total 56.1 million population of England and Wales, 86% are white and of the remaining Black, Asian and Minority Ethnic (BAME) population 7.5% are of Asian heritage and 3.3% are black, 2.2 % mixed ethnicity and 1% are other minorities. In the decade since 2001, the percentage of the population of England and Wales that was White British decreased from 87.4% to 80.5%, while the Other White group saw the largest increase in their share of the population, from 2.6% to 4.4%. In the same period, among the specific ethnic groups, people from the White British ethnic group made up the largest percentage of the population (at 80.5%), followed by Other White (4.4%) and Indian (2.5%). The number of black Africans doubled over the same period from 0.9% to 1.8%. The variations in population reflect changes in political and social scenarios. Increase from Eastern European communities reflects xenophobic racism. However, what is clear is that health needs vary and a short-term solution has to be setting up of an Office which looks after health of minorities in a joined up manner. The current COVID-19 pandemic and tragedy of the murder of George Floyd in Minneapolis and Black Lives Matter campaign have further highlighted the differences among ethnic and racial groups on a number of parameters and for a number of reasons. There is considerable evidence that ethnic minorities continue to experience tremendous discrimination in a number of fields including education, employment and health in particular. Death rates among BAME populations in general and in NHS frontline staff in particular are strikingly high. A number of explanations have been put forward varying from poverty, overcrowding, high ethnic density, pre-existing chronic co-morbid conditions to other less known factors. I have always believed that services need to be integrated but the COVID-19 pandemic has shown that integrated effort is needed. As we have argued recently, a joined up approach is critical. Disproportionate rates of infection and deaths in ethnic minorities highlight the urgent need for us to change our thinking. Research in health including mental health over the past five decades in the UK has shown conclusively that high rates of various physical and mental illnesses in minority ethnic groups from schizophrenia to depression, from hypertension to diabetes and other chronic diseases. There are also clear gender differences in the incidence and prevalence of physical and psychiatric disorders. To complicate matters further, not surprisingly there are cultural differences in behaviours. For example, smoking rates remain high in some black, Asian and other minority ethnic groups. Pakistani and Bangladeshi groups report low levels of physical activity. Dietary factors also play a major role in developing obesity which has also been associated with increased mortality with COVID-19. Furthermore, there are clear social and cultural factors in differential rates, access to services, response to treatment and outcomes in both physical and psychiatric disorders. Reduced longevity and poor health are also associated with differential attainment in education and also difficulties in obtaining employment in black and minority ethnic groups. Some of these factors may be attributable to ethnic variations but social inequalities, generational inequalities and social determinants appear to contribute a large part to this. Racism, discrimination and prejudice tend to play a major role in creating double and triple jeopardy where people from ethnic minorities choose not to seek help with delays contributing to chronicity of their conditions and resulting in poorer outcomes. Services in general are not culturally sensitive or competent, adding another layer to the complex nature of help-seeking. Another significant finding is over-representation of black and minority ethnic groups in prisons. The effects of incarceration are felt far beyond prison and jail walls and impact health not only of prisoners but also that of their families and dependents. It is well known that the rates of incarceration among certain ethnic groups such as blacks are higher as are rates of psychiatric and physical disorders as compared with the general population and majority groups. In addition, their needs for housing, employment, and educational opportunities after release are very often ignored. Thus, in order to deliver equity. there must be a joined up thinking, policy and planning between health, education, employment, justice and other ministerial departments. The solution is establishment of an Office of Minority Health (OMH) as a matter of urgency. We know the problems and there have been many enquiries in the past looking at the issues related to health of BAME groups. OMH needs to be set up as a public body within the Cabinet Office so that it gets the status it deserves. This needs to be established by an Act of Parliament to act as ‘public authority’ to deliver public duty. The aim of such an OMH will be to improve the health of racial and ethnic minority groups through the development of culturally relevant and culturally appropriate health policies across the lifespan of individual, leading to culturally appropriate services which are more likely to be used by the BAME groups. The OMH will also focus on health promotion, illness prevention and health improvement at population, community and individual levels and also through healthcare systems thereby helping eliminate health disparities. Its main role is to keep under review elimination or otherwise of ethnic inequalities across government, statutory organisations and bodies, social institutions and others. The OMH will be a repository of data on health discrepancies of the BAME populations as well as examples of good practice. It will develop evidence-based health and social care policies and to promote these to achieve health equity between mental and physical health and across ethnic groups in one generation and work with stakeholders and research funders to ensure that studies have a true representation of BAME participants and all studies include these groups. The main functions of the OMH will be to monitor the life outcomes and experiences of the BAME groups in addition to providing guidance on how to best advance life chances and achievements with suitable data framework and oversight. It must have a series of clearly defined , identified and agreed outcomes to provide direction for research, capacity building and setting standards for hospitals, primary care settings and regulatory bodies among others in delivery of services. The OMH has the potential to bring everything under one roof, cut bureaucratic costs and integrate research and joined up delivery of healthcare across life span for BAME individuals who need help in different settings. Profession and individuals need to highlight the discrepancies and influence local parliamentarians and as individuals advocate for establishing the Office. Making progress against these major problems of inequalities will require dedicated work for a long time, perhaps over a generation. This progress is certainly possible if we are able to learn and understand why and how the UK is changing. NOTE FROM THE EDITORS: We would like to once again say a big thank you to Professor Dinesh Bhugra, CBE, for sharing another wonderful blog with our InSPIre the Mind readers!

