Wednesday, 10 December 2014

Mental Health

The World's Most Profound Health Challenge

In these exclusive interviews we speak to: Dr. Thomas Insel (Director of the National Institutes of Mental Health, NIMH), Dr. Shekhar Saxena (Director of Mental Health for the World Health Organisation), Paul Farmer (Chief Executive of Mind, the world’s largest Mental Health NGO), Sergeant Kevin Briggs (Guardian of the Golden Gate Bridge) and Marcus Trescothick (International Cricketer and Mental Health Campaigner). We look at the realities of mental health worldwide, understand the true burden on individuals, communities and countries and look at the opportunities to deal with our global mental health crisis.


Vikas Shah, Thought Economics, December 2014

Everything we are now, and will ever be, is contained within 1.5 kilos of matter- intricately woven into what, as far as mankind knows, is the most complex object in the universe- the mind. This cage provides a filter that allows us (as individuals) to make sense of the incomprehensible diversity of sensory noise that fills our world and the billions of other beings that we share it with.

It should perhaps come as no surprise therefore that an object this complex- and in many ways beautiful- comes at a huge price. The mind is the seat of our self, and with this amazing capacity comes the ability to cause us profoundly deep pain; illustrated by the fact that every 40 seconds, someone in our world commits suicide (around 1 million people each year).

It is estimated (conservatively) that 1.3 billion people around the world suffer from mental health disorders, with around 600 million people doing so severely enough to be disabled (in some capacity) by them; and losing many years of their lives to mental health related disability. Barely an individual exists on this earth that has not directly or indirectly been impacted by mental health in some way, perhaps fighting their own battles, or experiencing them by proxy through a friend, family member or colleague.

The burden of mental health also puts huge financial pressure on our world. By 2020 (less than half a decade from now) it is estimated that mental health will cost our world over U$6 trillion in lost-productivity and direct costs each and every year (a similar figure to the aggregate current global health expenditure). Yet- with this in mind- we find that mental health is underfunded, poorly understood, and abhorrently low down the social, political and economic agenda of our world.

In these exclusive interviews we speak to: Dr. Thomas Insel (Director of the National Institutes of Mental Health, NIMH), Dr. Shekhar Saxena (Director of Mental Health for the World Health Organisation), Paul Farmer (Chief Executive of Mind, the world’s largest Mental Health NGO), Sergeant Kevin Briggs (Guardian of the Golden Gate Bridge) and Marcus Trescothick (International Cricketer and Mental Health Campaigner). We look at the realities of mental health worldwide, understand the true burden on individuals, communities and countries and look at the opportunities to deal with our global mental health crisis.

Thomas R. Insel, M.D., is Director of the National Institute of Mental Health (NIMH), the component of the National Institutes of Health charged with generating the knowledge needed to understand, treat, and prevent mental disorders.

Prior to his appointment as NIMH Director in the Fall 2002, Dr. Insel was Professor of Psychiatry at Emory University. There, he was founding director of the Centre for Behavioural Neuroscience, one of the largest science and technology centres. Dr. Insel has served on numerous academic, scientific, and professional committees and boards. He is a member of the Institute of Medicine, a fellow of the American College of Neuropsychopharmacology, and is a recipient of several awards including the Outstanding Service Award from the U.S. Public Health Service.

Dr. Shekhar Saxena is Director of the Department of Mental Health and Substance Abuse at the World Health Organization (WHO). A Psychiatrist by training; with about 30 years of experience in research and programme management, service delivery and information systems in the areas of mental health and neurological disorders, especially in low- and middle-income countries.

Paul Farmer has been Chief Executive of Mind, the leading mental health charity working in England and Wales since May 2006. Paul is Chair of the NHS England Mental Health Patient Safety Board, he is an advisor to the Catholic Bishops on mental health and was on the Metropolitan Police commission on policing and mental health. He is a trustee at the Mental Health Providers Forum, an umbrella body for voluntary organisations supporting people with mental distress. Paul is also trustee at Lloyds Banking Foundation and Chair of the ACEVO board. In November 2012 Paul received an Honorary Doctorate of Science from the University of East London in recognition for achievements in promoting the understanding and support of mental health.

Kevin Briggs entered the United States Army in 1981, where he spent three years serving across the United States and Europe. In 1987, he became a correctional officer and worked at Soledad and San Quentin State Prisons. In 1990, he graduated from the California Highway Patrol (CHP) academy and worked predominately on the Golden Gate Bridge (GGB). This assignment proved to be very challenging, as the GGB produced an average of four to six suicidal subjects, multiple collisions, and dozens of other law enforcement “calls” each month. In 1999, he completed training at the CHP Motor School, and in 2008, was promoted to Sergeant. Having graduated from the FBI’s Crisis Negotiation Course, one of his duties was to train new CHP officers and GGB staff on crisis interventions/negotiations. Sgt. Kevin Briggs retired from the CHP in November, 2013, to promote Crisis Management, Leadership Skills, and Suicide Intervention/Prevention worldwide.

Marcus Trescothick is an international cricketer, regarded as one of England’s most outstanding batsmen of the modern age.

At 29, Marcus Trescothick was widely regarded as one of the batting greats. With more than 5,000 Test runs to his name and a 2005 Ashes hero, some were predicting this gentle West Country cricket nut might even surpass Graham Gooch's record to become England's highest ever Test run scorer. But the next time Trescothick hit the headlines it was for reasons no one but a handful of close friends and colleagues could have foreseen. Marcus has since become one of the UK’s leading advocates for mental health awareness. He continues to play for Somerset, working as a commentator and analyst for Sky Sports in the off-season.

Q: What is the state of mental illness?

[Dr. Thomas Insel] Mental illness has been with us for centuries, perhaps forever.

We try to capture the public health significance of an illness by looking at mortality and morbidity. Mortality- when you think about it – is driven by heart disease, cancer, and to some degree infectious diseases. Morbidity - or disability- is quite another thing.

Mental illness accounts for 26% of all years lost to disability. It trumps virtually all other sources of disability- and this is for two reasons. Firstly, mental illnesses are highly prevalent. In the USA, nearly one in five adults had a diagnosable mental illness in the past year. More important, around 4-5% of the population is disabled by a severe mental illness- nearly 1 in 20 adults. Moreover, what makes mental conditions different from heart disease or cancer is that these disorders start very early in life- 75% before the age of 25. The current estimates are that depression is the single largest source of years lost to disability. That's extraordinary to think that depression is globally a leading source of disability -- this would not be on most people's lists of public health challenges.

[Dr. Shekhar Saxena] The state of worldwide mental health is a cause for very serious concern, not just for governments but also the World Health Organization. There are a very large number of people with mental disorders, but a huge number who also have mental and psychological symptoms (not amounting to disorders) who need support. Although some people require care and services, many require help to take care of their mental health, to prevent future disorders.

We are talking about a huge population; not just people who have diagnosed disorders and require treatment, but all of us - you and I - who need to pay more attention to our mental health.

3-5% of people in any given population, at any moment in time, have a mental disorder with substantial disability. 10% of people in any given population, at any moment in time, have a mild mental disorder. Overall, in 1 in 4 families there is someone with a mental disorder, and that's without including disorders related to alcohol and substance abuse.

What causes us great concern is that the attention paid to mental health by policy-makers and health services at large is extremely small. There is a large need, and not enough attention. The World Health Organization’s mental health programme is called the mhGAP – the Mental Health Gap Action Programme – which signifies the gap between the needs and availability of resources in this sector.

[Paul Farmer] We know that 1 in 4 of us will experience a mental health problem at any one given time- by which we mean people who will need help for their mental health. In broader terms however, we all experience mental health challenges- and one of the most important parts of our work is to think of mental health in context of the whole population as well as those specific individuals who do experience mental health problems.

[Sergeant Kevin Briggs] Mental illness in society today is more serious then ever before, in my opinion. According to the World Health Organization, there are approximately 800,000 suicides in the world each year. And, for each completed suicide, there are 20-25 attempts. We are still learning about the brain, how it operates, and how it is affected by mental illness. The key to reducing the stigma surrounding mental illness is education and an open mind. Take stress/mental illness in the workplace for example. They tend to remain near the top of the list for time lost from work. I believe if there were more training in the area surrounding this issue, particularly on how to recognize/approach a person suffering from mental illness/anxiety/stress, there would be a significant amount of money saved in lost time at work, thus reducing workmen’s compensation. People would also in fact be happier and contribute more to the success of their company.

