Supporting the social roots of mental health

Kwame McKenzie

Kwame McKenzie, CEO of Wellesley Institute, Director of Health Equity for the Centre of Addiction and Mental Health (CAMH), professor of psychiatry at the University of Toronto, and Commissioner of Human Rights for Ontario.

When you were young, what did you want to be when you grew up?

When I was young, or younger, I flirted with lots of different things. I flirted with the idea of being a writer. I flirted with the idea of being a dancer. It was very different when I was young, because I was in a low-income area of London, England. And our main focus was getting out of Southall.

What did you become?

I became a doctor. While I think it’s one of the greatest professions in the world, the problem with being a doctor in any high-income country is that you feel a bit like you’re in MASH, the American TV comedy and film about surgeons in the Korean war. You’re always patching people up and sending them back into a world where the social determinants of health are bound to injure them. A lot of people don’t notice that when they’re physical doctors, when they’re doing chest work, or they’re doing cardiology. But you do notice it when you’re doing mental health work.

In the UK, if you’re on some of the subway lines, you’re just about to get off, and there’s a loud announcement that says “Mind the gap.” You may have heard it. I think that after a few years of minding the gap, I’m saying, “Well, just fill in the bloody gap!”

Generally, in medicine, we’re pretty good at keeping people alive, and in psychiatry, really good at keeping people alive. We’re good at making people better. But our relapse rate is significant. And, so if your relapse rates are going to be significant, you’re going to get people better but they might get sick again. You either want to stop people getting in sick in the first place, or you want to change the social determinants of health to stop them from relapsing.

The reason why we’re interested in that is because when you look at just some simple things, like if you’re rich compared to if you’re poorer, in Toronto, there’s about a six year difference in life expectancy.

I turned into a doctor that does some clinical work, tries to teach other doctors to do clinical work, tries to do research to help on the clinical side, but I spend most of my time on the social determinants of health, because I believe that fundamentally it’s more likely to succeed. In Ontario, simple math — if you were to do a brilliant job in one of the best psych hospitals, somewhere like CAMH, you’re working with $320 million. That’s what it is. If you were going to work with the whole of the mental health budget, you’d have 10 times that. You’d be into $3.2 billion. If you’re going to work with the whole of the health budget, because there’s no health without mental health, then you’d be into working with $51 billion. If you’re saying, well now I’m going to do the social determinants in government, then you’d be into $130 billion. But then if you say, “well just a second, I want to do the social determinants in general, so I can make it work better. I want to make transportation better. I want to make sure people have the right pensions, and all of the other stuff. I want to make sure that people are safe and they don’t have injuries.” Then you’re into $600 billion because you will work with government and the private sector. So you’ve got a choice of doing a brilliant job with $320 million or trying to influence $600 billion. The math is pretty simple. If you’ve got a limited time in your life, you might want to focus.

Can you describe the scale of the problem that you work on?

It’s difficult to answer that because I have very different hats on. I’m going to answer it with respect to the place that you’re at today, which is the Wellesley Institute. The Wellesley Institute tries to improve health and health equity in the greater Toronto area. We use the lens of the social determinants of health to do that. We’re trying to have action on housing, actions on transportation, action on jobs, action on childhood development. We’re trying to move things forward. The reason why we’re interested in that is because when you look at just some simple things, like if you’re rich compared to if you’re poorer, in Toronto, there’s about a six year difference in life expectancy.

We’re interested in saying, “Well that can’t be the case.” You can’t lose all of those years just because of the way social policy works. You’ve got to be able to do something about it. The scale of the problem is that, not only in life expectancy, but in your likelihood of chronic illness. You know, there are social factors that increase your chances significantly, and that is the biggest health problem in Ontario.

What have you learned about how deep, lasting transformative change occurs?

It’s a very interesting journey that I’ve been on. I think everybody accepts it now – there’s this idea of ecoepidemiology. I think an easier way of thinking about it is conceptualizing the world as a system of Babushka dolls. These Babushka dolls are one doll inside of another doll, inside another doll, inside another doll. Each one of those dolls is perfect and complete. But they are housed inside another doll and another doll. The interesting thing about conceptualizing the world as Babushkas is, though they look the same, when you get to different sizes, the rules of how you might create one of those dolls starts becoming different. You actually have different scientific rules at different levels. If you think of, for instance, how you might cause lung cancer – does smoking cause lung cancer?

You can think of that at the cell level, and there are a bunch of rules about how you work with cells. You can think of it is as the organ level, looking at the lungs, and that’s a completely different type of science. You can think of it as the interpersonal level – why is that person smoking; who gave them the cigarettes? Or you can think of it at the system level – how did smoking become a cultural thing? What’s the cost? Can you regulate it? Each one of those has completely different rules.

I think after a while it’s pretty clear that individual simple actions are important, but they’re not the things that are going to make fundamental change. How are you actually going to deal with structural racism? Individuals are not going to deal with structural racism.