First pandemic in living memory has created a number of sensational issues in the minds and behaviour of the general population, healthcare professionals and policymakers. In many countries leadership has gone absent without official leave (AWOL). Particular ethnic groups have suffered disproportionately and the inequality between groups has been highlighted in unprecedented ways. The role of governments in protecting the populations has come into a bright spotlight and many governments around the world have failed abjectly. Over 4 million cases identified around the world with large number of deaths, the pandemic has laid bare the public health matters, have torn the respectability off the face of globalization and global health. Just when the leaders have to work together there has been an unprecedented rise in xenophobia, nationalism and racism. Scientists have been working together sharing data and findings and supporting each other in unprecedented ways. The population in lockdown have come up with ways to keep in contact with each other. In our street in London, a WhatsApp group was established early in March to help and support individuals who needed it. Until then we were on nodding acquaintances with our neighbours and those in the street. Every Thursday evening coming out of the house at 8 pm for two minutes with respectful physical distance maintained was not only acknowledgement of the NHS and social care staff but for the neighbourhood and often brief chats would occur. There is a strong possibility that good will come out of this tragedy. The question is whether we as human beings are capable of and interested in building on it. To my mind the following 10 positive things could emerge: 1. First one is already there to a degree where neighbours are keeping an eye out for each other, sharing food when possible and chatting. People have been donating money, food not only to the NHS but charities and food banks. This sense of collective responsibility and altruism is clear in abundance and we need to ensure that this continues. Those who need help, whether it is material, emotional or psychological, get it when they require it. 2. The pandemic has certainly illustrated the interconnectedness through social media. Of course there have been abuses, but humanity, kindness and generosity have shone through. Through street wide or block wide groups, keeping each other informed has changed the ideas of friendship and in the years to come can be built upon ignoring fake news, unnecessary Twitter storms and overfilled inboxes. The quality of interconnectedness will have to change and perhaps become more humane. 3. On a broader scene, many of us have been grounded but we have also noted the bird songs, the colour of the sky, empty roads and other scenes which we had taken for granted. As a race we have to take climate change seriously and respond appropriately to reduce carbon emissions and reduce rising temperatures of the seas. 4. In addition to the action against climate change, public and governments have to work on improving sustainability through better transport, aviation control, green spaces. 5. As Nigel Lawson had said, NHS is the closest thing to a religion this country has, the weekly service on Thursdays at 8 pm even though for two minutes by clapping has brought home to people the role of the NHS in our lives. There was a reason when politicians used save NHS before save lives in their slogan. If there are changes or more commercialisation of the NHS, there are likely to be more serious questions to be asked of the political masters. The new social contract for medicine will emerge to look at what patients and public expect from doctors and government, and what doctors expect from the patients, public and government, and in return what the governmental expectations are from the doctors. There is no such thing as free lunch and if people want the NHS they have to pay. A bit of honesty from the politicians in this regard will not go amiss. The social contract for medicine is something I have addressed in a previous blog earlier in the pandemic, you can read this here. 6. Martin Luther King Jr had highlighted four things that need to be dealt with. That is as true now as was over 50 years ago: these are poverty, racism, militarism and materialism. We know that Covid-19 affects BAME communities and poor people discriminately and other social determinants also play a role. Governments have used the term war on virus which is ridiculous as it is invisible to the naked eye. In order to manage climate change and materialism perhaps we come out at the other end with a knowledge that we need to reduce acquisitions and possessions. 7. With an awareness of ridiculous inequalities, perhaps capitalism may change its focus and become more humane and less neo-liberal. It is clear that we need governments to manage pandemics so perhaps more acknowledgement of the role of the government with better social contract may emerge. It may also lead to revisiting globalisation. For the sake of cheap goods being manufactured in different parts of the world with source materials from another part and reducing acquisitions may change the way markets work. 8. There is no doubt that public health, including public mental health, will emerge stronger after the pandemic. It is clear that in many countries science did advise politicians who took note of the advice. 9. The ways we work will change further. High streets were changing to more cafes and wifi spots but now for those who can work remotely, having got used to it with all the accompanying distractions, will like to and continue to do so. Policymakers and employers will have to change their expectations, and work-life balance will change further. 10. Finally we may become more aware and sensitive to our mortality and focus on other things. No one at their deathbed wishes that they should have worked more so spending time with people who matter and things which matter can be another positive thing to emerge. It may be that some of these may emerge in the short-term and then disappear whereas others may emerge in the long-term. The glass is half-full rather than half-empty.

Now that government has decided how the festival season is to be celebrated are we any clearer? In some area’s pubs may open but cannot sell alcohol, in some regions up to three families can meet but for one day, others cannot. Lockdowns 1 and 2 have affected almost everyone in very many different ways. There is a long way to go before a return to normality — said the health secretary just yesterday. I have already discussed in previous InSPIre the Mind blogs lessons that Covid-19 can teach us, as well as positive things that could emerge from the pandemic. How is Christmas going to be with the pandemics, and what do we need to do? The relationships are fraying, or are they? In two online surveys by Open University in the UK and the USA with over 1500 respondents from the USA and over 1300 from the UK, surprising finding was that in 44% of individuals their relationships had improved. Interestingly this improvement is reported by American men. A quarter of the men and women in the UK reported improvement and only a third of American women reported improvement in their relationships. It would appear that many people were able to take advantage of the changed situation — which may have improved their communication. It is certainly possible that they realised that the good aspects of relationship were the core of attracting them to each other and therefore strengthening their communication and thus relationship. It appeared that in both samples, more people were talking more with their partners spending more quality time together and were more demonstrative in their affection towards each other and also more likely to demonstrate affection with thoughtful gestures. Of course being locked down in a pandemic may well have been frightening for some couples bringing home the message of risks, danger and mortality which may have led to re-prioritising to a degree to coming together and giving each other more emotional support. At the same time during the same period, other surveys have shown a dramatic increase in domestic inter-personal violence against women in particular in many countries around the globe. Although men may say that they are helping more around the house but their role in being with their children and parenting has shown a mixed picture in this survey. Interestingly, around half of Americans, over half of UK women, and three-quarters of UK men, don’t seek advice from anyone regarding relationship issues. This is not surprising for a number of reasons. Firstly in general there are difficulties in acknowledging that there are problems, secondly in the middle of lockdown it may well have been problematic in knowing where to seek help from. Linking this with male patterns of help-seeking and stigma may have deterred people from seeking help. Again not surprisingly, among those who do seek advice, friends and family are the most common source. 11% of Americans and 4% of British respondents seek advice from a therapist or counsellor. Christmas has always been seen as a stressful time with families cooped together. This year it is likely to be perhaps even more so as almost the whole year’s pressures are coming together. The good news is that vaccines are becoming available and some individuals may well have already received their first dose. Secondly, for those who are able to come together for the day in the face of horrendous virus and year, it may generate a degree of positivity and appreciating families a bit better. Couples need to spend quality time together and support each other and both partners need to have clearly agreed responsibilities during the holiday period. In the couple clinic, a common strategy used to be to spend half an hour per day aside to discuss various things and if there were tensions, this was the allocated time to share those feelings and not allowing those to spill over rest of the time. In addition, looking forward to sharing celebrations will help lift the mood. In order to survive Christmas, one must: 1. Make sure that safety is paramount 2. Sharing positive messages and lessons from the lockdowns will be helpful 3. Spending time together in pleasurable activities 4. Appreciating positive aspects of relationships and family 5. Create transition times during the day 6. Have a structure to the day 7. Focus on positives and acknowledge the negatives but put these in perspective 8. Connect to your senses be they visual, olfactory or sensual 9. Avoid too much time watching the news. 10. Remember that there are things that you cannot change and there are things you can so focus on the latter, if need be 11. Reach out to friends and family 1:1 As the good book says: this too shall pass. Have a wonderful joyous season and very merry Christmas.

