Introduction

The Section of Social and Transcultural Psychiatry at McGill University—the first of its kind in the academic landscape—was created in 1955 and was one of the major research teams in the postwar period to produce knowledge at the intersection of cross-cultural psychiatry and epidemiology. In the 1950s and 1960s, before the creation of the Department of Epidemiology at McGill in 1964, the team led by the psychiatrist Eric Wittkower (1899–1983) had already embarked on a series of surveys about major mental disorders like schizophrenia and depression. The early surveys differed from asylum statistics and the global programs developed by the WHO. They were based on local comparative Canadian studies and on a large network of correspondents created by means of the first transcultural psychiatry international newsletter and later journal, Transcultural Research in Mental Health Problems. Thanks to this visibility, the group at McGill played a central role in the organization of panels to present its survey results at the World Congress of Psychiatry in Zurich (1957) and in Montreal (1961).

In this chapter, I will explore the types of questionnaires used at McGill in cross-cultural psychiatry. Next, I will turn to the evolution of the surveys after the arrival at McGill of the psychiatrist and epidemiologist Brian Murphy (H.B.M. Murphy, 1915–87) in 1959, and I will focus on the standardization of techniques. Finally, I will describe their use in various cultural environments in Canada, including in Canadian rural communities in the 1960s, partly inspired by the work of Alexander H. Leighton (1908–2007), then at Cornell University, principal investigator of another Canadian epidemiological investigation, the Stirling County Study in Nova Scotia. McGill's approach emphasizes the importance of interdisciplinarity in the early history of psychiatric epidemiology. Furthermore, it illustrates how schizophrenia, perceived at the same time as a universal category and as a category whose prevalence is affected by sociocultural factors, was a boundary object between psychiatrists and social scientists in the postwar years.

The Foundation of the McGill University's Transcultural Psychiatry Unit in 1955

In 1955, the first university unit in transcultural psychiatry (today, called the Division of Social and Transcultural Psychiatry) was established by the psychiatrist Eric Wittkower and the anthropologist Jacob Fried. Born in Berlin to a Jewish family and originally trained as a specialist in internal medicine, Wittkower left Germany in 1933 as a consequence of its new Anti-Jewish Laws.

Taiwan has been pivotal in the development of international psychiatric epidemiology not only because of its pioneering work in the comprehensiveness of mental disorder surveys but also due to its advanced survey methods. Its lauded island-wide survey conducted in the early post–World War II period and the follow-up studies, collectively known as the “Formosan model,” are important pioneering works among developing countries in the Asia-Pacific region. In one of my previous works, I demonstrated that in the 1950s and 1960s, collaboration between international and Taiwanese psychiatrists in the field was critical in shaping the World Health Organization's (WHO) international social psychiatry projects. This might provide a non-Western exam ple of a crucial post–World War II venture in psychiatry. However, it might also overemphasize the importance of Taiwan on the world map. In fact, such advances have a much more complex historical background. In this chapter, I examine studies conducted by psychiatrists working for Taihoku Imperial University (1928–1945), arguing that tropical governance under Japanese colonialism was the most significant factor in the development of psychiatric epidemiology in East Asia and that the psychiatric research methodology developed during the colonial period (1895–1945) laid the foundations for postwar international collaborative works on psychiatric epidemiology. The combination of statistics and field observational surveys developed for the purpose of Japanese colonial expansion and the opportunities for Taiwanese doctors to participate in international academic activities were cornerstones of the postwar global decolonization that accompanied developments in psychiatric epidemiology.

The Genealogy of Modern Psychiatry in Colonial Taiwan

Modern psychiatry was introduced in Taiwan in various stages during the Japanese colonial period (1895–1945), serving colonial governance in various ways. Psychiatric knowledge or, more broadly, knowledge of the psychiatric sciences was introduced to the tropical island as part of the colonizers’ plan to conduct social and cultural surveys in line with the “biological principles” of colonial planning. These principles were proposed by Gotō Shimpei (後藤新平), the first Minsei Chôkan [chief civil administrator], in 1898, three years after Taiwan became a Japanese colony. His vision was instrumental in creating the infrastructure for Japan to govern Taiwan by applying a range of administrative methods to govern the complex, but wayward, society earlier ineptly controlled by the Chinese Qing rule (1683–1895).

