Better Health For All

Given the widespread recognition of COVID-19 as a public mental health emergency that has deepened existing mental health inequalities, the theme set by the World Federation for Mental Health for World Mental Health Day on Sunday 10^th October – Mental Health in an Unequal World – was especially fitting.

It seemed to have come around even more quickly again this time, which probably says a lot about what the past year has been like. Those of us working in public health will be well versed in efforts to promote wellbeing in our own organisations and others, particularly at a time when workload and stress have been high and morale has been low.

What comes through less clearly is where the focus is not just on reducing stress in individuals, but on tackling wider underlying issues contributing to that stress – particularly where there are marked disparities.

I don’t just mean equal access to support, services and activities that help to improve wellbeing, although that is extremely important – both in our own workforces and the populations we serve. I’m talking about workplace policies, working practices and cultures that seek to actively counteract prejudice, discrimination and structural disadvantage, all of which are detrimental to mental health and wellbeing.

In other words: what are we doing to advance equality in our own workforce?

Last year the FPH highlighted the importance of embedding anti-racism into public health practice. This means challenging our own unconscious biases and refusing to be silent bystanders to racism in our own organisations. The same principles can be applied for other forms of discrimination, including but not limited to sexism, ableism and homophobia – however, this is as much about questioning the status quo in the ways we work as it is about challenging overtly discriminatory behaviour.

The public health workforce is diverse in itself (people, roles, organisations) and has wide-reaching links across partner organisations and communities. If we want to be effective advocates for mental health equality in the population, we need to start with equality overall and we need to start from within.

What stress means and what it looks like is different for everyone, but can be summarised as ‘a lack of fit between individuals and their world’ (Cassidy, 2001).[1] We’ve started to recognise the limitations of traditional workplace wellbeing approaches, which focus on supporting individuals to fit into existing structures rather than improving their ‘world’ to fit them – but we also need to be looking at who built that world in the first place. Many workplace policies and interventions for inclusion and wellbeing still operate within norms and cultures that have been established by white, middle class men without disabilities – even where workforces are considerably more diverse, and even where there is representation at senior levels.

For example, offering flexible working arrangements such as flexible start/finish times and remote working can improve work-life balance and wellbeing for people with children or care responsibilities (who are disproportionately women), or those with disabilities or long-term health conditions. Yet limiting the offer to these groups where there is no real business need to do so just reinforces the current culture as the norm and those who don’t fit in as ‘others’, instead of including everyone as equal partners in re-shaping that culture.

It also ignores the wellbeing benefits that these changes can have for everyone. A workplace that promotes equality and diversity is a workplace where everyone can flourish and feel that their contribution is valued. More flexible working as standard can help to improve work-life balance for all. Making workplaces more autism friendly can make those workplaces happier, calmer and more productive spaces for everyone. When we default to the status quo and consult rather than co-produce, we all miss out.

The brilliant Dr Nisreen Alwan explains this far better than I ever could in the context of language and anti-racism:

“Diversity” and “inclusion” imply charity from a position of power and superiority.

They give the impression that the group who is opening the door to diversify and include others still holds the key. The point of antiracism is that there should not be a key in the first place. The door should be widely open to all. Clubs with locked doors should not exist in an equitable society. Once that is achieved, the natural result of equity is diversity. It is the end not the means.”

So what does this mean for promoting mental health equality?

We cannot improve mental health and wellbeing in the public health workforce without actively tackling inequities in our workplaces – and we cannot address those inequities without confronting the structures underpinning them. Whether it’s improving opportunities and experiences of people with mental health problems, or reducing disparities in mental health and wellbeing, we have to actively change working practices that allow systemic discrimination to persist.

It isn’t enough to work to improve mental health in an unequal world; we also have to work to make the world more equitable to improve mental health.

Lina Martino

Chair, FPH Public Mental Health SIG

[1] Cassidy T (2001). Stress, Cognition and Health. Psychology Press: Hove & NY.