Another Year, Another COVID Christmas Here we go again… just when you thought it was safe to get back with the family, friends or colleagues to celebrate Christmas, the Omicron variant of SARS-2 (Covid-19) arrives, shattering some of the plans you may have made. Another year has flown by and once again travelling abroad, office functions, and family parties appear to be heading towards a freeze. In the UK, within the last week, wearing masks in public places has become mandatory again. About 10 days ago, while on the tube, I noticed that almost 40% of travellers were not wearing masks. That number had dropped to about 10% yesterday when I visited some friends; although in very crowded shops on Oxford Street and Westfield shopping centre, the numbers of people wearing masks were surprisingly low. On the London Underground, Transport for London (TfL) kept announcing every few minutes that masks were compulsory unless there were any exemptions. Surely for close to 10% of people to have exemptions is a surprisingly high rate of pathology than one would normally expect. A vast majority were young people who looked healthy. Perhaps people were experiencing some unknown anxiety or phobia in this age group that we have not identified as yet. We must acknowledge that they have had a particularly stressed time for all kinds of reasons and the end is not yet in sight. This observation of not wearing masks, brought to mind a story (possibly apocryphal) shared by an A&E physician friend. He was approached by a patient who wanted an exemption to wear masks. The physician smiled and said, ‘yes, of course. There are three reasons for exemption: stupidity, selfishness or immortality – which of these should I write on the certificate?’ Needless to say that patient walked away in a huff. There are likely to be many others to do with arrogance and ignorance. As I write this, news of parties in Downing Street last Christmas are filtering out. Seeing that those in power were not following the rules they had made led many people to feel disheartened, disenchanted, and let down. Anti-science attitudes as evidenced by anti-vaxxers and anti-politician feelings have contributed to these negative responses. This may well have led to a lack of altruism which was in great evidence when the pandemic hit these shores. The change in people's feelings and actions over the last 20 months or so has been amazing. During the first lockdown in 2020, when the Prime Minister asked for 250,000 volunteers nearly three times that number registered. People created street WhatsApp groups, looked after the older and people who were living alone. So what has led to this loss of altruism and regeneration of selfishness? The messages about hanging on to vaccination doses even if they are reaching expiry dates give a subliminal message of selfishness which then becomes accepted. Leaders have to lead by example and if the perception is about falsehoods and people see that their leaders are getting away with it, it sets bad precedents. There is no doubt that over the last 20 months or so, a series of lockdowns have narrowed and restricted our world, world-view, and social interactions. We may have even forgotten how to mix socially. Freedoms to mix and travel have been curtailed severely. Restrictions and narrowing one's external world and may well have contributed to an increased rate of mental illnesses, as well as a general anxiety about living and surviving. The Christmas holidays have always been a stressful time for people for a number of reasons. Research has noted that irrespective of religious denominations, Christmas is a time for reduced life satisfaction and emotional wellbeing, though a higher degree of religiousness can reduce this stress and anxiety. A survey by the American Psychiatric Association published last week showed that 41% of Americans admitted that their stress levels increased during the holiday period whereas only 7% acknowledged a reduction. This survey was conducted between November 7-21 with a sample of 2119 adults. The combination of the pan­demic and holiday season was seen as contributing to increased stress. Over half (54%) of the health workers reported that their stress levels increase during holidays in general, and one third (33%) were expecting higher stress levels when compared with last year. This survey also reported that parents are more likely to be worried – both about Covid-19 infection among their children but also being able to afford gifts. With the Omicron variant gathering pace and more likely to be affecting children more, it is not surprising that parents are worried. Interestingly younger adults were more likely to report being anxious (and yet they appear to be less likely to follow the restrictions). This may reflect a double bind at the level of altruism versus self-preservation and the sense of immortality young people often have which may make them feel invincible. In this survey, Hispanic respondents were more likely to report feeling more stressed in comparison with last year. Laura Spinney, in her excellent book on the history of Spanish flu of 1918 and beyond, noted that health and social inequalities contributed to both morbidity and mortality, and that is exactly what has happened in this pandemic too. Poverty and race then as now have contributed to differential rates of death and infections. So in spite of increases in productivity and better economic state, very little appears to have changed in the last 100 years. These survey findings reflect the attitudes of a US American population, but the observations are interesting in the context of other countries too. Americans are faced with two important holidays – Thanksgiving and Christmas – within a month of each other whereas in the UK and elsewhere, the scenario may be somewhat different. Nevertheless, stress related to Christmas is well recognised. There is little doubt that several surveys in the last year have shown increasing rates of anxiety, phobias, depression and more. These can, however, be seen as expected human responses to the pandemic rather than full-fledged psychiatric disorders and so, with this in mind, it is vital that normal reactions and responses are not pathologized. Restrictions on actions do lead to increased anxiety, panic and reactive depression but another recent study reported that patients with severe mental disorders such as schizophrenia were 3.74 times more likely to die of Covid-19 infection. These variations across psychiatric patients need to be borne in mind by health workers who are likely to be on the front line of health care. The past year has also been a year of success with vaccinations. Among the UK population, 88% over the age of 12 have received the first dose, 80.9% have received the second dose. This has taught us that there is still vaccine hesitancy in many groups but it has also taught us to remain vigilant and focused as the virus is not going to disappear overnight as it seemingly appeared. Christmas is a time for giving. Wealthier nations need to come together to offer vaccines to underserved populations in low-income countries. None of us is safe from this virus until everyone is safe and we know that vaccinations work. We need to acknowledge the sacrifices the younger generation have made through the last 20 months and that these have been worth it. Selfishness from leaders downwards needs to give way to altruism. Cooperation locally, nationally, and internationally should be the gift that keeps giving, not only over Christmas but forever. That is the only way we can manage this virus. Exemption from the patents of vaccines, altruism from the leaders who lead by example and vaccines for everyone globally would be my wish. As Plan B kicks in the UK, and we are back to working from home, it is important for everyone to look after their wellbeing by looking after their physical, emotional and mental health. It is imperative that we look after ourselves and also others who need help but maybe hesitant to ask for it. Take time out for yourself, use relaxation, physical exercise, yoga, mindfulness or whatever floats your boat to maintain your wellbeing – only then can you look after others. And give before you are asked. Have yourself a very merry, healthy Christmas. Happy holidays and a very happy New Year. Stay safe, stay well, stay healthy. Header Photo by Tessa Rampersad on Unsplash

Almost thirty years ago, in one of my earlier return visits to India, I was sitting chatting with my mother. Somehow the topic of poverty came up. She was really surprised that there were poor people in the UK. She wondered why that should be the case. I tried to explain the notion of relative poverty but obviously failed. The general assumption was that in rich countries everyone is rich. Trying to explain relative poverty itself takes some doing as people are often working long hours and struggling to feed their families and pay their bills. Recent events such as climate emergencies seen in the UK and continental Europe, fires, an earthquake in Taiwan and the Russian invasion of Ukraine have brought home how interconnected we are and how interdependent we are even if we do not acknowledge it. The euphemistically named cost-of-living crisis has been attributed to the UK’s dependence upon import of fuel and gas. Having had North Sea oil perhaps made the policymakers rather indolent to plan for the future. There is little doubt that very few politicians have a long-term vision, mostly their eyes are on the next election and an 18 month cycle is about the period they concentrate upon. A lack of planning by consecutive governments has been truly startling in this context. This lack of planning was clearly evident in the governmental and political response to the pandemic which may be subdued but is not over by any means. The shock of flu and Covid-19 infections in the winter will be accumulative and will undoubtedly hit those living in poverty and