In 1917, as World War I was at its height, the gothic novelist Arthur Machen attempted to describe the growing sense of fear and unease that haunted the United Kingdom. He depicted a rootless and invisible emotion, a nameless terror, that moved silently across the land leaving a trail of destruction in its wake. Frightened horses, suicidal farmers, and paralyzed children mapped out the emotion's itinerary across the kingdom. Machen's tale of a transformative horror was rooted in a tradition of gothic literature that had been reinvigorated in the late nineteenth century. However, its central device of an epidemic of fear and its disease-like transmission across the population drew upon different sources: the scientific literature on the pathology of collective emotions that served as a precursor for psychiatric epidemiology in Victorian and Edwardian Britain. Even without its supernatural overtones, this tale seems curiously remote from contemporary psychiatric epidemiology. The distance between the epidemics of feeling described in those early writings and the organization of contemporary practice is striking. Although there was a large literature on the relationship between mental disease and poverty, there is little attempt to map the movements of affect or read transformations of emotion as an index of social or historical change. Instead such epidemics of feeling were read through the psychological concept of suggestion— as a form of primitive and unconscious communication—anchored in the evolutionary frameworks of crowd psychology and the herd instinct.

By the end of World War II this epidemiological understanding of fear had been transformed. Insecurity, terror, and anxiety were no longer seen as capricious forces but instead understood as environmental conditions that could be defeated through political interventions and social planning. Fear was tamed. It moved from being a fickle and fantastic force to become instead an object of political calculation. Indeed in the wake of the war, it would provide the grounds for a new program of social and material reconstruction. As this chapter will partly show, the architects of the welfare state in the 1940s and 1950s saw their task as the engineering of a society in which individuals would be freed from the pathological anxieties of financial insecurity, unemployment, and homelessness. Aneurin Bevan, widely seen as the architect of Britain's National Health Service, complained that modern lives were wrecked by anxiety.

Introduction

Commenting on the slow penetration of applied sciences in the global South, late twentieth-century academics and development actors labeled Africa the “latest of the late developers.” Three decades later, epidemiologists decried sub-Saharan Africa's psychiatric “epidemiology gap,” in an era when global health institutions constantly solicit numbers on the distribution, frequency, and determinants of mental disorders to construct metrics like the Global Burden of Disease (GBD). This uneven advancement of postwar psychiatric epidemiology within sub-Saharan Africa troubles the assumed space between expectations and the conceptual-material resources and political will necessary to meet them.

From the mid-1950s, a constellation of actors, including the World Health Organization (WHO), the World Federation of Mental Health, psychiatric leaders, and other experts, stressed the urgency for psychiatric services in “undeveloped” regions of the world. The landmark 1958 Bukavu conference (Belgian Congo) specifically focused on African psychiatry. At the WHO, experts debated whether to prioritize mental health statistics over services and whether an epidemiology of mental disorders was even possible, given the plethora of nosological and methodological conundrums encountered even in “developed” countries. In the early 1960s, the WHO consolidated a psychiatric epidemiology canon, disseminated through technical reports and international training sessions.

During the turbulent decolonization of Africa and emergence of nationstates, psychiatric experts, ideas, and epidemiological tools regarding mental disorders circulated between the North and South through networks including the WHO, the US National Institute of Mental Health, the UK Medical Research Council and Institute of Psychiatry, McGill University’s Section on Transcultural Psychiatry, and other First World research institutes and psychiatric associations. More rarely, psychiatric experts and knowledge flowed to the global North from countries like Nigeria, India, and Taiwan, evidence that some young nation-states, including in sub-Saharan African, were already engaged in psychiatric epidemiology.

This chapter analyzes the lesser-known trajectory of Senegal's first modern psychiatric epidemiology study, which wound in and out of the margins of these global flows of knowledge-production and dissemination. Directed by Henri Collomb (1913–1979), the celebrated founder of the pioneering psychiatric clinic and research group, the Ecole de Fann, in Dakar, Senegal’s capital, this study barely surfaces in the historiography of Senegal's scientific endeavors. Compared to other Fann clinic vestiges, it hardly attracted international attention. Hence, a legacy ignored: Senegal's only attempt to systematically ascertain in a population the prevalence of mental disorders with a standardized nosology.

