The writer Susan Sontag noted in her essay Illness as Metaphor, “Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”1 Some people spend most of their lives feeling well, while for others, being healthy is an ephemeral state. The Covid-19 pandemic has stripped bare the sharp divide between those who are well and those who are ill. Not only in physical terms, but in terms of the pandemic’s worsening of global mental health. As people try to cope with the conditions of living in the pandemic and the continuing loss it brings, this trajectory of mental health and its aftermath is far from over.

The events of 2020 have caused a set of changes that have moved from global pause to global unrest. This essay treats the unfolding tension between this unprecedented global pause and the public health response to mental health. The term “global” with respect to mental health is less than forty years old, first used in 1982.2 As such, mental illness in the age of Covid-19 cannot be understood in isolation but should be analyzed in light of histories of collective trauma and imperialisms. Particularly relevant to this context are those following the colonization of parts of the Middle East and North Africa. Beyond addressing the present worries of the pandemic, it is important to understand these longer histories of psychiatry, in order to excavate the intersecting psychiatric stories of the global history of mental health. 

For some of us, absorbing the pain of trauma is familiar. We carry a deep wound that seeps to our necks, our backs, and our heart. It is a pain that reverberates whenever we hear about another death, or about the perpetual stress that comes with displacement. This pain can also be accompanied by anxiety, disorder, or depression, which can paralyze you from thinking, feeling, and acting as you wish. The current pandemic has resulted in many more people witnessing and experiencing the ripple effects of tragedy, which has cruelly and disproportionately killed the elderly, the immunocompromised, the working class, and people of color. The pandemic has exacerbated a huge polarization in the hierarchies of life and death and created psychological burden for all those who must endure social isolation.

The implications of economic uncertainty, social distancing, closed borders, illness, and grief have exacerbated pre-existing mental health conditions, producing new forms of worry and stress around the coronavirus. In particular, frontline workers, including but not limited to healthcare workers, have experienced exhaustion and heightened anxiety. Marginalized communities such as the incarcerated population in the United States have faced a far higher risk of exposure, given their confined living spaces and poor conditions. Queer people, who often face precarity in work and housing, have been made even more vulnerable. 

The present pandemic has created a new history, in which emotional and psychological conditions are being pushed to the limits, and mental health has become crucial to surviving. In March 2020, near the beginning of the pandemic in the United States, the Kaiser Family Foundation (KFF) conducted a survey and found that 32 percent of participants reported that their mental health had been negatively impacted. By July, 53 percent of people surveyed reported that their mental health was negatively affected.3 Researchers have found that mental health issues, such as depression, have surged since the beginning of the pandemic; likely due to social isolation, uncertainty about the future, and fear of getting the virus.4 Psychologists have suggested that public health restrictions have contributed to this stress; as Tom Heffernan argues, “some people subsequently develop a post-traumatic stress reaction, which can manifest in feelings of exhaustion, low mood and irritability.”5 These mental health implications prompt us to think about the consequences of prolonged periods of social isolation, and the mental health resources available. Communities across the globe have to cope with an excess of collective loss—of loved ones, employment, and daily life—which has caused further psychological burdens.

Next, by sketching the therapeutic histories of the MENA region, I aim to highlight the ways in which mental health institutions and professionalization have created fluid and ambiguous mental health regimes that can be understood within a global context of trauma and its treatment in the Covid-19 era. The history of psychological illness in the Middle East and in places beyond the Eurocentric mindset assists us in bettering mental health from a global perspective, especially with respect to trauma, pharmaceuticals, and care.

It might also be beneficial to consider the histories that involve the complexities of what Vinh-Kim Nguyen has called “therapeutic citizenship.”6 Nguyen uses this term, echoing Sontag’s kingdoms of the well and the sick, to lay out how the global distribution of therapies, including medication, are predicated on international social hierarchies and “biological” notions of citizenship. Delving into such ideas can deepen how we recognize stress, mental health, and healing, within the moral and social economics of epidemics.

The circulation of psychiatric knowledge and techniques in the Middle East and North Africa emerged during periods of European colonialism in the nineteenth and twentieth centuries. While there are differences between countries in these regions, for example those that experienced colonization in the mid-nineteenth century (as was the case in Algeria), in comparison with those that were not formally colonized by European countries (like Iran), it is possible to understand the rise of psychiatry within a complex matrix of Eurocentric power and medicine. The power dynamics between colonizer and colonized were particularly stark in French Algeria, where colonial psychiatrists began to carve a place of authority for the French imperial project and its asylums as early as the 1880s. In his text, Colonial Madness, Richard Keller outlines how the French construction of “insanity” was designed to enact order and to deter the Arab population from engaging in local ritual practices.7 The settler-colonial context, war, and occupation in Algeria created a transnational network of global psychiatric expertise situated in the asylum, but also with psychologists working in the context of colonial resistance.