Q: What was your experience of mental health challenges?

[Marcus Trescothick] If I look back, mental health impacted my life more back in 2006- when I was away playing in India, and became too much of an issue to deal with… which is why I returned from there and began the process of dealing with it, understanding it, and learning how to live your life with it.

In truth, it had been underlying for quite a long period of time. It had always been there and I hadn’t perhaps given it the credibility it warranted. I used to suffer quite a bit from homesickness from an early age- around 11- and the symptoms were very similar back then to how they are now still. At the time you think it’s just homesickness and you learn to cope with it for that period of time and it moves on. It’s only really at the time when it became more severe, that I understood what it was- and the reasons why. It became more of a ‘problem’ once I acknowledged what it was!

Mental health impacts everything. When I’m playing cricket, I could immerse myself in the game and what I had to do. I could distract myself and manage it more easily- and that’s part of the problem where if you’re not doing a great deal, you can sit with it, dwell on it, and it can become a bigger problem. My challenges certainly did have an impact on my job, but I learned to manage it to carry on and still deliver- and do what I need to do- even if I don’t feel 100% or as good as I would normally do on a daily basis.

Q: What is the social, economic and political burden of mental health on the community?

[Dr. Shekhar Saxena] Mental disorders have an impact on a number of levels. First, there is the health impact; they cause deaths and a huge amount of disability. More than 10% of the world's Disability Adjusted Life Years lost is due to mental and psychological problems. This is huge. We mustn't forget though that lives are lost. People frequently identify mental illnesses as causing disability, but not death; but that's not correct. Around the world over 800 000 people lose their lives to suicide each year, and a large number of people with mental disorders die significantly earlier than the general population as they ignore their health needs and may not therefore get treatment for tuberculosis, cardiovascular disease, respiratory disease, cancers and so on. Unfortunately mental illness are often ignored by the health system; and they get much less attention in the hands of policy makers and health-care providers.

The social burden of mental illness is huge. Mental health problems give rise to absenteeism in the workplace, marital discord, child maltreatment, neglect and abuse, and also violence. I don't want to feed the misconception that mentally ill people are violent, that's absolutely not true. People with mental health disorders are more often at the receiving end of violence. Both people with mental health disorders, and their families, often suffer from stigma and discrimination. Sufferers are often denied access to social services, the jobs market and even social and cultural activities. This is extremely hard to measure in monetary terms, but is hugely significant.

The economic impact of mental health disorders is also very large. Working populations may experience reduced productivity, greater absenteeism and even ”presenteeism” where the person is at the job but not performing at well. You also find economic burden within the justice system as a result of drug and alcohol usage. A very large proportion of the prison population all over the world, but particularly in North America, has mental health disorders. In effect, the state spends more money on the indirect effects of mental health on society than actually treating the disorders in the first place. 

The cost of mental health on society is not measured in millions or billions, but in trillions of dollars. This scale is largely unrecognised by policy makers.

The best voices to highlight these concerns are the people with the mental health disorders themselves, and their families; the advocacy organisations in this sector are not just few in number, but weak in stature. There is a lot of self-advocacy for HIV, cancer and so forth, but not so much for mental health. The people who suffer the most have the quietest voice - not just because of the illnesses themselves - but because of the stigma. This is one of the reasons why mental health issues do not get the attention they deserve.

[Paul Farmer] Mental health can be seen as a continuum. Many people manage their mental health well, and are able to live the lives they want to- and there are numerous examples of people who have achieved fantastic, incredible things whilst living with mental health problems… others have more complex and enduring problems that impact every aspect of their lives… ultimately and very sadly, there are also 6,000 people in the UK alone who take their own lives- and that is the ultimate impact of someone’s poor mental health.

Q: What is the toll and impact of suicide globally, and what is the challenge of suicide prevention?

[Dr. Shekhar Saxena] Over 800 000 people die by suicide each year, and the numbers are almost certainly under-estimated; a significant number of suicides are reported as natural or accidental deaths. For each death by suicide, there are over 20 attempts. These attempts leave a great deal of mental and physical disabilities. For each death by suicide, there are family members, friends and colleagues that are affected, and who sometimes blame themselves. It's a huge problem that countries need to discuss. This is beyond health; it is a cross-sectoral issue.

We must recognise mental disorders at an early stage and provide proper care so that suicides can be reduced. We must also make sure that people at the front-end of services (such as medical staff, together with those working in the law enforcement and judicial systems) are trained to ask the right questions to detect people with suicidal tendencies early. Most people who eventually commit suicide and die have sought help within the previous 12 months, but did not receive appropriate help. We must also ensure that the means of committing suicide, such as pesticides and firearms, have restricted access. It's genuinely believed that if a person is bent on suicide, that they will do but this is not true. Suicidal tendencies are often transitory and if you can prevent the person from taking their own life for a few hours or days, they may often never do it. We must also look at the fact that alcohol is very closely linked to thoughts of suicide and death by suicide. Reducing the amount of alcohol consumed in society will have a very positive impact on preventing suicide.

We believe that there is no acceptable rate of suicide, that each and every suicide is one too many and that each and every country has a responsibility to act on this issue.

Q: Why do you think people see suicide as a final way out?

[Sergeant Kevin Briggs] This of course is just my opinion with regards to why people become suicidal. This is based on my own observations of the many folks I have dealt with. With mental illness comes shame. In most of the world, mental illness is looked upon as a sort of made up concoction is one’s head. You dare not speak about, for fear of loosing family, friends, even your employment. So, people suffer for years with getting treatment. Even those who face this head on can struggle greatly, due to the severity of the illness at times. Some of those who suffer, even after seeking help, become so ashamed and incapacitated by their illness, they believe they simply cannot go on. They feel they are a burden, and are actually doing everyone a favour by their demise. Then they are the one’s who have committed criminal acts, such as lewd acts with children. When they are discovered, they shame and embarrassment is too much. As many ways as there are to loose one’s life to suicide, are that many reasons to do it.

As far as a cry for help, there are those that start to do an act, say, come to the Bridge and go over the rail because they know they are going to get attention. It is my belief that most do not do this for attention. We do have our “frequent guests” so to speak, but each and every time they are handled with respect and as if it was their first time on the Bridge. You just never know what is really going on in a person’s mind, so it is important to take each case with the utmost care and concern.

Q: What were the reasons why people had decided to make attempts at taking their own lives on the Golden Gate Bridge?

[Sergeant Kevin Briggs] There are a multitude of factors why people think suicide is their only way out of the pain/loneliness they are suffering. The vast majority of the time years of suffering from mental illness have occurred. Mental illnesses like Depression and Bi-Polar disorders wreak havoc on a person. Some do very well with therapy and medication. Others loose their way and decline steadily, over the years, emotionally, financially, and finally loose their ability to cope. Once is a while a person will loose their life to show another person what they have done to them. It is a retaliatory action based on what a loved one, business partner, or person close to them has done.

Q: What was the mental state of those you observed on the Golden Gate Bridge?

[Sergeant Kevin Briggs] Most of the people I have encountered over the rail did in fact suffer from a diagnosable mental illness in one form or another, and varying degrees of severity. Alcohol and drugs was observed in many, as this helps to alleviate pain and give them courage for the task at hand. Two of the people I dealt with directly were in fact not under the influence of alcohol/drugs. They had been suffering from mental illness for years. Their demeanour was generally calm and collective. Both were extremely polite, and seemed as if they were ok with what they intended to do, and had made peace with it.

Q: What was the impact you saw from suicide?

[Sergeant Kevin Briggs] The impact of what occurs when we observe a suicide is difficult to fully explain. If we have spoken to the person for some time, it is like loosing a friend. The bond created just before one’s death leaves an emptiness in your heart and guilt in your soul. “Could I have done better?” We ask this of ourselves each and every day. But this is just the tip of the iceberg. The family and friends can be affected so deeply that it may trigger other suicides. I have seen parents simply give up on life after their child has lost his/her life to suicide. The guilt can be tremendous. Although they may, and probably did, do everything to the best of their ability, a suicide has ripple affects that lasts a lifetime.