in overcrowded places. Poverty levels are rising, with an increase in the number of food banks, lack of nutrition for children outside school terms and fuel poverty. The world’s sixth largest economy seems to be unable to look after its vulnerable citizens…when in many cases the vulnerability itself has been caused by the government’s policies and inactions. A mental health crisis tsunami is on its way not only due to the pandemic but fuel poverty and cost-of living crisis. Particularly concerning is the impact of poverty per se and fuel, food and finance poverty on the on growth and development of brains of children and adolescents. The social and health impact on future generations where people are struggling to work in gig-economy and zero hour contracts must not be underestimated. The headline in The Guardian of September 21 says: Last week, the government has announced giving money to households to manage energy prices increases, with tax rebates for high earners and other measures which are likely to benefit high-income individuals more than low-income ones. The inflation is rampant, and the rich are less likely to spend their money locally. There has been no evidence in the last 50 years that trickle down economy works. Reversal of National Insurance contributions will provide £7.66 p.a. to low income individuals but around £1800 to high income ones. Even the International Monetary Fund has stepped in: IMF’s stinging rebuke is without a clear precedent. Increasing Inequalities, threat of choosing between heat or eat, increasing mortgages and possibilities of losing homes are all real and likely in turn to contribute further to stress, distress and poor mental health — not only that of the current generation but future generations too. So what are the potential solutions? We need to think in a collective socio-centric manner. During the pandemic, street WhatsApp groups were established. This is one way of ensuring that those who are vulnerable can be protected and looked after by neighbours and friends. Food banks and energy banks may have a role to play and communities need to ensure that support is available according to need. The impact of Queen’s death brought people together and people queued for up to 24 hours to pay their respects. It reflected that people do come together in the times of crisis. Similarly, Covid-19 pandemic (irrespective of what our leaders did) brought people together with a definite sense of purpose. When the then Prime Minister asked for 250,000 volunteers three times that number came forward. So the community spirit and good will is there — we must channel this. What is all this to do with psychiatry and psychiatrists? All psychiatry is social and we have a moral obligation to speak for our patients. Through advocacy at local, regional and national levels, change can be made and sustained. The can-do spirit of the British nation has to be summoned again. This has to be seen in short, medium and long-term solutions. Working with policymakers, advocating and challenging when necessary, must happen. Clinicians at all levels have a moral obligation to speak up for our patients and advocate for them. However, our training does not teach us to advocate which can be done on a professional basis through professional organisations and as clinicians as well as individual members of the society. The time to come together is now so that at this time of social stress we can look after our patients better.

By all accounts, the last 12 months have been tumultuous. The Russian invasion of Ukraine has led to food shortages, refugees, isolation of Russia with impact on energy supply. In addition, other natural events around the globe such as earthquakes in Taiwan, hurricanes in the USA, and flooding in Pakistan, have contributed to distress and stress among the populations especially those who are vulnerable. The impact of these events confirms the interconnectedness of the modern world but also highlights the futility of trying to deal with these matters in an isolated nationalistic way. Meanwhile, in the UK we have a new Monarch and a new Prime Minister with inflation running rampant, a cost of living crisis and strikes looming ahead. The cost of living and fuel prices are rising, and a hot summer with unprecedented temperatures has led to drought and hose pipe bans. As we head towards winter, it is extremely likely that a large number of people will face a choice between eating or heating. Tragically, this is all occurring in the middle of a pandemic, which has by no means gone away. There is considerable and impressive evidence from the WHO Commission on Social Determinants of Health led by Sir Michael Marmot that social factors such as poverty, overcrowding, unemployment, lack of access to public transport, lack of access to green spaces etc. can contribute to ill health, both physical and mental. However, what is often forgotten is that these social determinants are affected by geopolitical factors which can lead to increased displacement of people within and out of the country. Geopolitical determinants have to be seen in the context of a truly interconnected world where there are very few completely isolated countries. The interconnectedness works at very many levels from trade, manufacturing and exports to sharing of information. These geopolitical factors can be man-made such as climate change, wars and conflicts, and natural disasters such as hurricanes, tsunamis, earthquakes, and volcanic eruptions. Somewhere in the middle of it are epidemics and pandemics. As I write this, WHO has declared monkeypox to be a serious condition. In the past decades we have had Ebola, Zika, and SARS-1 epidemics. These geo-political factors are often not taken seriously and regrettably many of our international organisations are failing to absorb and act on the seriousness of the impact these factors can have on the mental health and wellbeing of communities as well as individuals. All of these factors affect the mental health of populations and individuals directly and indirectly. However, tragically, policymakers often do not take the impact of their policies on the mental health of communities and individuals into account when designing their policies. Geopolitical factors may push people away from their residences and expose them to additional stressors. There is considerable research evidence to suggest that the numbers of refugees and asylum seekers increase during wars and conflicts but also during drought and flooding. Some of these migrants are for a short period whereas others can be long-term and permanent. Global migration is tempered and shaped by geopolitical factors. With war and conflict, the impact of violence, political unrest and food insecurity can lead to internal and cross-border migration. Urbanisation and industrialisation can lead to an increase in rates of psychiatric disorders. This is determined by economic cross-national factors. Clinical and research evidence has shown conclusively that refugees and asylum seekers as well as migrants have high rates of psychiatric disorders and often these are related to social factors after migration. The impact of epidemics and pandemics, although increasingly studied, still ignores the resulting bereavement and grief and survivor guilt in addition to the impact on wellbeing and mental health in general. As physical and mental health often are seen separately, the mental health needs of vulnerable people are less likely to be prioritised. The integration of physical and mental health is crucial in our understanding of the role that geopolitical factors play. Geopolitical factors and determinants are truly international. Both supranational and intra-national factors have to be seen as a system of relationships between individuals, their human, economic, cultural and social capitals and assets, alongside communi­cation styles. Geopolitical determinants are thus to be seen as certain structures which modify various processes, which in turn influence the health of individuals and communities. The direct and indirect effects of geopolitical factors are to be seen at emotional, physical, economic and social levels. Their impact has to be understood so that health and social care services can be improved. In addition, integration of health with education, employment, housing and justice is an absolute must. Geopolitical determinants thus cross national boundaries and influence nations, communities, families and individuals. Types of cultures will affect responses. In socio-centric or collectivist outlines, the response may be seen in the context of community level. This was demonstrated in the case of the Ebola virus outbreak in Sierra Leone as described by Luke Mogelson in his 2022 book The Storm is Here. It illustrates that collectivist cultures can come together successfully in times of epidemics and understand what is needed. The role of cultural factors is evident in the acceptance of rules and restrictions. For example, in some cultures such as parts of the USA, according to Mogelson, the message to wear masks was ignored, whereas in others the message that wearing a mask to protect others was accepted readily. Using a geopolitical approach in the framing of illnesses, be they physical or mental, is in the context of policy-making which can focus on both preventive and curative aspects of healthcare. An important recognition which is likely to influence mental health is climate change. The environmental impact of climate change is self-evident but only limited attention is being paid to this. Recent heatwaves in continental Europe and the UK and flooding in Pakistan have highlighted that urgent action is needed to deal with the impact of climate change, in the way we live, work and play. A truly international intervention is needed, but where is the leadership from the international organisations? Simply passing resolutions is not enough. Concerted solid action is needed.