One account of how French imperialism caused psychological damage to North Africans was outlined by Martinican psychiatrist and anti-colonial theorist Frantz Fanon, who showed how French imperialism exercised physical and psychological violence, which was associated with traumatic disorder.8 Fanon initially worked for the French imperial project, documenting and providing treatment to Algerians in the 1950s, but during his tenure he became disillusioned and joined the Algerians in their struggle against French colonialism. During the final years of his life while living in Tunis, he wrote The Wretched of the Earth (1961). Fanon connected his own life and history not only with the Black people of the African content, but also with various peoples who were fighting for independence. His political trajectory, albeit circuitous, was in part a product of the international delegations and struggles that were brewing in his era. 

Since the anti-colonial period, scholars from the MENA region have tried to unpack the histories of psychiatry, linking them with a new set of political events, with some pointing to interregional conflict and more recent trauma. The medical anthropologist Lamia Moghnieh draws attention to the emergence of psychiatry from the nineteenth century to the present, and the ways in which psychiatry has been leveraged to make amends for civil war in Lebanon.9 At the same time, scholars have looked at the evolving relationship between professionalization and psychosomatic drug production in psychiatry. Working in the Iranian context, Orkideh Behrouzan documents how mental health discourse after World War II tried to destigmatize post-traumatic stress disorder and other psychological disorders.10

While the discourse around mental health is welcomed by many practitioners in the MENA region, there are some limitations in terms of how it is understood. The issues of reliability and consistency fail to account for neurodivergence across different cultures, revealing the ethnocentrism of the DSM, and its inherent bias against non-Western people. Mental illness is a spectrum of neurodivergence, with 971 million people worldwide suffering from some kind of mental disorder. From a genetic perspective, mental illness is polygenic, meaning that there are, for example, forty-four gene variants that raise the risk of depression. There are life experiences that compound the risk factor for mental illness such as abuse or trauma. 

Although the specific and dynamic (hi)stories of the Middle East are important for the questions at hand, so too are the wider global narratives that shape disease. What role do medical narratives have in shaping our understanding of international diseases and how do these align with the shifting definitions of disease today? “Psychiatric disorders are increasingly widespread in the Middle East,” remarks Mohammed Yahia in Nature Middle East, “however, the model used to assess and treat patients in the region was developed by a primarily Anglo-Saxon population based in the United States and Western Europe.”11 Yahia underlines that there are a set of material and social concerns that account for psychiatric disorders. Moreover, he argues that there are particularities of trauma, which are crucial to how we understand mental health in the Middle East and North Africa. 

As Hanafy A. Youssef and Salah A. Fadi attest: “Frantz Fanon paid particular attention to these social problems and his brand of political psychiatry is as relevant today as it was during his time. Alienation and oppression still exist. Unemployment is widespread and tyrannical rulers still oppress their people. Mental illness cannot be solved by drugs but by changes in the political and social order.”12 What Youssef and Fadi are gesturing to is the necessity to approach psychiatry from a holistic viewpoint, in which we seek to understand society’s role in shaping mental illness. 

Returning to the present day, it is clear that no country is immune from mental illness. Mental health data collectors report that countries that have been at war clearly suffer from a large incidence of trauma-related mental illness. In a pandemic, too, alienation can be strongly felt. The pandemic and its subsequent reshuffling of society exacerbates the structural differences brought by centuries of racial capitalism throughout the world. How we understand them, document them, and heal from them is the change that we need—the social mutation that is necessary for repair. The entanglements of medicine and power in the age of Covid-19 call for the globality of particular forms of medical expertise.

Amid the disarray of the immediate situation, even with an awareness of these global inequalities, the way privileged communities react to epidemics often depends upon varying degrees of empathy. This extends differentially to the sick and dying, to those who fall under the jurisdiction of the carceral state, and to those who do not. When the Covid-19 pandemic hit, it warranted a call to action—a global shutdown, albeit one that saw uneven responses. Unfortunately, even in countries of the Global North, the spread of the epidemic exposed how microbial contagions mutate along the open veins of society, disproportionately affecting the poor and the disenfranchised. In this period of needless death, we must find a politics of reflection, a meditation on all the troubled yet path-breaking perspectives on mental health, and on what it would mean to afford the resources, energy, or triage for comprehensive care. Along with an epidemiological machine, tied to the rollout of vaccines, there should be more community-based intervention, and mental healthcare should be activated as a vital component for living in this fragile period. In this way, we might find new modes of contemplation and healing, and relevant ways to conceptualize the social aspect of the psychology of mental illness in the midst of a pandemic, so that more people may exist in the terrains of good health.