Elements for a History of Psychiatric Epidemiology

Psychiatric epidemiology, like the epidemiology of cancer, heart disease, or AIDS, contributes increasingly to shaping the bio-politics of nations and worldwide health campaigns like the Global Burden of Disease and the health objectives of the UN Sustainable Development Goals. Epidemiological pronouncements spill over from the professional and pragmatic confines of public health and psychiatric research into popular culture, where multiple media sources feed public concern, if not fascination, with the increase in rates of psychiatric distress and disorders. Epidemiologists, pundits, patient advocates, and ordinary citizens debate whether epidemics of mental and neurological problems are real or whether conditions like depression or autism spectrum disorder are rising. Widely disseminated mental health statistics act as a thermometer, broadcasting the emotional temperature of nations, communities, and identity-based groups. Awareness of psychiatric conditions classified according to Euro-American nosology3 and treated with modalities developed in North American, European, and Australian research centers surfaces in “mental health talk” and facilities in nations wealthy and poor. The temporal and geographic distribution of psychiatric conditions translates into the language of “contagious” or at least communicative psychic epidemics, like the spread of hikikomori, a rampant phenomenon of acute social withdrawal, from Japan to other countries.

The science of patterns of mental disorders underpins mental health bureaucracies that foster public health education, programs, and treatment. Psychiatric epidemiology also contributes to the governmentality of everyday life, in the shift from lab to living room, from survey to self-surveillance. Health democracy efforts often accompany this displacement, as patient organizations, employees, communities, and others arm themselves with epidemiological facts, officially or popularly conceived, in their struggles against stigma and victimization and their pursuit of health equity or chemical and psychological treatment and enhancement.

In what follows, we present an overview of our current knowledge of the history of psychiatric epidemiology, viewed globally, and offer summaries of this volume's essays. Some readers may prefer to skip directly to those synopses.

In the Beginning

Modern epidemiology began within population health concerns in the early nineteenth century, with the systematic enumeration and analysis of birth, death, and disease events in populations and with national censuses. Statistics on health had been systematically developed in the previous century, such as those gathered by royal representatives in the provinces of France's ancien regime.

Introduction

The 1950s and 1960s were a time of significant promise for the development of psychiatric epidemiology around the world. While much of the nascent historiography has focused on the development of methods and projects in Europe and North America, it is also well recognized that the field had global ambitions during those decades. Through a number of international collaborative networks, preliminary efforts were made at developing methods for cross-cultural psychiatric epidemiology in a variety of non-Western contexts. This chapter will examine the historical development of psychiatric epidemiology in Africa, with particular emphasis on Nigeria and its relationship with two different projects: the Cornell-Aro project, which conducted a community study of symptoms of mental disorder in Yorubaland in 1961 to compare results with the famous Stirling County study in Canada, and the World Health Organization's International Pilot Study of Schizophrenia (IPSS), carried out from 1968–69, in which the same region served as a field research center contributing to the establishment of a methodology for the cross-cultural identification of a specific diagnostic entity.

This chapter uses these two projects to make three broad arguments for the types of inquiries historians should be making in developing a global history of psychiatric epidemiology. First, this chapter argues that psychiatric epidemiology in Nigeria (and Africa more generally) has a multifarious history that complicates narratives of sources and origins at the same time that it recognizes the complex synergy between the “global” and “local” in the construction and dissemination of scientific knowledge. Second, in making the first argument it becomes clear that such a history must focus on the ways that conceptions of “culture” and cultural content are mobilized in service of the universal aspirations not only of these particular projects, but also psychiatric epidemiology more generally in postcolonial spaces. Third, this chapter demonstrates that a fruitful way to examine the mobilization of culture is through the tools of cross-cultural psychiatric epidemiology itself: namely the surveys and questionnaires that generate data about symptom prevalence and categorization.

Neither the Cornell-Aro project nor the International Pilot Study of Schizophrenia were designed to produce definitive epidemiological data about mental illness in specific communities. They were established primarily as experiments in developing methodologies for psychiatric epidemiology that could be standardized and replicated in diverse cultural landscapes.