You call it soccer, we call it football….but the true conversation we should be having is about migrant labourers and LGBTQ+ people. On a recent visit to the USA, while we were watching the FIFA World Cup soccer currently being played in Qatar on TV, David Beckham appeared in an advertisement trying to explain the difference between soccer and football and chips and crisps to an American Football player. The Twitter-sphere had been buzzing with views that due to Qatar’s human rights record, particularly the treatment of migrant labourers and LGBTQ+ people, audiences should boycott the World Cup and not watch it. This raises very interesting ethical questions. In an episode of ‘Have I Got News For You’ (a British panel show), Gary Neville was put on the spot when the panel asked him whether he was going to Qatar to provide commentary and, rather sheepishly, he said that he was. There is no doubt that the persecution of LGBTQ+ individuals there is a major issue, but, around the world, private, consensual, same-sex activity is illegal in 68 jurisdictions. In 11 countries, same-sex activity is punishable by a death sentence. Follow this link to an interactive world map providing more information about the criminalisation of LGBTQ+ people. It has been shown that more secular and affluent countries are more accepting of same-sex activity. The challenge is how do we, as psychiatrists, members of society, and advocates, deal with these situations? If we were to boycott every country where same-sex activity is illegal, should we exclude playing cricket in and with countries like Pakistan and many Caribbean countries? Should we engage with countries where same-sex activities are illegal, whether it is to do trade deals, exchange academic activities or play sports, in the hope that jaw-jaw is better than no jaw? There are no easy answers. There is impressive evidence even within the USA, where rates of psychiatric illnesses drop in states which have equal rights for their LGBTQ+ population in law. If we assume that 5% of the population is LGBTQ+, then 500 million people in the world belong to sexual minorities and providing equity to them is a significant and major task. The discrimination and stigma they face lead to psychiatric illnesses, confirming that as clinicians we need to be cognisant of the model of bio-psychosocial causation as well as management. Vulnerable groups, be they women, LGBTQ+, religious minorities, or persons living with disabilities, all need equal rights. Regrettably, all these vulnerable groups face discrimination in one way or another. These negative attitudes are moulded by personal factors, family influences, community factors, and national policies. Cultures mould, shape, and reflect negative attitudes, which then tend to get enshrined in law. Tragically, very often belonging to sexual minorities, even though they exist in all cultures, is seen as a Western condition which is perceived as being imposed upon non-Western cultures. Often, with a Euro-centric worldview, cultural relativism gets forgotten and other cultures are denigrated as inferior, backward, or traditional, without exploring the cultural factors which we may well disagree with. The challenge for psychiatrists across the globe is how to advocate for vulnerable groups. Being aware of research evidence which confirms that vulnerable individuals have higher than expected rates of psychiatric disorders, which drop when equity and equality are introduced, is an important factor. Perhaps pilot studies in each individual culture may give further understanding of cultural norms and variations. It is obvious that once people feel mentally well, and their physical and mental health is better, they function better and show better productivity. This in turn has a major impact on the economy and on the culture and country. Clinicians can work with all those who are sympathetic and understanding of the challenges and discrimination faced by vulnerable groups and may be able to advocate better. Using research evidence can help reduce discrimination, which in turn can lower rates of psychiatric disorders and consequent help-seeking. Boycotting the World Cup on the grounds that human rights are being ignored is important and conveys a message. If all the teams had negotiated and gone with the love band, that would have been a significant act and a very clear message to politicians and rulers but also to players’ organisations and FIFA. In managing the mental health and wellbeing of populations, political, cultural, and commercial determinants of mental health need to be understood and can be employed using a multi-layered approach, rather than a single angle. Clinicians need to learn about advocacy and working with patients in order to change the laws so that true equity can be achieved. It is important that all healthcare professionals are taught about how to advocate at community, regional, national and international levels.

The total population of the world crossed 8 billion a couple of months ago. Although a clear milestone has been passed, there remain additional challenges about where the population is concentrated. The population of the world is an important determinant for resources and needs of humanity and how these are met. The population map of the world is interesting to look at. People like to have children for a number of reasons; biological, social, emotional, material, or seeking support in their old age. People need food, freedom, finances, friends and shelter. With the increasing pressures on very many limited resources, what are the responses? How should humanity look at this milestone and respond? There are undoubtedly challenges in short, medium, and long-term. The increase in population is a result of people living longer and better infant survival. However, the recent pandemic has illustrated that longevity of population if anything has stalled. Indeed, the growth is not uniform, as was demonstrated a few days ago, when it was reported that China’s population has fallen for the first time since 1961. The Japanese Prime Minister, also, expressed concerns about Japan being on the brink because of its falling birth rate and with an increase in longevity and ageing. At the same time, more than half of the world population lives in seven countries: China, India, USA, Indonesia, Pakistan, Nigeria, and Brazil. All the countries bar the USA are low or middle income groups, although their national economies are large enough, with China as the second largest economy and India now the fifth largest. Differential birth and survival rates may be contributing factors to these variations. Arguably, even though census data from many countries may be old, partial, or even exaggerated, these numbers in themselves are very impressive. Pew Research reported that only 8 years ago, in 2015, half the world’s population was living in just six countries. Nigeria moved from 7th to 6th place, overtaking Brazil in these last 7 years. As Pew Research reports, the United Nations estimate that the population will be closer to 10 billion by 2050 and pass that figure in the next 5 decades, going from 9.7 billion to 10.4. Not surprisingly, the bulk of this population growth is set to occur, and be concentrated, in sub-Saharan Africa. This inequality of population distribution raises further challenges for the survival of humanity We know that geopolitical determinants affect social determinants which affect health, including mental health, although there are challenges in making sense of data from population surveys in many countries. Health inequalities occur on a gradient influenced by wealth. The impact of climate change due to deforestation, population increase, industrialisation, and urbanisation is only now being understood. The unequal distribution of populations brings with it challenges regarding access to basic resources and needs: migration, selective depopulation, unemployment, poor housing, and overcrowding. Around the world, medical services are largely based in urban areas, making access to them by rural populations difficult. People are living longer, but they are also likely to have multiple, often complex co-morbid conditions. This makes their healthcare needs more complex as well as diverse, for which a younger and physically able workforce may be required. This basically means that countries like Japan and China may require economic migrants, the simple idea of which is anathema to many nationalistic politicians. With negative population growth in many countries, there appears to be an urgent need for young migrants who can help with economic growth. There have been recent calls in the UK for retired people to return to work. In many low-income countries, where cultures are in transition, younger physically able people are moving away to towns and cities and across national borders in search of employment, while older individuals are often left to live by themselves and often consequently left feeling alone with increasing frailty. In many countries, the notion of filial piety is beginning to change, adding to a sense of abandonment by older adults. In India, where the majority of the population is aged between 24–35, rapid urbanisation has added stress to people living in both rural and urban places. For example, in my recent visits to India, I noticed a massive demand and expansion of old people’s care homes. In the past, the world has adapted successfully to what was called euphemistically ‘population explosion’, but at the present time, it is impossible to predict the curve of change at various levels. India appears to be on track to most likely overtake China as the most populous nation in the world. Birth rates in Nigeria are 20 times that of China. Food security, poverty, overcrowding, and a lack of familial support are all likely to increase rates of psychiatric disorders. How can healthcare systems cope with it? Healthcare services around the globe need to take these population changes into account and develop services that meet the needs of these changing populations. Services need younger healthier trainees and workers, but also more experienced individuals who can train and mentor others. Firstly, we need culturally appropriate services. The explanatory models of mental illnesses vary tremendously according to educational, economic and social status, but are also culturally influenced. Hence, we must take full account of these. Undoubtedly these models will continue to change as cultures become less traditional. We need to build on cultural capital and, even more importantly, as the population increases, we must use human capital properly. Use of AI is likely to increase in clinical services but will also remain supplementary in many settings. Developing community-based support systems with volunteers, community leaders, and non-governmental organisations (NGOs) will be some of the ways forward and reflect how social cohesion can work. Creating community social hubs where people can find information and seek help without facing stigma must be encouraged. Increasing population might be a milestone, but can also be a millstone as far as resources are concerned. In order to avoid that eventuality, we must use this opportunity to be innovative in delivering healthcare which is appropriate and helps improve the assessment and management of mental illnesses away from the institutions and close to where people live work and play.