Q: How did suicides impact you (personally) and the officers/personnel you worked with?

[Sergeant Kevin Briggs] The suicides that we do witness will forever be ingrained in our minds. It is very personal, and each of us deals with it differently. We (the California Highway Patrol) have what’s called an Employee Assistance Program (EAP) where we can see a psychologist seven times a year. This has helped many of us.

I look at it a couple of different ways. One is that fact that I believe we help many more then we loose. The other are words a Rabbi from New Jersey told me once after I spoke to a young man, just 32 years old, who flew out to the Bridge from New Jersey and jumped after I spoke with him for an hour. I was feeling extremely guilty and very down on myself. The Rabbi told me, “Kevin, if you ever stop feeling the way you do right now, get out of the business.” He explained it is the compassion and thoughtfulness that’s helps so many, and that even though we try with all our heart and soul, some folks just cannot be reached.

Q: In your role; how would you try and diffuse the situation(s) and talk-down individuals?

[Sergeant Kevin Briggs] I use active listening skills in the hopes of generating conversation to find out what is going on in their life. Honesty is huge. I in no way advise them their life will be a piece of cake if they come back over the rail, but I do relate the importance of their life, their self worth, their responsibilities, and try and install hope. Listening is critical. Many times, all a person needs is someone who will listen, without an agenda or argument.

Q: What is the state of attitudes towards mental health?

[Dr. Thomas Insel] There is a lack of understanding about mental illness.

In the developing world, mental illnesses tend to be viewed as a first-world problem. In the developed world, it's often seen as a private family issue and is rarely a priority for people who set the public health agenda. Mental health oddly has been carved away from the rest of medicine as being a social-services problem rather than a medical or public health problem. That's a critical part of the difficulty we've had bending the curve for mortality and morbidity as they relate to mental illness; we've not been able to get traction in the world of medical practice.

The World Health Organisation reckons that around 3% of healthcare dollars are spent on mental disorders, yet these disorders account for 26% of years lost to disability. It's a huge gap between investments and costs.. Patients receive the equivalent of less than $2 per person per year in this space- and that's incredible considering the disability associated with mental illness. It's not simply a question of disability – mortality is also a concern. The WHO global suicide report cites conservatively that there are more than 800,000 suicides in the world each year, 90% of which can be attributed to mental disorders and 75% of which are in low and middle income countries. Mental health is not only a first-world problem, and the suicide data demonstrate that, when neglected, this a problem with fatal consequences.

In the USA we have around 12 suicides per 100,000 people each year- a rate which is about average for an OECD country. Note that the deaths from suicide are more than double the deaths from homicides each year: the USA has around 16,000 homicides each year, and 39,000 suicides! In the USA, there is an immense focus on homicides, it's a lead story in each and every newspaper but you rarely read about suicide which is twice as prevalent. In fact... homicides have come down around 50% whereas suicides have only trended upwards.

There's a remarkable neglect for suicide. Around the world we have people accountable for reducing medical deaths, road traffic accidents and so forth, but it's difficult to find who's accountable for preventing suicide in most countries.

[Dr. Shekhar Saxena] The stigmatisation of, and discrimination against, those with mental health disorders is found all over the world.

The stigma is not just due to a lack of knowledge, but attitudes. It's easy to change knowledge, but hard to change attitudes and behaviours.

One of the reasons self-advocacy is weak, and we are experiencing a policy hiatus, is because policy makers don't like to think or plan around mental health because of the stigma. The public discourse in developed countries is changing, but it's far from adequate ̶ and in much of the world, the discrimination is rampant.

There is also a very clear link between mental health disorders and human rights violations. These violations occur in mental institutions and in the community. Almost 70% of psychiatric beds are in mental hospitals and not general hospitals. Mental hospitals, by their definition, are isolated and often far from cities. They have conventionally been more of a place to keep people with mental disorders away from society, rather than for treatment and services; this unfortunate reality continues in the present day in both the developed and the developing world. Human rights violations are rampant and because of a lack of transparency and accountability, these violations are able to occur both within and outside the law. In many countries, there are laws that deprive people with mental disorders of their basic civil rights such as voting, driving, property ownership and so forth. Laws aside, we see frequent abuse of people with mental disorders; they are deprived of their liberty, and sometimes locked-up in institutions for life. Even basic physical needs, such as food, clothing, shelter and basic healthcare, are often denied.

It's not just within healthcare settings that these abuses occur. Communities frequently violate the human rights of their citizens who are suffering with mental health disorders. We hear stories about people being chained and locked-up in their houses for years ̶ this is indicative of the way society treats people with mental disorders. This is not just illegal, it’s immoral.

Mental disorders are disorders like any other, but they are stigmatised and deprive people of their human rights. Society must do something about this.

[Paul Farmer] There is no doubt that mental health stigma remains a huge challenge to overcome. For generations, we’ve ignored the issue of mental health, and those with mental health problems have been literally kept out of sight, out of mind. Let’s not forget that it wasn’t that long ago that people were locked-up in long-stay institutions! That was the way that society viewed mental health!

We are beginning to see progress… For the first time, partly as a result of the Time to Change campaign, that we run with ReThink Mental Illness we’ve seen an improvement in public attitudes to mental health. In specific areas, attitudes are changing quite quickly. In the workplace for example we know that many employers are recognising the importance of improving well-being for employees, and supporting people who need it. We also still know that many people feel they can’t disclose their mental health problems to their employer or colleagues. 

It’s important for leaders to be open about their experiences, and that’s not something that happens very often. It makes a huge difference. There’s been a lot of work around how leaders can be open about their mental health challenges, as it can often be doubly-difficult in a workplace. If you’re a member of staff, it’s hard enough going to your manager – but if you’re in charge? Who do you talk to and how!?

[Marcus Trescothick] I [personally] don’t see this perhaps as much as it’s reported in the media, but I can only really judge it on my own circumstances and a few friends in the profession who’ve been through it. Whether we’re just lucky and people allow us to carry on playing the game? …it doesn’t affect us too much. It doesn’t affect the decisions made on us, we’re still allowed to carry on and do as normal. You do hear a lot about it in other areas.

Even now however, I know lots of people who still don’t want to admit to their boss or team-mates what they’re going through. That’s people within the game, but also from other walks of life.

People still believe there’s an issue or stigma… but it’s not until it’s a major problem that people go, ‘sod it, I’ll just tell everyone….’ And that made it a lot easier for me!

Q: Is there a link between high performance careers and mental health?

[Marcus Trescothick] From what I see, I think there probably is. There’s a lot of demand put on yourself – you push yourself through hours and hours of work; that could be hours of training at the gym, practice, on the pitch, travelling and being away from home. The England team for example spend around 270 days a year away from their families and homes- that’s pretty demanding.

There must be some correlation between demanding lives and mental health… that said, I know many people that suffer these problems who don’t have those same life challenges. Everyone’s issues are relative to how their brain operates- they still have the same stresses and worries that we all do.

Q: What is the state of treatment for mental illness?

[Dr. Thomas Insel] We think of treatment in two big buckets. One is medications. The medications we have today, around 30 anti-depressants and 20 anti-psychotics, are not strikingly different from the drugs we had 40 years ago. That's not to say they're not effective; they're actually quite useful and may be essential for those who are severely ill.

Medication isn't sufficient however... you need a series of non-pharmacological interventions deployed with medication. In much of the developed world, people get medication but not much of anything else. The second bucket includes the range of non-pharmacologic treatments, from psychotherapies to devices, including mobile health apps. There is a lot of innovation right now in the development of inexpensive, accessible treatments that can be used in low resource environments.

Medications can treat the symptoms, but may fail to address the core of these illnesses, which are often cognitive. In the developed world, we're too singular in our approach- focusing on medication or cognitive therapy but rarely combining treatments to get optimal outcomes.. In many developing world, patients don't- in many cases- even have access to the medication! The WHO estimates that 85% of people in the developing world receive no treatment whatsoever! All these medicines are generic and incredibly cheap, and could be available everywhere to everyone. It wouldn't be enough of course, but antidepressant and antipsychotic medications should be in every formulary in the world.

[Paul Farmer] There is a very long history of mental health being continuously underfunded as a result of which, only 25-35% of people with mental-health problems receive treatment at all. There’s an enormous treatment gap between the number of people who need help and support and the number of people who get help and support.