Not only do they have different rules and different sciences, but if you try to transplant the rules from one area to another, they just don’t work. So if I was going to use the rules of molecular genetics to explain why one teenager starts smoking and then the other teenager starts smoking, everybody will just say, “Well, that’s crazy. It doesn’t work!” But what I’ve actually seen from moving from one level to another is that you have people believing that their way of looking at the world is right, and that they have the rules that can be transplanted from an individual level to a family level to a community level to a country level to a world level.

One of the things that I’ve been getting interested in, and investigating, is whether lasting change is about being able to translate between different levels and different sciences so whatever you’re doing at one level actually works while you’re doing something else that works at another level — but you get them to talk to each other.

Given the complexities of the way that society operates and the way that these systems are set, what must one keep in mind when approaching the work of transformation?

I think a humble and respectful approach works. And trying to really understand what the problem is. Some of the problems are not what you think. To give you an example, in the UK, they decided that what they really needed in order to decrease consumption of electricity was to put lagging (that’s what they call it there, but I think here we’d call it insulation) in the roof space. In the UK, most houses have attics, and they have roof space in the attic. So the government produced this program of completely free insulation in your roof that the government would pay for.  Somebody comes to you and they say, “You’re going to spend 10-15% less in your electricity and your gas bills, and we’ll do it for free. You just have to sign a form.” There was almost no take-up. When they interviewed people and said, “Why haven’t you done this?” people said really simple things. “I’m a bit embarrassed but let me show you my attic.” And when you go up to the attic, it’s like a classic Canadian basement. It’s full of stuff! So what the government did is that they created firms who would sort out your attic for you. That was what people needed and then people started getting the insulation fitted.

What does social innovation mean to you?

Innovation has become one of those words that everybody uses for everything. Whether you’re a social innovator or social entrepreneur, or whatever, these are phrases that are used all of the time. A government can say that they’re social innovators. I mean, what are they trying to do? They’re trying to improve the social fabric of society by changing the rules and by trying to produce increased social capital or increased returns in the social space. But what does it mean to me? I don’t know.

What do you find challenging about this kind of work?

Personally, the challenge is that every problem is a cross-cultural problem when you’re thinking of different needs. So you’re thinking of the needs of the politicians who are narrative-based people and they’re interested in stories. They’re interested in whether whatever you’re suggesting is going to increase the number of people who vote for them or not. Then you have to take into account the bureaucratic side. The bureaucratic side wants to get things done. However, the things they tend to want to get done are about process. Because they aren’t necessarily going to be around there to see the outcomes, because they move and you have to move in order to move up. Then you have to take with you professional groups with a whole bunch of interests, and also communities who actually want change. So that can be quite challenging if you want to get things done. You have to be patient and realize that lasting change can be quick change, but often it isn’t. I’m a person who’s moved from the immediacy of clinical medicine, when you do something, you get a result. Somebody comes in, you tell them a diagnosis, they feel happy. You give them prognosis, you find a path to the future, somebody needs a prescription, you give it to them. That is classic immediate gratification. But it’s always small. The challenge is to move from that to population change and societal change where you can work for a long time doing what you think is the right thing. And you might not see anything.

What do you think it is about your personal philosophy or your mindset that draws you to do this kind of work?

I think there’s something special that comes from the outside or the immigrant experience. There’s something special from being a Brit in Canada or being of Caribbean-origin in the UK that starts you asking more fundamental questions. You can’t take a whole bunch of stuff for granted that everybody else takes for granted. You have to think about how things are actually going to improve for people of colour in the world. How’s this actually going to happen? I think after a while it’s pretty clear that individual simple actions are important, but they’re not the things that are going to make fundamental change. How are you actually going to deal with structural racism? Individuals are not going to deal with structural racism. How are you going to deal with health equity? Individuals are not going to produce health equity. Individual doctors won’t do this and clinicians won’t do this either. So if you really want to get to a place where people have an equal chance in life, it becomes pretty clear that you have to think about structural change.

How you feel about the state of the world?

I was born in 1963. When my parents came to the UK in the 1950s, there were signs up which would say, “No Irish, Dogs or Blacks.” Forty years after that, you have the head of the UN who’s black, you have the head of the United States of America who’s black. Things haven’t improved as much as they could, but they’ve moved on significantly. When you look at the problem of Brexit or Trump, or whatever – which are real problems – people just have to remember that the base has changed, and we are moving from it. I just find it really difficult to believe that we’re going to go back 40 to 50 years. And my main disappointment with the world is not the Trumps. There are always Trumps. We’ve got to be playing on a different field than Trump. We can’t be having a conversation about that. It’s not because I think what they’re saying isn’t valid. It’s not because I think 61 million are voting in a strange way. It’s not because I disrespect the people who voted for Brexit. It’s because I believe that that way is not a useful way for anybody to go, and that the way of changing it is to come up with a better plan – a plan which other people will attach to and they’ll find imaginative, and they’ll find exciting.

We need to really start thinking about what we want and how we’re going to get it.