Why do we need rituals? For a number of reasons, in many settings and situations people need rituals to give them a degree of comfort, and in other situations we have always done things so routinely and not doing certain things in specific order may create problems or bring the heavens down upon us and on how we manage our anxieties. We all have rituals even when we choose to deny these. Is it because they give us some kind of defence? Or is it because they make us feel in control? Or is it because rituals make us feel comfortable? Is it simply superstition? As the anthropologist Mailnowski noted in Papua New Guinea, fishermen going out to see had certain rituals. These rituals made fishermen feel better about their trip on the sea. Malinowski recorded a large number of rituals that fishermen followed, as the writer Karan Johnson reports in this piece on the power of rituals. These rituals gave people a degree of confidence about their survival but also comfort to those who had been left behind while fishermen were out to fish. Rituals certainly provide us with an order which allows us to continue dealing with what could be a potential source of stress and distress. Rituals are a predefined sequence carried out with a degree of formality and sequence. These behaviours also have a symbolic meaning to ward off superstition or pray to gods for protection. They are seen as having a degree of predictability which introduces a degree of comfort by virtue of the constancy of the ritual. The scientists Gino and Norton point out that rituals do have certain functions. They suggest that the symbolic behaviours we may carry out at various points are ubiquitous. In certain settings, such as weddings and death, rituals can help us celebrate and acknowledge various facets of life. Rituals are seen as a confirmation of human beings as social species, as Teddy Prout, from Humanity UK, writes. Not surprisingly, the rituals can be community based or individual in religious settings, personal settings or socio-familial settings. Furthermore, rituals can have very many forms, but the function by and large is to reduce anxiety and improve confidence. Rituals can have a causal impact on people’s thoughts, feelings and behaviours. Rituals provide a degree of familiarity which in an extreme form can turn into obsessions or compulsive behaviours. It is interesting to note that when rituals do not work or the person perceives that they do not or have not worked, individuals still carry on doing those. Interestingly it has been argued that certain ritualised behaviours may have emerged to avoid disasters whereas others may have become peculiar and purely social activities. It is entirely possible that certain rituals prevent infections and others reduce anxiety. It has been noted that in the COVID-19 pandemic, reducing certain behaviours such as handshakes and wearing masks have become new rituals. The anthropologist, Rebecca Lester, makes the interesting observation that rituals such as graduation events play a certain role in the life of students. These are not only to do with milestones in students’ lives but also, according to Lester, create time for rituals. It can thus lead to celebration, acknowledgement and ending. One can argue that certain rituals have disappeared altogether, or reduced, and other rituals have taken their place. Social rituals demonstrate what people value. Rites of passage mark specific points in one’s, life be it personal or social. These rites of passage have not reduced in prevalence, rites associated with puberty, marriage, death, still continue. All of us carry cultural capital with us wherever we go. Work with refugees showed that not being able to do certain rituals, such as paying homage to and performing rites and rituals for ancestors, led to cultural bereavement. Similarly, it is likely that not being able to perform rituals can contribute to anxiety and depression. Rituals can help in grief but also in business by gaining a sense of control, and rituals have been proposed manage oneself through the pandemic. It is apparent that new rituals have appeared, some of which are purely personal and others social, especially using the social media to post events and follow individuals. It is fascinating to see even when walking the number of people who have their phones in hand and are busy reading or answering texts, although it is likely that at least some of them would be looking at street maps. Although Han (2020) argues that rituals have disappeared as a result of neo-liberal capitalism, and it may be that certain rituals in businesses may have gone down or changed shape, in cultures around the globe rituals are thriving, and it is likely that as we enter more uncertain phases due to conflict and climate change people will revert to rituals to reduce anxiety.

