Synopsis: This paper examines the World Health Organization’s efforts to advance global mental health through its Constitution and Comprehensive Mental Health Action Plan for 2013-2030. While the WHO has established mental health as a fundamental human right and created an action plan for member states, the research identifies significant implementation challenges that hinder progress toward the organization’s goals.
Abstract
This paper explores the World Health Organization’s (WHO) role in promoting mental health and accessible mental health resources worldwide. The WHO is a United Nations (UN) agency that leads the UN’s efforts in promoting and improving health, including mental health, internationally. Various international materials will be explored, including the WHO’s Constitution and Comprehensive Mental Health Action Plan for 2013-2030 (CMAP30) to determine where it falls short of making substantial progress toward its goals and how the WHO could improve the plan. Although the WHO has identified mental health as a fundamental human right and has implemented an action plan to facilitate the improvement and protection of mental health in member states, implementing new mental health policies and infrastructure is a massive undertaking for states, some of which fail to follow the action plan and thus contribute to insufficient advances toward the WHO’s goals. Mental health is not at the forefront of member states’ legislation, and the variety in development of each state, as well as limitations on resources, contribute to a roadblock to which a one-size-fits-all approach cannot be efficaciously implemented.
This paper will address a gap in scholarly research by going beyond a simple analysis of the WHO’s currently-implemented plan for improving mental health and instead suggest an alternative approach. This paper argues that the WHO’s approach to addressing worldwide mental health is too broad and that a more individualized approach needs to be developed so that member states’ needs can be considered. Additionally, this paper argues that the CMAP30 is tainted by western bias and a decolonization approach must be taken to improve its effectiveness. While recognition of mental health as a human right has grown, the efforts made by the WHO have not been effective due to the limitation of member state resources and the gap in the abilities of states to implement required policy changes. More effective efforts can be made to implement mental health improvement efforts by decolonizing global mental health law, considering the resources and concept of mental health in member states, applying international agreements in a way that distributes obligations based on such considerations, and adjusting action plan objectives to guide states toward meeting compliance objectives.
I. Introduction
In the United States, mental health has become increasingly present in the national consciousness, with 76% of Americans believing that mental health is equally as important as physical health.[1] A typical example treatment can be seen in the case of an unnamed adolescent patient diagnosed with major depressive disorder (MDD).[2] The patient, a 15-year-old Puerto Rican adolescent girl, presented symptoms that included frequent reports of sadness, increased appetite, anxiety, hopelessness, difficulty concentrating, interpersonal difficulties, persistent negative thoughts about herself, and guilt regarding her parents’ marital problems.[3] Using the Diagnostic Interview Schedule for Children (DISC-IV), the patient was diagnosed with MDD and provided with cognitive behavioral therapy (CBT), an individualized problem-oriented treatment focusing on working through and finding solutions for current problems; additionally, the plan extended the typically 12-week treatment to 16 weeks.[4] By the end of the patient’s treatment, she reported an improvement in self-concept, dysfunctional attitudes, and suicidal ideation.[5] This positive trend continued at both her 6- and 12-month follow-up assessments.[6] This case is but one example of an individualized western approach to mental health. Compare this U.S. case with one from a non-western culture. In Ethiopia, only 33.4% of people with MDD had sought treatment from government health services in the preceding three months.[7] Because of the limited availability of resources and a greater emphasis placed on a tight-knit relationships, the majority of mental health treatment in traditional African societies is provided by the patient’s family and community.[8] Additionally, a cross-cultural analysis shows that of the sample populations of patients seeking treatment from traditional healers in rural Pakistan, Uganda, Kenya, and Tanzania, 61%, 60.2%, 64.3%, and 49%, respectively, had a mental health diagnosis.[9] In this sense, traditional healers are influenced by the indigenous religion of the region and diagnosis and treatment are derived from personal and social circumstances, indigenous beliefs, and cultural interpretations of the disorder.[10] Thus, even though traditional healers provide much of the same services, diagnosis and treatment can vary between healers and cultures.[11] In this sense, the western idea of mental health does not translate to the diagnosis and treatment of the same disorders in non-western states.