Self-Fashioning of an Epidemiological Subject

The recent global rise of preventive psychiatry has brought psychiatric epidemiology into a more public arena, generating new sets of community surveys about developmental disorders, depression, and dementia. This is certainly the case in Japan, where one psychiatric epidemiologist has diagnosed the field as having long remained in a “prenatal stage.” Despite its early footing in Japan at the turn of the twentieth century, psychiatric epidemiology faced an inhospitable environment there. Particularly in the latter half of the twentieth century, stigma against psychiatry was so strong that community mental health surveys would cause alarm about their underlying political implications and possible invasion of privacy. Aside from a few WHO collaborations, psychiatric epidemiology was further hindered by the long-lasting antipsychiatry movement from the late 1960s to the 1980s, which critiqued it as an insidious surveillance tool that appropriates ownership of self-knowledge and promotes/naturalizes certain ideologies through a particular vision of psychiatric health. Thus, mental health community surveys only began to reflourish in the 1990s, with a community survey on depression in 1994 that may have helped pave the way toward near-mandatory “stress checks” (mental health screening) among workers nationwide, beginning in 2015. With the installment of the Act to Support Persons with Developmental Disabilities in 2004, surveys about developmental disorders followed. Dementia has received much attention recently, as mandatory dementia screening is required for anyone over seventy-five wishing to renew a driver’s license. With the increasing “neuropsychiatrization of the lifecycle,” psychiatric epidemiology is gradually gaining acceptance in this country and being incorporated into pre-existing health screening systems in the school, the workplace, and the community nationwide.

Despite the changing attitude, public ambivalence continues to be expressed at more thorough attempts at collective surveillance of mental health, as seen in the debates regarding epidemiologically based, preventionoriented community experiments such as the “Smart Wellness City,” an urban planning innovation for managing the health of residents who volunteer to monitor their daily health information via an automated, electronic system. Even as some doctors and policymakers rejoice in the technological advancement that such a thorough screening system provides and the autonomy it can create for individuals, other social commentators have expressed concern about potential invasion of privacy and unease about surveillance that seeks to reveal our (hidden) neuropsychological health.

In the decades following World War II, epidemiology developed a signature approach to chronic, noncommunicable disease, namely, seeking multiple independent risk factors as possible determinants of a particular clinical outcome. The risk factor paradigm developed within a medical and public health context marked by a decline in deaths from infectious disease and a sharp rise in mortality from cancer and heart disease. Proponents of this risk factor approach employed and further developed this model within the framework of now classic case-control and cohort studies. Sometimes referred to as the “black box” model because the underlying pathophysiology of most chronic diseases was poorly understood, the paradigm, in the words of Mervyn and Ezra Susser, “related exposure to outcome without any necessary obligation to interpolate … intervening factors.”

In the absence of cure or even effective treatment, the public health imperative was to capitalize on knowledge about risk factors and to test efforts to prevent or forestall the clinical onset of chronic diseases. Search and discovery of such factors was famously used by epidemiologists to link cigarette smoking to lung cancer, and, in a more sophisticated form, to expose the multiple variables that contributed to coronary heart disease (CHD)—and then to launch primary prevention campaigns. CHD, perceived as epidemic in the United States since the 1940s and responsible for over one-third of all US deaths by 1960, had been the leading cause of US mortality since the 1920s. For heart disease, researchers, ignorant of its cause, seeking potentially modifiable risk factors, including behavioral patterns, was imperative.

Risk Factor Epidemiology, Psychiatric Epidemiology

In addition to heart disease, risk factor epidemiology proved useful in many areas, but, generally, that was not the case in American psychiatric epidemiology. As epidemiologists Ezra Susser and Alfredo Morabia observed, until recently, “the enormous potential of risk factor methods for revealing the causes of mental disorders remained largely untapped.” There were some exceptions. Several research groups in Great Britain had already pursued what would become risk factor epidemiology in the decades following World War II. Two specific initiatives warrant mention. Starting in the late 1950s, investigators conceptualized mortality not simply as the end of a disease process but as a risk factor for survivors’ mortality and morbidity.