Evidence suggests if we invest systematically in mental health, not just at the treatment-end, but also with early interventions and appropriate crisis care, that it can be clinically and economically effective. There isn’t any reason why these investments can’t be made now, especially given the savings that could be made in acute hospitals and primary care; lots of people who go to their Doctor or A&E have mental-health problems, and many people on acute wards have some mental health problem. There’s a really good opportunity to change the way that mental health services are provided, and in our manifesto for the next government, we’re encouraging this to be at the heart of thinking.

Q: What are the most promising areas of science in mental health?

[Dr. Thomas Insel] At the NIMH we think a lot about how we get better at diagnosing and treating these disorders. Much of what we do today, and have done for the past several decades has been focussed on symptoms rather than the underlying cause or strategic treatments. The hypothesis we have here is that mental illness is related to something going on in the brain, just as chest pain is usually related to something going on in the heart or the lungs. We don't know enough about these illnesses as brain disorders, but if we apply the extraordinary tools of modern neuroscience- there's great potential. Modern genomics and neuroscience could transform how we think of mental disorders and provide us with new diagnostic tests and treatments. Just as an example: in the era where pharmacology was the main foundational science for mental disorders, there was a tendency to think of the brain as a black-box and to consider an illness as a chemical imbalance- as if depression meant you were a quart low in serotonin. The new perspective views depression as a problem with circuits in the brain that aren't operating properly- something more like an arrhythmia in the heart. The task of treatment is to get the circuit synchronised in the right way- Medications can help but circuit tuning may require cognitive psychotherapy or targeted brain stimulation. It's becoming increasingly clear also that depression is many different disorders that impact brain circuitry, as much as fever comes from many different causes- neuroscience should give us the assays to understand depression in this way.

Science is taking us in a new transformative direction for mental illness.

Q: What are the key determinants of mental health?

[Dr. Shekhar Saxena] Mental health disorders have many causes. I can say upfront that we don't fully understand the causes of all mental disorders, although for some we have a very good idea.

The causes of mental health disorders vary from biological to social, and also psychological. Biological causes are to do with brain functioning, neurotransmitters, genetics and even structural lesions within the brain. The psychological and social causes are due to stress factors, and the risk factors that exist as a result of inequality, conflict, wars and so-forth. There are avertable causes, and also non-avertable causes, but we do know that rapidly changing societies, and those going through upheavals caused by conflict and natural disaster for example, predispose their populations to a higher incidence of mental disorders; and we can do something about that through anticipatory action and the right interventions post-event.

Q: How do demographics impact mental illness?

[Dr. Thomas Insel] One of the things that is so unique about mental illness is its prevalence in children. A fascinating question has come up about the genetics of conditions ranging from autism to schizophrenia and bipolar to ADHD. It turns out that the genetics are very similar across them all, indicating there may be a common vulnerability. Some disorders occur more in children, some more in men than women. Autism and ADHD are 4 times more common in boys for example, while depression and eating disorders are more common in women. Is there something about the fundamental mechanisms of these diseases that causes some to occur by aged 2-3 (such as autism) and some much later (such as schizophrenia) which emerge in the early 20's. Could the age of symptoms reflect the development of relevant brain pathways? Do the gender differences represent hormonal influences that are protective?

It is also possible that age and gender alter the presentation of these disorders.  One line of thinking today argues that the same disorder looks like anxiety at aged 8, depression at 28, and dementia at 68. It can be the same biology and may require the same treatment. We know that men and women with the same disorder have different presentations. For instance, women with depression more often present with the sadness and gulit; men often exhibit irritability and hopelessness.

[Paul Farmer] At Mind we’ve been thinking about how we can support the resilience of those who are most at-risk of developing mental health problems. We’ve been doing quite a lot of work thinking about mental health in a public health concept in much the same way as people look at smoking or obesity. There’s also benefit in identifying groups who are at specific risk; for example- older people who are at risk of isolation, mums-to-be, who are at risk of post-natal depression, unemployed men in particular due to the elevated risk of mental health problems in those who are not at work, vulnerable migrants, people from the African and Afro-Caribbean community, and also those with long-term physical health problems- they are all at greater risk of developing mental health problems. We want to work with public health teams at a local-level to put in place strategies that allow people to have the resilience they need to deal with mental health problems.

[Sergeant Kevin Briggs] Most of the time it is white males, ranging from 18 to 45 years old that jump from the Bridge. They differ in socio-economic levels. There really are no patterns to suicide on the Bridge. Some years have more age groups then others and sometimes more in the spring and after school begins, but really, suicide from the Bridge crosses all races and economic borders.

Q: How do the justice system and our political framework deal with mental health?

[Paul Farmer] We have three cornerstones in legal terms when thinking of mental health. The Human Rights Act is an incredibly important part of the support and safeguards that people with mental health problems have, and so too is The Equalities Act. Since mental health is perhaps the only situation where someone can be forced to receive treatment against their will, The Mental Health Act and The Mental Capacities Act provide those legal policies and frameworks to safeguard and define any state intervention in someone’s life.

We are detecting a greater degree of political interest in mental health as an issue, and all of the [UK] political parties are taking it a lot more seriously. There is still a long road to travel down before mental health is embedded into government policy-making, and that’s really what we would like to see.

Q: Is there enough will to fight mental illness?

[Dr. Thomas Insel] We're stuck in a situation where mental health has become hugely fragmented and misunderstood. Secretary Hillary Clinton recently spoke about the need to redefine mental health as a public health problem. She pointed out that in some countries, including the US, mental health has become a criminal justice problem- as more people with mental illness are in jails than in hospitals.

There's a great need to educate policymakers as to the importance of this problem, and the need to address it. It's not expensive! We're not talking about high tech diagnostics and therapeutics for each ill-person, but re-organising resources to achieve better outcomes. In fact, we know how to do this. For example, NIMH supported scientists are about to publish the results of a large study to improve outcomes in individuals following their first psychotic break (usually in their early 20s). To reduce subsequent arrests, re-hospitalisations, and poor treatment compliance, this study bundled together treatments that have been available for three decades. We can do so much better without any new science; just by making sure we do what we need to.

Q: Who are the key stakeholders in mental health solutions?

[Dr. Shekhar Saxena] Mental health issues should be everyone's business, starting from policy makers who have a responsibility to make national policies to prevent mental disorders and promote mental health, and service providers. The budget allocated to mental health in low- and middle-income countries is less than 2%, and less than 3% elsewhere in the world - but the burden of mental and neurological disorders worldwide is around 10% of the total disease burden.

Civil society has a huge responsibility to highlight issues and take action to make things better. Those with mental health disorders (and their families) have a responsibility to speak out and demand the services they need. The media also has a role to play. Many misconceptions about mental health are strengthened by inappropriate reporting ̶ meaning that people are given the picture that those with mental health disorders are abnormal, cannot be cured, are violent and aggressive, cannot take responsibility and more. All of these things are untrue. In the majority of cases, those with mental health disorders can become 'normal,' and work, marry, look after themselves and their families and have good lives. People with mental health disorders need the support of society, not the ridicule that is often heaped upon them.

Commercial organisations play a role. The healthcare sector (including pharmaceutical companies and researchers) have the responsibility to further research treatments of mental health disorders ̶ this is not just good business, but also in the public health interest. Employers must do a better job of looking out for the mental health of their employees. We have a large responsibility for mental health in the workplace, and that's often ignored.

Even you and I are stakeholders in the mental health agenda. We need to be on the look-out for people who may need help, in our own families and among our friends and colleagues. Often, because of stigmatisation, those needing help do not get it in a timely way and may be at risk of suicide.

Q: Will we see a world free of mental health problems?

[Dr. Thomas Insel] The community of people involved with mental health have really never sought a cure, the way advocates have campaigned for cures for cancer, heart disease, and AIDS. Mental health advocates are developing a culture of recovery -- their most ambitious aim is to make sure that everyone can recover. That is fine, but prevention and cure need to become part of our vision when we think about autism, severe depression, and schizophrenia.