Are you dating, married, or in a relationship with someone struggling with depression? Maybe you suspect that your significant other may be depressed, but you don’t know what to do. Perhaps you feel frustrated because your partner has changed, and they've completely withdrawn from you. You feel as though you can’t get through to your partner because they're drinking more than usual, they get easily irritated, or they've isolated themselves completely. Sound familiar? Dealing with a partner who is struggling with depression can feel challenging and may even affect your own mental health. So, how do you offer care and support to your partner without abandoning your own needs (physical, emotional, and mental wellbeing)? The key to being supportive and loving when your partner is struggling with depression is to first understand how depression affects your partner. My name is Irene Wangari Migwi, and I am a Life Coach, Mental Health Advocate, and Writer who is passionate about spreading awareness about mental health and equipping people with helpful resources and knowledge to help them navigate the challenges of everyday life. I am also dedicated to helping people learn about self-care and self-love so that they can show up as the best version of themselves in their relationships. Kindly note that the advice I offer below is purely based on my own experience as a life coach and is not medical or psychiatric advice. Depression is an important topic for me because it's something that I have lived through and experienced. When I lost my dad in 2017, I became so depressed that I wanted to give up on everything because l felt like nothing mattered anymore. My whole world had turned upside down and I didn’t think I would ever enjoy life again. I was wrong. After embarking on a life-changing journey of healing and processing the trauma and grief, I was able to come out on the other side of depression and improve my mental health. My experience allows me to relate to people struggling with depression and encourage them to keep fighting for their mental health because healing can be possible. In addition to learning how to take care of a depressed partner, this article will also help you learn how to take care of yourself so that you can be a healthy, supportive, and loving partner to your loved one. How can depression affect a relationship? Depression is a mental health disorder that affects a person’s feelings, thoughts, and actions, and manifests itself as persistent negative thoughts and severe feelings of sadness, emptiness, and hopelessness. So, how can you support a depressed partner? How do you know when your partner’s depression is negatively affecting your relationship? There are a few key signs that you need to look out for. Increased irritability Are the fights between you and your partner getting more intense? Do they seem easily irritated by your perceived flaws, making you feel as though you must walk on eggshells around them? If your partner is always annoyed or angry with you, it could be an indication that their depression is impacting your relationship. Heightened substance abuse People suffering from depression may turn to substances like alcohol to numb the torture of poor mental health. If you notice that your partner has been drinking more than usual, it could mean that they're using alcohol to cope with the effects of depression. A poor or non-existent sex life Depression has a staggering effect on one’s sex drive. In fact, research shows that 70% of depressed people experience a drop in their sex drive, if they’re not on any medication. The lack of self-drive in your partner could be caused by a variety of issues connected to depression such as performance anxiety, shame, low self-esteem, hidden resentment, and chronic fatigue, among others. If you gently address the issue and let your partner know you still care for them, it could reignite the sexual connection, which may strengthen your relationship and bring you guys closer together. This may also encourage your partner to reveal their mental struggles and allow you to help them. Pessimistic view towards the relationship Does your partner seem overly pessimistic towards your relationship? Maybe they say things like ‘What’s the point of staying together?’ or ‘You'll leave me because everyone always leaves’ or ‘I am not worthy of your love’ or ‘You should just let me suffer’. Perhaps your partner doesn’t seem to appreciate you enough. They find flaws in everything you do, or they withhold their emotions, yet in the past, they could freely express how they felt about you. If that sounds like your relationship, then your partner may be depressed or struggling in some other way and feeling unable to open up. How can you provide support without self-abandoning? Well, you first need to understand that it’s not your partner’s fault that they're depressed. Believe me, if it was up to your partner, they'd get rid of the depression and get back to being their normal bright, loving, and cheerful self in a heartbeat. But they can’t. Depression isn’t a feeling that your partner can snap out of. It’s something that they must live through while working on their mental health to get better. Your partner needs all the love and support they can get, even if they don’t show it. Here are a few tips on how you can support your partner without neglecting yourself If you have a partner struggling with depression, ensure that you encourage them to seek help from a medical or mental health professional, such as their GP/family doctor, or a therapist. You can show your support by taking your partner to therapy sessions and letting them know that they're not alone. By helping your partner seek help, you'll be playing a crucial role in their healing. Develop healthy boundaries When depressed people get easily irritated or annoyed, they might say negative or hurtful words towards you. Since you know that they're depressed, you may excuse their behaviour and ignore their negative words. Over time, their harsh words may influence your self-esteem or mental health negatively. Therefore, ensure that you set healthy boundaries with your partner. Let them know that even though you care for them, you'll not accept any disrespect from them. Anytime they say something negative towards you, speak up and remain firm with your boundaries. You can still be loving and supportive while being firm. Have time for yourself Being with someone that’s struggling with depression may make you feel like you must be available to them all the time. Although spending quality time with your loved one is necessary to make them feel loved and supported, ensure that you're not availing yourself at the expense of your own needs. Make sure that you have time to focus on other areas of your life too. Go to work. Don’t miss that interview. Take that nature walk that you desperately need. Start that business. Ensure that you don't put important areas of your life on hold because it will eventually lead to feelings of resentment. Let your partner know that they can always count on you or call you when you're not around. Finally, I would like to add that the self-care tips above are not exclusive to depression. If your partner is struggling with other mental health disorders or going through a really difficult time, you can use the tips above to be supportive without self-abandoning.

This year, at Apple’s 2023 Worldwide Developers Conference (WWDC), the tech giant unveiled many exciting new projects, with its first new product launch in over a decade, the Apple Vision Pro. This new virtuality headset has been the main talking point for many, but aside from this futuristic hardware, Apple has also announced a new range of physical and mental health tools that will soon be available for all iPhone and Apple Watch users. As a marketing aficionado, I have always been captivated by Apple’s marketing strategies, from selling a lifestyle to product placement and overall rethinking the need for advertising, allowing them to enjoy unparalleled revenue growth. It is no surprise that Apple continuously ranks within the top 4 Fortune 500 companies, year after year. The new updates to the inbuilt ‘Health App’, “will allow users to log their daily emotions and moods, see valuable insights and easily access assessments and resources”, by allowing users to continuously reflect on their current state of mind. This new feature will have sliding scales of emotions, ranging from very unpleasant to very pleasant, with each feeling being accompanied by a different colour. From this, users will then be able to identify what may be contributing to their feelings, creating trends, and identifying patterns – whether these are due to associations like family factors, or lifestyle factors such as sleep or exercise. Apple proudly demonstrated how this tool will give its users the ability to reflect on their mental state and “help build emotional awareness”. Additionally, Apple claims that their Health App will enable users to take the same depression and anxiety assessments used in clinics, which will supposedly help users “determine their risk levels, connect to resources available in their region, and create PDFs shareable with their doctor”. To this, Sumbul Desai, M.D., Apple’s vice president of Health, said that this new software feature was created to “empower people to take charge of their own health journey”. “Mental health is important, but often overlooked, and we’re excited to introduce features that offer valuable new insights to provide users with an even better understanding of their health,” Desai added. “These insights help support users in their daily decisions and offer more informed conversations with their doctors.” Yet, I have varied concerns about this new feature. Not only is this tool solely based on emotional appraisals, but how securely stored is this data really? According to a study reported by Forbes Magazine, there are 2.5 quintillion bytes of new consumer data created each day and it is only accelerating. So, whilst this allows businesses, especially in the tech industry, to gain rich and timely customer insight, it threatens the privacy of all its users. Author Cathy O’Neil even goes as far to say that “big data increases inequity and threatens democracy” and claims that “algorithms are mathematical models that have harmful outcomes by encoding socio-political biases and enable predatory companies to advertise selectively vulnerable people”. Her book, Weapons of Math Destruction, offers a critical look at the growing third-party data algorithms, arguing that they have the power to manipulate conversations and are essentially misleading tools used to merely sell products. Over the last years, there has been been a major push for better consumer privacy regulations, data protection and transparency about the information companies are collecting about users, challenging tech giants like Apple and Google to give their users the ability to choose whether apps and websites can access their data, as well as providing information as to how their data will be used. Whilst Apple specifically installed a system that offers randomised email addresses to use when signing up for new apps and services, they still have a far way to go and must find a bulletproof way of securing this data, or not collect it at all. Now, what about the health concerns of this new tool? A software cannot possibly, accurately, and sustainably, diagnose the owner to the same level as a licensed healthcare professional. Making mental health accessible and providing information that allows people to acknowledge their own mental health, allowing them to take matters into their own hands, is not bad at all. I believe that it is important to provide easy and convenient ways for the population to recognise mental health and provide appropriate resources for further assistance. But this new feature has inbuilt anxiety assessments that even suggest next steps based on assessed risks. This technology, was created to diagnose depression, anxiety, and cognitive decline. These special algorithms are already able to analyze mobility, sleep patterns, physical activity, heart rate and even your typing behaviour to see if you should be concerned about your physical and mental health. But mental health conditions are incredibly difficult to diagnose as they are because they can manifest very differently from person to person, with different symptoms at very different times. Sometimes, patients cannot even be diagnosed due to the complexity of their symptoms or other comorbid health problems. So, while we can train machine learning on large pools of data, there is an incredible complexity to mental health and a wrong diagnosis could have incredibly harmful effects on an individual, both physically and psychologically. Today, the momentum for digital software and AI solutions in mental health is building rapidly. However, my mixed feelings remain. I believe in making mental health more accessible and as user-friendly as possible. It’s important for this information to be approachable, available, and welcoming. But it is vital for health-based platforms to be precise and error-free and for the data to be transparent, secure, and protected… unfortunately, I am not convinced that we are there just yet.