Introduction

The history of psychiatric epidemiology, particularly in Anglo-Saxon countries, can be separated into two phases. The first period (1960s–1980s) shifted from treated samples, unsystematic diagnoses, and descriptive statistics to population-based studies and standardized case-identification tools. Risk factor analysis appeared in later years. By the 1980s, short-form symptom inventories were being replaced by more detailed, diagnostic instruments, although they, like inventories, relied on psychometric techniques. In the second period (1990s–present) more accurate diagnostic tools, such as physiological measures, biomarker probes, and neuroimaging technologies were introduced. Phase two also supported the rise of statistically based risk analysis and global metrics for estimating the burden of psychiatric disorders relative to all diseases worldwide. Such measurements are further linked to new econometric approaches to mental health. Consequently, contemporary psychiatric epidemiology seems poised to become a “a bridge between upstream translations from genetics, neuroscience, and psychology, and the downstream development of public health policy and mental health services for all vulnerable groups.”

But another reading is possible. Following the epistemological reconstruction typical of biomedical sciences, modern epidemiology and its subfields developed by taking the so-called hard sciences as a paradigm for all sciences. But within epidemiology, epistemological critiques have pointed out the a-theoretical character of this trend, which is heavily influenced by mono-causality, the reification of concepts of health-disease, linear quantitative analyses, randomized clinical trial models, and evidence-based applications. 3 Such a perspective is reductionist because it reduces human beings to physicochemical and biological dimensions, underestimating life's ecosocial, political, and cultural aspects. The reductionism typical of this epistemology of the global North is captured by the expression “If you can't count it, it won't count,” that McGrath et al. apply to what they call pragmatic psychiatric epidemiology. This statement updates, bur erroneously interprets, Lord Kelvin's famous 1883 quote, “When you can measure what you are speaking about, and express it in numbers, you know something about it.” This version of reductionism implies that “noncountable” phenomena have no place in epidemiology, and that epistemology requires the transformation or reduction of all its objects of inquiry into numbers. Basically, it flagrantly rejects the reasonable assumption that the most frequent and meaningful psychological phenomena are noncountable, instead insisting they should be counted. Antireductionism argues what is being computed or measured must have meaning to make sense of the scientific understanding of people’s mental health.

A Subaltern Framework for Psychiatric Epidemiology in India

The World Health Organization (WHO) international program on the epidemiology of mental disorders began in the 1950s. By the 1960s, ground rules had been established for what was becoming the scientific discipline of psychiatric epidemiology and for facilitating its expansion throughout the world. Non-Western countries like India soon initiated studies in this area within their own constraints. By the 1960s, psychiatric epidemiology articles first appeared in the Indian Journal of Psychiatry. They borrowed methods and tools from the Western epidemiological canon but for different purposes and with markedly different results than those produced in wealthier countries. In retrospect, dissimilarities between findings in India and in Western countries tended to be attributed to methodological rather than contextual factors.

This chapter explores the specificity and evolution of the epidemiology of mental disorders in India and their social, cultural, and political significance. Numerous scholars claim that the history of psychiatry in India began in a period of Indian subalternity to British colonizers, who represented the diversity of “Indian” pasts through a homogenizing narrative of transition from a “medieval” period to “modernity.” We argue that psychiatric epidemiology in post-Independent India also exists in a position of subalternity but to a globalized psychiatry that has developed in the global North. This chapter further addresses subalternity within India by focusing on the mental health of lower castes, slum-dwellers, and other subpopulations that exist in a subaltern relation to social groups in their own country.

The “subaltern,” as we use the term, stands in an ambiguous relation to power, subordinate to it without fully consenting to its rule. Nor does it accept the point of view or vocabulary of dominant powers as a valid expression of its own subaltern identity. The Italian Marxist Antonio Gramsci (1981–1937) used the term subaltern to designate social groups subjected to the hegemonic power of a society's ruling class. In the 1980s, the Subaltern Studies Group, a collective of radical historians from the Indian subcontinent, re-conceptualized the term, focusing their attention on the disenfranchised peoples of India. “Subaltern studies” came to signify a “history from below.” Proponents of subaltern studies have produced counter-discourses that contest the dominant colonial, postcolonial, and post-imperial narratives, with the hope of connecting their analytic work to acts of resistance by oppressed peoples themselves.