People are now starting to talk about prevention, recovery and cure in their agendas. We need to look at this in similar terms to heart-disease. We need early detection- rather than waiting for someone's first psychotic break at 22, we need to detect the prodromal problem at aged 8, 12 or even 15. In the USA, we have around 100,000 people who have their first psychotic break each year, we want to reduce that by 50% through early detection and intervention. This field simply hasn't had a vision of prevention and cure – which will require better science. We’ve been mostly about provision of services. Better services are critical but will this reduce morbidity and mortality? It's a real challenge for us to realise that maybe what we have to offer today is not good enough and that we need to do something better to prevent psychosis and suicide.

[Dr. Shekhar Saxena] I don't see a world in the foreseeable future that is free from mental health disorders, but I do see a world with greater attention given to mental health, and a world where people are encouraged to promote their mental health and to effectively take care of disabilities and conditions if and when they occur. I also see greater participation of people in society within the mental health agenda, and the mainstreaming of mental health into policy making. This is a realistic goal. We are not seeing the end of cancers in the foreseeable future for example, but we have a better understanding of prevention, care and services, and this is what we want for mental health.

The World Health Assembly Resolution on Mental Health was passed by all the health ministers in 2013. I see this as a major advancement in the recognition of mental health, and a commitment by the world. It was remarkable that all 194 Member States of the World Health Organization, committed themselves to the same vision, objectives and targets for mental health. This gives me a lot of hope about future actions and achievements in improving the lives of people suffering from mental health disorders and their families.

Q: What is the role of education as it relates to mental health?

[Paul Farmer] There is a serious need to give young people a good grounding in mental health. In the Time to Change campaign, we take mental health messages directly into schools and work with teachers, pupils and support staff. When our team leave, we hope that people are able to ask the right kinds of questions and talk around these issues. Formally and informally, there’s a huge job to be done…

We’ve also seen positive evidence around supporting mental health right back in the 0-2 year old group where you can do a lot to build positive resilience through positive parenting programmes for example.

Q: How is technology impacting mental health?

[Paul Farmer] Accessing information and support has helped people with mental health issues tremendously. For example, our Ele-Friends peer-support community is a fantastic example of what you can do in a positive way using online empowerment. We are also seeing the emergence of access to online therapy, and the use of apps to monitor mood and so forth.

There’s also a strange-paradox where people may feel that technology can make them more isolated rather than less isolated; so despite the fact that we have may ways of communicating perhaps we’re doing it less in quality terms.

We have to keep a close eye on the impact of modern technology on the mental health and mental wellbeing of any society, but on the whole we see it as a force for good.

Q: What would be your view of the future of mental health?

[Paul Farmer] We are living through a key-part of mental health’s journey. We are coming out of the shadows, and mental health issues are now much more visible in a positive way. The next 10 years or so could hold a great opportunity to reach a tipping point in public attitudes to mental health in the same way that attitudes have changed towards gender, sexuality or race. With that will come a significant increase in demand for help, and so it’s important that the support services are in place to absorb that demand.

In a really optimistic way, I think there’s an opportunity for a real significant sea-change, and we are on an inexorable path towards that.

Q: What was the greatest lesson you learned in your time as a guardian on the bridge?

[Sergeant Kevin Briggs] I have learned so many things since I began working on the Bridge, not only about people in general, but about myself also. My professional career has been primarily in “macho” jobs (military, corrections, CHP). This path had hardened me somewhat, making me emotionally shut down. To see what we see in this business and still be able to go back and do see the same thing the next day, you need to be able to put the bad away and move forward in a fast manner. What has really struck me is the empathy you show can really make others shine, no matter where that be. Everyone of us has emotions, and when confronted by obstacles in our life that can seem overwhelming, all it can take is just one caring individual to really make a difference. That little amount of time you spend with someone can make a lifetime’s worth of hope for them.

Q: What has been your greatest insight during your recovery journey?

[Marcus Trescothick] One of the most valuable lessons I learned was that you only start to learn how to cope with your problems when you acknowledge what they are. You then come to terms with what it is, learn about it, understand it – and start to improve yourself!

I had been hiding from my mental health problems for a long time, almost since I returned from India. You’re almost trying to cover your tracks, and cover your ‘secret’ – the best thing to do at that point was to tell everybody. It made it easier, it meant I didn’t have to lie to the media about the reasons why I was doing this or that – when you talk about it, you find that people understand what you’re going through and often are going through it too. The point where I was open and honest about my mental health was definitely an important turning point for me.

I didn’t have any preconceptions about mental health before then. You obviously hear a lot of people talking about how they’re depressed and so on; and I didn’t really realise what it was about – I thought maybe people were run down or worn out. You hear a lot of stories about people prejudging those with mental health issues, but you never really understand it until you go through it yourself.

Q: What would be your message to those currently experiencing mental illness?

[Dr. Thomas Insel] I am hopeful but also I think we need to be realistic. The tools we have today are unprecedented, we have never been able to offer so much to so many.... however.... we need to admit that the quality of care in most places is not good and that, in contrast to much of medicine, diagnosis and treatment depends more on whom you ask rather than what you have.

All of us have family members who have been impacted by mental health issues, and many have done remarkably well, while for some it's still a challenge. We need to be honest -- we don't have the treatments we need for autism, for many aspects of schizophrenia, and for dementia. I am hopeful that science will give us better diagnostics and therapeutics, but this is a long-term effort. We also need to recognize that we can do much better with the treatments we have today. For instance, creating toolkits with medication and evidence-based psycho-social treatments could make a big difference in the short term. And for the best outcomes, we need to involve families and patients to empower them to direct their own care. If we can do that, my message is that there is hope for recovery in the short-term and prevention and cure in the long-term.

[Dr. Shekhar Saxena] People with mental disorders can help change the world around them. By recognizing and articulating their needs, and by having a say in decisions made, they can not only improve their own lives, but make the world a better place.

[Paul Farmer] It’s important for people to realise that you are not alone. So many people who are developing a mental health problem feel very alone, isolated and even scared about seeking-help. We want to send a message to people saying that it’s OK, you’re not on your own, and that there’s a lot of help and support out there for you- formally and informally. We want to encourage people to seek-out and reach that help.

[Sergeant Kevin Briggs] To those who are suffering from mental health challenges, or just feeling low at times, which very much includes myself, I’d like to give you some advice that I use for myself. I know all too well how hard this illness can be in your life. At times there is extreme loneliness, lethargy, and even disgust with one’s self over what may be occurring in your life. At least this is how I feel at times. But, I also know there will be days when all just seems right with the world. When those days occur, write down how you felt, what you did, whom you were with (if anyone) and if anything assisted you in feeling better (sunlight, foods, walking the dog….). On your bad days, look at this and it will help you get through it, knowing it will pass.

[Marcus Trescothick] You have to seek help straight away; whether that’s a doctor or a psychologist. You have to try and get a bit of direction, and get to a point where you know how to start dealing with your mental health. You need to get to an area where things start to improve, and that takes time- but if you’re not asking or seeking the advice, then you’ll never get the clarity about how it’s going to get better.

If I broke my leg, I’d go straight to a hospital and they’d put a cast on me and give me a rehabilitation programme; but because you don’t see the physical problem, you move away from it, and think you can cope with it yourself.

Men are often guarded about what they’re feeling, and may perceive it as a weakness to ask for help. It’s often only when they have been through-it and experienced it that they realise this isn’t true. We [as men] can get help, we can ask for help, we’re just normal people at the end of the day.


It is perhaps appropriate for this author to conclude this piece by disclosing a rather personal interest in the subject matter.

I have lost more than one of my closest friends to suicide, and have spent decades at the torment of my own mind’s depressive states and, on occasion have come to understand- quite vividly- the depths of darkness that lead people to think- and do- the unthinkable.

I contend that I am me, and nobody else will ever know how I feel- and with that contention comes the realisation that the challenges of mental health are solitary unspoken battles between myself and my soul, with invisible wounds and selfish victories, which- in turn- create my greatest weaknesses and most profound strengths. It is this contention that means that I (and many more) fight alone….

… The truth is, I am not alone. Should humans be categorised by those with, and those without mental health challenges – I would be part of an immense family – and one desperately in need of a voice.

Mental health challenges kill over a million people each year, and cause profound levels of suffering to billions more. Given we have the technology and capability to treat the vast majority of mental health disorders, each and every life lost is a failure on our conscience- and each and every moment of suffering is an injustice at our hands.