I am an MPhil (Masters of Philosophy) in Neuroscience student at the University of Cambridge, mental health advocate, and blogger. I was born and raised in Zimbabwe. The term “mental health” was non-existent in my life until I started my tertiary education at the University of Zimbabwe. In this article, I unpack a mental health intervention I established, anchored in young Zimbabweans’ lived experience. I have been told that I am biased towards young people’s mental health and that is true. I am not ashamed to admit it. I have seen young people suffering in silence because societies are not prepared to support a young person’s mental health needs. I have heard statements such as “young people do not get depressed.” Some have said, “young people are entitled.” Generations have been compared with each other with some millennials and Gen Z being seen as “too soft.” It is disheartening when a cry for help is mistaken for attention seeking. The year 2018 was transformative for me. I had just started my undergraduate degree, but that did not transform my life – rather the reality of mental health challenges. Upon starting my degree, suicide cases were recorded bi-monthly. This was horrifying news because the cases were of fellow students. My first reaction was that I needed to understand suicide risk factors and potential interventions. To my surprise, that information was not readily available. I struggled to get access to mental health statistics, and information about service providers. In searching for mental health knowledge, I realised that there was a lack of mental health awareness and limited mental health services in Zimbabwe. In my tertiary institution, there was a disparity in understanding mental health issues alongside the greater student population. Through blogging, I took on the responsibility of providing mental health education to my peers. In my advocacy journey, I have realised that the mental health education available is not culture sensitive. This creates multiple barriers for different groups to access mental health knowledge. Most mental health research lacks cross-cultural validity because its ideologies are based on a eurocentric narrative that dominates the global mental health space. The way mental health, as a concept, is communicated reflects the mental health inequality gap within our communities. Language is a good example that creates barriers for people to access mental health knowledge and services. If the foundation of mental health knowledge is not a reflection of its target audience, how can the knowledge be spread and attained? What has been apparent is that there is a great need for mental health professionals to immerse themselves in the target population’s culture to understand its needs and tailor services accordingly. Mental health difficulties are a major concern for young people. Globally, one in seven 10-19-year-olds experiences a mental health challenge, contributing 13% of the global burden of disease in this age group. Today, suicide cases in Zimbabwe keep skyrocketing, with drugs and substance abuse threatening society. The Zimbabwean suicide rate for 2019 was 14.10, a 0.71% increase from 2018. The World Health Organization (WHO) has reported that, globally, there is a high number of 15–19-year-olds who engage in heavy episodic drinking. In Zimbabwe, the prevalence of drugs among young people is 57% and in 2019 45% of the patients admitted to mental health facilities were youth suffering from addiction. Historically, mental health challenges have been overlooked in young people mainly because they are “young.” In African communities, one is expected to be strong and resilient. One is bound by certain duties, expectations and obligations that dictate how feelings and emotions must be expressed. A cry for help can easily be mistaken for a sense of entitlement or weakness. It is evident that youth mental health is in a crisis yet mental health education and services are still inaccessible for the majority. Designing a mental health system for youths How do we make mental health dialogue a norm in youth spaces across the globe? How do we shift the perception of expression from weakness to strength in youth spaces? These are questions I have been asking myself for the past six years. Young people want to be exposed to environments that are fun, exciting, and stimulating. Providing mental health education like a university subject is likely to capture the attention of a few people. Not because young people are not prioritising mental health; but because the information is simply not designed or packaged for young people. Although blogging provided a platform for me to raise mental health awareness, it was a barrier for me to reach disadvantaged communities. I became cognisant of the fact that some people may not have access to the internet or digital devices, therefore, I created a mental health space that could physically reach communities. In the year 2021, I decided to start a community-based organisation called Ndinewe Foundation to promote good mental health and well-being among young Zimbabweans. Ndinewe is currently based in Harare, Zimbabwe. Long-term, I want to scale Ndinewe across the globe making it a global movement that is culture sensitive. The organisation is led by youths who are trained to facilitate mental health campaigns, workshops, and support groups that promote personal development, emotional growth, and peer support. Guided by professional psychologists, the Ndinewe team enters predominantly youth spaces such as: high schools, art and music festivals, sports tournaments, and facilitates referrals to the psychologists that offer their services pro bono to the organisation. Ndinewe in my native language, Shona, means “I am with you,” and the organisation itself has become a safe space for young Zimbabweans to receive knowledge and support. One of the reasons youth spaces are important locations for mental health advocacy is because young people are in their element. If a space is perceived as “cool”, one is likely to be curious about elements in the space. What is special about Ndinewe is that the content and activities are guided by a model I have coined “Mental Health in the Zimbabwean Context.” The model is concerned with defining mental health and its experiences from a Zimbabwean perspective, a perspective that reflects a Zimbabwean’s orientation to the meaning of life, the world and relationships with others and oneself. Impact “Thank you, Ndinewe Foundation, for helping us understand mental health issues.” (Zimbabwean Youth) In July 2022, Ndinewe launched its first Mental Health Booklet titled "Understanding Mental Health" which seeks to educate young people about mental health, its risk factors, warning signs and coping mechanisms. The booklet has been endorsed by Allied Health Practitioners Council Zimbabwe, which has the mandate through the Health Professions Act (Chapter 27.19) to regulate allied health practitioners. Today, Ndinewe has engaged with over 10, 000 individual accounts across LinkedIn, Facebook, Twitter, and Instagram. The organisation has provided mental health support, gender-based violence sensitisation workshops and mental health education to over 200 young people across 6 communities. Through these activities young people have engaged with the local authority such as the Ministry of Youth and Police Victim Friendly Unit; creating platforms for young people to tell the government their needs. The Ndinewe team has also interacted with over 230 children through sports tournaments: raising substance abuse awareness through music, art, and poetry. The organisation’s monthly support groups have consistently had an attendance of 25 people. As the world reshapes how people perceive mental health, it is key to have youth voices at the centre of mental health education and service development. In Zimbabwe, Ndinewe Foundation has become a movement for young people to have hope.