I hope, dear reader, that you will join me in taking up arms – and speaking from the heart, on behalf of the mind.

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Tuesday, 11 November 2014

How Power Shapes our World

In these exclusive interviews, we speak to Moisés Naím (Distinguished Fellow at the Carnegie Endowment for International Peace, former Minister of Trade and Industry for Venezuela and Executive Director of the World Bank) and Admiral James Stavridis (Dean of The Fletcher School at Tufts University and former Supreme Allied Commander at NATO). We discuss the fundamental nature of power, how it shapes our world economically, politically, socially and how it impacts the lives of every single individual on the planet.


Vikas Shah, Thought Economics, November 2014

To understand the story of humanity is to bear witness to the story of its greatest paradox; power. This phenomenon creates the constraints in which we operate, yet is responsible for the structures that bind our society together.

The exercise and accumulation of power is endemic to humanity. In the 20th century alone, this phenomenon has been responsible for over 200 million deaths through war and oppression, and has concentrated over 50% of the world’s wealth into the hands of just 1% of the world’s population meaning that billions of our global family have been subjected to hunger, thirst and disease. Power has also enabled social movements that have brought rights, freedoms and opportunity to many billions more.

The unrelenting growth of technology in the past quarter-century has brought with it conceptually challenging notions to our incumbent ideas of power. Facebook, with more than 1.3 billion users is now (perhaps) as powerful as many sovereign states. Diffuse communications networks have also enabled hundreds of millions to come together in revolutions and acts of protest; in some cases, dismantling power structures that have been incumbent for hundreds of years. Even the most abstract seat of power- knowledge- is being challenged as the Internet democratises access to the total sum of human insight. Technology has also allowed the world’s governments to infiltrate our lives ever more deeply; being able to monitor, analyse and consume unimaginable quantities of information on the daily lives of citizens and entities, and build weapons to destroy them in more astonishing ways. “We have the power to make this the best generation of mankind in the history of the world - or to make it the last.” - John Fitzgerald Kennedy

Regardless of whether we stand on the opposite plinths of that which is considered the moral good or evil, we must agree that every major advancement and challenge our species has experienced has been as a result of the ebbs and flows of the great forces power projects into our world. As Michel Foucault comments, “Power is not an institution, and not a structure; neither is it a certain strength we are endowed with; it is the name that one attributes to a complex strategic situation in a particular society."

In these exclusive interviews, we speak to Moisés Naím (Distinguished Fellow at the Carnegie Endowment for International Peace, former Minister of Trade and Industry for Venezuela and Executive Director of the World Bank) and Admiral James Stavridis (Dean of The Fletcher School at Tufts University and former Supreme Allied Commander at NATO). We discuss the fundamental nature of power, how it shapes our world economically, politically, socially and how it impacts the lives of every single individual on the planet.
Moisés Naím is an internationally-syndicated columnist and best-selling author of influential books including the recently-published The End of Power, a startling examination of how power is changing across all sectors of society, and Illicit, a detailed expose on modern criminal networks. In 2011, he launched Efecto Naím, an innovative weekly television program highlighting surprising world trends with visually-striking videos, graphics and interviews with world leaders which is widely watched in Latin America today. Dr. Naím gained international recognition with the successful re-launch of the prominent journal Foreign Policy and, over his fourteen years (1996-2010) as editor, turned the magazine into a modern, award-winning publication on global politics and economics.

His prize-winning work is highly influential in the world of international politics, economics and business. In 2005, Illicit was selected by the Washington Post as one of the best nonfiction books of the year; it was published in 18 languages and is the basis of an Emmy award-winning National Geographic documentary. Of his recent book, The End of Power, former US president Bill Clinton said it “will change the way you read the news, the way you think about politics, and the way you look at the world.

Dr. Naím’s columns and media commentary have a worldwide audience. He is the chief international columnist and “Global Observer” for El Pais and La Repubblica, the largest daily newspapers in Spain and Italy, a contributor to The Financial Times “A-list”, and an associate editor at The Atlantic. His columns are also carried by all leading newspapers in Latin America, and have been published in The New York Times, The Washington Post, Bloomberg Business Week, Newsweek, Time, Le Monde and Berliner Zeitung. In 2011, he was honored to receive the Ortega y Gasset prize, the most prestigious award for journalism in the Spanish language . In 2013, Naim was named one of the world’s leading thinkers by the British magazine Prospect and in 2014, Dr. Naím was ranked among the top 100 most influential global thought leaders by GDI Gottlieb Duttweiler Institute for his work on The End of Power.

Dr. Naím is a distinguished fellow in the International Economics Program at the Carnegie Endowment for International Peace in Washington, DC. He is the founder and Chairman of the Board of the Group of Fifty (G50), which brings together top-flight progressive Latin American business leaders, and a member of the board of directors of the National Endowment for Democracy, Population Action International, the Open Society Foundations as well as several global companies.

In the early 1990s, Dr. Naím served as Venezuela’s Minister of Trade and Industry, as director of Venezuela’s Central Bank, and as executive director of the World Bank. He was previously professor of business and economics and dean of IESA, Venezuela’s leading business school. Dr. Naím holds MSc and PhD degrees from the Massachusetts Institute of Technology. He lives in Washington DC.

Admiral James Stavridis, is the 12th leader of The Fletcher School since its founding in 1933. He holds the title of Dean of The Fletcher School, Charles Francis Adams / Raytheon Dean's Chair

A former Admiral in the U.S. Navy, he led the NATO Alliance in global operations from 2009 to 2013 as Supreme Allied Commander. He also served as Commander of U.S. Southern Command, with responsibility for all military operations in Latin America from 2006-2009. A Fletcher PhD, he won the Gullion prize as outstanding student and has published five books and over a hundred articles. His focus is on innovation, strategic communication and planning, and creating security through international, interagency, and public/private partnerships in this turbulent 21st century.

Admiral Stavridis served as Supreme Allied Commander, NATO and commander of U.S. European Commander (2009-2013) and is currently Chair of the Board, U.S. Naval Institute (2013-present). He led U.S. Southern Command in Miami (2006-2009), served as Senior Military Assistant to Secretary of Defence and Secretary of the Navy and was first commander of Navy’s “Deep Blue” strategic and tactical think tank after 9/11 Pentagon attacks (2001-2002).

Admiral Stavridis is the recipient of numerous prestigious awards including Intrepid Freedom Award, Athenagoras Human Rights Award, Council on Foreign Relations International Affairs Fellow, Alfred Thayer Mahan Award, John Paul Jones Award, Arleigh Burke Award, 38 US and international military medals and the Gullion Prize (Top in class), The Fletcher School, Tufts University

He holds a PhD and MALD from the Fletcher School of Law and Diplomacy, Tufts University and a BS from the U.S. Naval Academy. Stavridis is also a Member of the Council on Foreign Relations.

In 2014, he released a book of his story, "The Accidental Admiral: A Sailor Takes Command at NATO"

Q: What is power?

[Dr. Moisés Naím] The classical definition of power, commonly used by political scientists and others, is that power is the capacity to get others to do or stop doing something now, or in the future.

Power is also a source of order, and a source of comfort for some people. Remember that the extreme situation where nobody has power, is anarchy… and Anarchy is an inferior Hobbesian society and leads to inferior social outcomes to societies where structures and entities that impose power, limits and rules to create stability and prosperity. Some neuroscientists have even argued that power is hard-wired into our brains, and evolutionary psychologists have similarly argued that power (and the quest for it) is an evolutionary trait- an instinct.

[Admiral Stavridis] There are several centres of powers that drive society in a broad sense. First and foremost we see demographics; human capital, the people and population- tied to which we see their education levels and productivity. Traditionally, we also talk of military power- albeit I think this is suffering the law of diminishing terms as in our current global society, huge force on force confrontations are less-likely, though not impossible. Increasingly cyber or information power is also extremely significant, and I would tie this to the idea of 'idea' or 'message' power, which is society's ability to influence other parts of the world in the power of its messages. I would argue that western society, over the past several centuries, has been able to move the ideas of democracy, freedom of speech, freedom of education, freedom of assembly, gender rights, racial equality and more. Given the centre of power can be seen as your ability to produce or convey influential ideas; this is certainly important. Cultural power is also significant, the degree to which your society's popular culture; films, books, art, theatre, music and sports are received nationally and internationally. Separate from this is political power which, in many ways, derives from all the other things I've spoken about. Geographic and resource power are also fundamentally important, and are derived from not just the size of your country, but how much water and energy you have access to. Innovation power is also very important; the creative spark your society has.

All these factors taken together will determine how influential a nation is at influencing the behaviours of other nations and organisations.

Q: What are the dynamics that influence power?

[Dr. Moisés Naím] The sources of power have changed, and the ability of incumbents- those who already have power- to maintain it, is diminishing. Power is decaying because it has become easier to acquire, much harder to use, and thus easier to lose.

Q: Is it inevitable that power will concentrate?

[Admiral Stavridis] Today, sociologically speaking, we are seeing a broad diffusion of power. Look at the way that individual ideas, groups and individual people are able to exert power using communications technology. This could be violent or extreme groups, and also groups who are doing wonderful things for sustainability, the environment and ecology. Groups are forming, and power is diffusing away from nations and moving more toward sub-groups. The recent referendum in Scotland, the potential Catalonian split and the break-apart of Ukraine are all examples of power diffusions. Counterbalancing this, it's worth pointing out that power is concentrating in Europe; through the European Union. I believe this is in a state of tension however; and generally power is diffusing.

The most important form of power is human capital, people.. and their education. In today's world it is easier for people to amass education and communicate their ideas than it has ever been before. Education is still withheld from vast portions of the globe, but these individuals will get there. Today, education constitutes around 10% of what moves the internet. When that number moves up to 20, 30 or even 40%, more people will be educated and have access to technology. Over time, this will cause power to diffuse even more.

New corporations such as Google and Facebook are also examples of power diffusing from nation states and moving to new forms of entities. Technology will only accelerate this trend.

Q: What are the instruments used to maintain power?

[Dr. Moisés Naím] The instruments to maintain power vary between sector and activity. If you are a church, power sits in the number of your followers… If you are a political party, power sits with the scale of your voters and your ability to fundraise… If you are a company, power is your balance sheet, your brand, your unique selling points and technology… If you’re an army, power is your resources; your troops, ships, tanks and technology and if you are a nation, power is a combination of demographics, resources, military capability and so on.

Q: How do those with power defend their positions?

[Dr. Moisés Naím] The Historically, size was very important. We came to equate power to size; the larger your balance sheet- for example- the more difficult it was for challengers and rivals to displace your market dominance. If you were an army and had huge expenditure, budgets, weapons and technology- it was difficult for others to fight you. Now everything has changed. In the case of the military, we have relatively small groups like Al Qaeda, The Taliban and the Islamic State who are capable of challenging the mightiest and most advanced militaries of the world. In the commercial space, we have also seen how small start-ups are able to contest- and even displace- the dominance of centuries-old multinational corporations. We have also seen how new churches are attracting believers that have traditionally been faithful of other religions. Size continues to be important, but is no longer the main factor shielding the powerful from the challenges of newcomers and new arrivals.

Q: How can power be dismantled?

[Admiral Stavridis] How power can be governed is one of the most fundamental questions of the 21st century. Most of what passes for crises is- in reality- about governance and the ability of some entity (usually a nation) to contain and shape behaviours by sub-groups; some very small violent extremists, or large corporate entities.

If nations are not going to be able to exert governance, who will? The answer to this question is unclear, and whether this Westphalian state that emerged in the 1600's will continue to be the dominant governance structure of society is in doubt. Long term, my intuition is that society will have different organising features. Just think about this... What is a global citizen? We think today about passports, and we treasure our individual national passports that allow us to stride boldly from country to country, and yet in a century it may be more important to understand what it means to be a global citizen. I suspect that Bitcoin or some variant of it may have grown to become a global currency; and by that time, technology will allow us to speak commonly- although we may hang onto the precious nationalism of our languages for a long time. All these trends will slowly start to create the idea of global citizenship as distinct from what we think of today, which is state sovereign citizenship.

Q: How is power changing in our world?

[Dr. Moisés Naím] The definition of power has not changed, but the ability of those who have it to retain it, and the ability of those who want it to acquire it has changed. The common wisdom says that these changes have mostly occurred due to the Internet; personally, I question that. I don’t doubt that technology has an important role, but I believe that role is far less defining.

The barriers to entry that have previously defended the incumbents are getting significantly less protective. The forces that are weakening those barriers are many, manifold and diverse- but I group them in three large categories. The ‘more’ revolution, the ‘mobility’ revolution, and the ‘mentality’ revolution.

The ‘more’ revolution tries to capture the fact that ours is an age of profusion. There are more people, countries, cities, political parties and armies. There are more goods and services, and more companies selling them. There are more students, and more terrorists, more preachers and more criminals, more medicines and more food. The world’s economic output has increased five-fold since 1950, income per capita is 3.5x greater than it was then. There are also two billion more people than just two decades ago. By 2050, the world’s population will be 4x larger than a century before. The ‘more’ revolution has progressed in the face of terrorism, repression, earthquakes, economic recession, repression, civil wars and environmental threats. It’s much easier to wield power into smaller and less-educated, less nourished, populations than to apply it to larger- better educated- and better informed peoples.

The ‘mobility’ revolution looks at the fact that not only do we have more of everything, but… we move more. Products, goods, services, ideas, criminal entities, terrorist enterprises, religions, political parties, universities, companies… they are all moving more. Borders are no longer the limits in which activities take place, everything is going global. Power needs a captive audience, and given the erosion of distance- and the lower costs of communication, coordination, transportation and interaction- the ‘mobility’ revolution has an impact on weakening historically strong barriers. Here; the Internet and communications revolution play a part, but they are just one factor.

The ‘mentality’ revolution is important. We live in a world where the aspirations, expectations, assumptions and values of populations change. People no longer stay in the religion of their fathers or forefathers, ideologies are no longer stable, and traditional sources of power such as the assertion that, ‘you do this because it’s always been done this way…’ no longer hold water. The traditional psychological forces have weakened, and people are more willing to question authority and less willing to tolerate the behaviours and obligations that were expected of them in the past.

The ‘more’ revolution overwhelmed the barriers that protect the powerful, the ‘mobility’ revolution helped people circumvent those barriers and the ‘mentality’ revolution undermines the barriers themselves. Together these forces interact to create a situation where power is easier to acquire, harder to maintain and easier to lose.

Q: How will our notions of leadership and diplomacy change in the future?

[Admiral Stavridis] My hope is that the future will see more of what I have coined 'Open Source Security.' Over time, the answer is collaboration. At the moment, collaboration is primitive; it's NATO, alliances, coalitions such as those we have in Afghanistan and loose partnerships. Over time, this idea of global citizenship and collaboration will lead us to a very different kind of governance construct; the trends are already pointing in this direction.

Asserting control by letting-go may sound paradoxical, but societies that try to exert enormous levels of control will create bodies that will blow them apart. Nations that embrace the idea of open-source diplomacy, collaboration and sublimation of nationalism to larger ideas and causes will be the nations that have a better chance at attaining and maintaining the loyalty of their citizenry.

China is a prime example of a nation that has a better chance of succeeding by easing back on the throttle of control. Whether they do that or not remains to be seen!

Q: Do citizens understand the influence of power in their lives?

[Dr. Moisés Naím] Increasingly, broader populations are aware of the impact power plays in their lives. There is so much to applaud in the trends we are seeing. This is a world with more opportunity, and where those who have been excluded and disempowered can shape their own futures and change their conditions. This is a world where authoritarians have a hard time holding onto power, and where those who want to create a political movement, a company, an religion or NGO; have a chance to do so.

I’m not saying that power concentrations exist. There are countries, companies and individuals who continue to possess immense owner. From Vladimir Putin to the Head of Goldman Sachs, and from the Editor of the New York Times to the head of Google and even China’s leader or Pope FrancisThe Vatican, Pentagon, Kremlin and even Mountain View (the headquarters of Google) are all immense centres of global power. All of these centres do- however- have a harder time wielding and retaining their power. Their ability to perpetuate power is significantly less than the past.

[Admiral Stavridis] The vast majority of our citizens enjoy their lives, face the challenges of the world, struggle or are entertained by what happens, are occasionally threatened by it or- if they're unfortunate to live somewhere like Syria, they will feel it very extremely and tragically. Most people however, do not spend time focussed on these larger questions. 

Leadership matters. In a democracy, we select somebody to worry about the big problems for us. We criticise them, support them and maybe tire of them and throw them out of office.

We- as a people- do not spend an inordinate amount of time worrying about big problems, we outsource that to our leaders and use tools to shape the outcomes for our country. Democracy has a better chance overall of being the long-term solution, it creates a safety-valve. If you don't have democracy, if you don't elect a leader and 'put some of your skin in the game...' the pressures build up, and this is what we're seeing in China right now. People there do not have a say in the election of their leaders, and while they were content when growth was in double-digits... when that growth slows and leaves debt overhangs, environmental damage, inequality and corruption- they are found without a safety valve. This can play out very broadly in a society where there is no buy-in with a system like democracy. While the Chinese may argue the counter and say that democracy is messy and cannot be used to make decisions; I would point them to Winston Churchill who said, "Democracy is the worst system of government, except for everything else...."

Power is more diffuse in democracy, and that allows those at the centre to let-go a little bit and allow power to be more equally shared through the population.

Q: What is the power of the illicit economy?

[Dr. Moisés Naím] I was previously the Editor in Chief of Foreign Policy Magazine. The remit of this publication is to understand the consequences of globalisation, and to detect the unintended consequences and surprises from the new ways in which the world is connected. That role led me to discover that international traffickers of money, people, drugs, weapons, human organs, counterfeits and so-on are at the frontiers of globalisation. These transnational networks are faster and more effective than anyone else in detecting and exploiting the new opportunities created by globalisation.

There are significant asymmetries faced by traditional Weberian bureaucracies when they have to confront and compete with decentralised fast-moving networks. Governments therefore face huge challenges (which they often lose) when tackling these transnational criminal networks. Interestingly however, the same challenges to power faced by governments, and other institutions, are also faced by transnational criminal networks. If you look at the traditional Russian mafias, the Yakuza, the Columbian drug-traffickers… there’s no doubt they still wield power. There is no doubt that huge drug cartels exist in Mexico, and it’s common knowledge that Russia is deeply penetrated by organised crime and that China and Japan, criminal organisations hold significant sway. If- however- you look in detail at who they are, how they work, and their challenges- you discover that they are also part of the story… They have more contestants, more challenges and the barriers that gave them power are no longer as protected as they used to be.

Q: Will the changes occurring in power impact our notions of sovereignty and identity?

[Dr. Moisés Naím] Just look back at the Summer of 2014, you see there is weakness everywhere. Analysis has shown that even Putin who is looking like Russia’s new Tsar- who has an ability to grab territory across borders and impose views- is experiencing weakness at home. He is using nationalistic land-grabbing and expansionary 19th century tactics to boost popularity at home. He is succeeding, but just in the short term- he has brought sanctions against an already frail economy. He hated NATO- it was one of his most despised institutions and was (frankly) on its way towards irrelevance. Thanks to Putin’s moves in Crimea and Ukraine, NATO has a second lease of life and Putin has therefore revived his mortal enemy. He has created a more-unified set of alliances against Russia. This is a clear example of how power is changing political sovereignty; we also in this sense see the impact Islamic State is having in challenging the US government to re-enter conflict in Iraq and elsewhere in the region. 

Many have argued that technologies have created virtual environments capable of challenging the notion of statehood, but I am not in this camp. I do not believe the nation state will be in decline within the next 100 years. We will have states that must create new ways of relating to their citizens, new political institutions and changed interactions with the real and virtual economies. There are many challenges ahead, and many sovereignty eroding forces at work such as the creation of Bitcoin- the first time that the creation of money is delinked from central banks… and onwards to communication structures and even criminal and terrorist networks. The state is being pulled in all kinds of directions. Trends like decentralisation and fragmentation are very real in this regard; we are speaking today in the week that Scotland is voting for independence. Regardless of the outcome, this shows that power is eroding. Nation states are also pulled by supranational forces- that can guide them in many other directions. Unfortunately however, most states are unable to respond to these challenges- as governing structures are stagnating in terms of ideas, organisation and ways of operating.

Q: What are the opportunities created by changes in global power?

[Dr. Moisés Naím] Depending on the sector and country you’re in, the changes of power have created differing effects. For many people and many countries, it has created fantastic new opportunities for participation, economic growth and social creation, dynamism and more. In politics however, we have seen extreme polarisation, fragmentation and paralysis and gridlock. 

We live in a world of innovation. For our waking hours, and even when we’re sleeping, our lives are touched every day by innovations of the past 20 years. Innovation has transformed our lives in almost every aspect- aside from how we govern. In government, politics and governance- innovation is stagnant- especially in political parties. We need to bring the spirit of innovation, disruption and empowerment into government and political parties.

Q: What will be the shape of our geopolitical landscape over the next quarter century?

[Dr. Moisés Naím] 25 years is a very short time in geopolitics. I do however think that China will have overtaken the USA in terms of GDP; but China will also exhibit deeper frailties and will be rocked by social and political upheaval in more ways than we have ever seen before. If you ranked countries in terms of where the more, mobility and mentality revolutions are happening in greatest effect? I will bet you that China is at the top of the list. This will have important consequences for the rest of the world. I feel will also see a Russia that will be beset by economic problems, and perhaps greater political frictions. 

The two most powerful forces that will reconfigure the world over the next quarter century will be the energy revolution taking place in the United States and elsewhere. We are looking at an incipient new world energy order. The Summer of 2014 witnessed plummeting oil prices at a time when- historically- oil prices ought to have been soaring. Conflicts in the Middle-East, Russia, Ukraine and many other factors should have lifted oil prices and made them skyrocket. Instead of this, oil prices came down. This is because the United States is now the world’s largest producer of oil. July 2014 saw global production of oil reach the highest figure since 1987. We are looking at an incipient new global order where the key players in Carbon Energy may not be the usual suspects. The United States now produces more oil than Saudi Arabia and Russia for example. Just imagine a world over the next 25 years where oil- instead of being U$100 per barrel is in the band of U$80-70. That changes geopolitics and country interactions in profound ways. The other powerful reshaping force is climate change- which is giving us climate accidents, extreme weather and severe, often catastrophic, changes to our human environment.


Understanding power requires the same philosophical rigour we apply to the question of free will. The author Sam Harris notes that, "The question of free will touches nearly everything we care about. Morality, law, politics, religion, public policy, intimate relationships, feelings of guilt and personal accomplishment - most of what is distinctly human about our lives seems to depend upon our viewing one another as autonomous persons, capable of free choice. If the scientific community were to declare free will an illusion, it would precipitate a culture war far more belligerent than the one that has been waged on the subject of evolution. without free will, sinners and criminals would be nothing more than poorly calibrated clockwork, and any conception of justice that emphasized punishing them (rather than deterring, rehabilitating, or merely containing them) would appear utterly incongruous. And those of us who work hard and follow the rules would not 'deserve' our success in any deep sense. It is not an accident that most people find these conclusions abhorrent. The stakes are high..." (Sam Harris, Free Will, 2012)

If we consider power through the lens of free will, we quickly start to understand its relative shape and form. On the (fair) assumption that we (as humans) are beings of (relatively) free will, we can see power in abstract as being the perimeter of the environment in which that will is allowed to exercise; or- to put it another way, power defines the boundaries in which we are allowed to be free.

For those wielding the power however, Newton's second law (from his work Philosophiæ Naturalis Principia Mathematica) is more relevant. Here, Newton states that F=ma where F is the vector sum of forces on an object, m is the mass of the object, and a is the acceleration of the object. Power, when applied in a sociological sense follows a similar structure whereby the amount of power exerted by an idea or ideology (F) is directly equal to the gravitas of those who support it (m) multiplied by the pace at which it is accepted (a). One need only look to the Arab spring as proof of this where a hugely influential public movement (m) spread the idea of freedom incredibly quickly through the population (a) and as a result had the power (F) to topple governments.

Ultimately we need to cease referring to power as being a phenomena that exists outside us, akin to the weather. Power is a human phenomena; it is the manifestation of our collective will, and a reflection of who we (as a society) want to be; and that's profoundly impactful.

"All the forces in the world are not so powerful as an idea whose time has come" - Victor Hugo

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