Unfortunately, just as some states do not see mental health with the same perspective as western states, many states also simply lack the necessary resources for the proper treatment of mental health. Consider, for example, the teenage girl mentioned above. Had she sought treatment in a low- or middle-income country (LMIC), her treatment may have looked much different. The World Bank is an international organization that lends money to member states to improve their economies, the standard of living of their people, and reduce poverty.[12] The World Bank divides states into four categories based on their gross national income per capita: low- countries (LICs) at $1,135 or less, lower middle-income countries at $1,136—4,465, upper middle-income countries at $4,466—$13,845, and high-income countries (HICs) at $13,846 or more.[13] The teenage girl seeking treatment would likely not have received treatment, as only 7—21% of patients with a depressive disorder receive treatment in LMICs.[14] In fact, approximately 75% of those with mental health disorders who live in LMICs, such as Afghanistan, Haiti, India, and Kenya, receive no treatment at all and must simply live with their disability.[15] For example, in Malawi, which has a population of 20 million, only four psychiatrists could be found, a ratio of one psychiatrist per 5,000,000 people.[16] To put that in perspective, the US has an average of 16.6 psychiatrists per 100,000 people, or 830 psychiatrists per 5,000,000 people, compared to Malawi’s single psychiatrist for the same population.[17] Even if the teenage girl had received treatment in a LMIC, it would most likely have only included pharmacological intervention rather than psychotherapies such as CBD.[18] This reflects the fact that most psychotherapies have been developed in HICs located in North America, Europe, and Australia, further cementing the western lens through which mental health treatment is approached.[19] The fact that the U.S. has a higher ratio of psychiatrists to the population and contributed to the development of psychotherapies does not make it the perfect model state for mental health treatment. The U.S. has many of its own issues with mental health infrastructure, but its position as a HIC and the fact that mental health is generally approached from a western bias allows the U.S. to provide an easy comparison for mental health resources in other states. This stark difference in approaches to mental health shows that while recognition of the need for mental health treatment has grown, a global standard has yet to be developed.
One may ask why mental health even matters when there are numerous other causes around the world that require intervention, such as combating AIDS, regulating big data, and preventing climate change. The fact is that mental health falls under the banner of noncommunicable diseases (NCDs), a classification of diseases that result from genetic, physiological, environmental, and behavioral factors, and account for the highest proportion of global disease.[20] In addition, mental, neurological, and substance use disorders account for 10% of global disease, and over 13% of deaths in 2019 were attributed to suicide.[21] For adolescents, depression, anxiety, and conduct disorders are one of the leading causes of illness and disability.[22] The World Health Organization (WHO) claims that there is “no health without mental health.”[23] That is, mental health is an important part of one’s overall health, which is defined as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”[24] Mental health can be affected by an individual’s psychological and physical attributes as well as social, cultural, economic, and other environmental factors.[25] This relationship is reciprocal as well, and physical health can be affected by an individual’s mental health. Mental disorders often affect, and are affected by, other diseases, a phenomenon known as comorbidity.[26] Because of this, mental disorders often require treatment when providing services for reasons other than mental health.[27] The term “mental disorder” encompasses both mental and behavioral disorders within the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10).[28] Such disorders cause a high burden of disease and include MDD, bipolar disorder, schizophrenia, anxiety disorders, dementia, substance use disorders (SUDs), intellectual disability disorders (IDDs), and developmental and behavioral disorders.[29]
Mental health also matters because it disproportionately affects vulnerable populations. Good mental health means a state of well-being where an individual can successfully cope with normal life stressors and work productively to contribute to society.[30] Vulnerable groups also include certain groups who are at a higher risk of experiencing mental health issues and may vary from state to state.[31] These include, but are not limited to, those living in poverty, neglected children, adolescents exposed to substance use, minority groups, those who have experienced discrimination or human rights violations, and members of the LGBTQ+ community.[32] Because exposure to adversity at a young age is a preventable risk factor for mental disorders, when in the context of children, extra emphasis is placed on the developmental aspects of mental health.[33] The ease at which children can develop mental disorders categorizes them as a vulnerable group, and such groups must be protected if the development of a disorder is preventable.
Finally, mental health must be protected because it is a human right.[34] The WHO has implemented multiple calls to action for the improvement of mental health, including in its own constitution, but the most recent, and subject of analysis here, is the Comprehensive Mental Health Action Plan 2013-2030 (CMAP30).[35] However, progress under this plan has been slow and insubstantial. This paper will analyze the WHO’s Constitution, which is the founding document for the WHO that states its goals and powers, and the CMAP30, which is currently the WHO’s foremost effort at improving global mental health. This paper argues that the WHO’s approach is too narrow to broadly apply to many states, and its concept of global mental health contains an inherent western bias that must be overcome for global mental health to see true improvement. This paper fills a research gap because while many other scholars address similar topics by analyzing why the CMAP30 has not shown significant progress toward its goals, this paper will instead suggest an alternative approach. Section II. begins by exploring who the WHO is, including the reason for its founding and what its goals are. Section III. discusses the WHO’s past efforts to address global mental health. Section IV. analyzes the WHO’s current efforts through the CMAP30 and why the CMAP30 has not seen significant results. Section V. discusses the current state of global mental health under the CMAP30. Section VI. explores the common but differentiated responsibility technique (CBDR), a tool used in environmental agreements that has proven to be effective in driving global change, as well as the Montreal Protocol on Substances that Deplete the Ozone Layer (the Montreal Protocol), an extremely successful international agreement that may be used as a model for improving global mental health. Section VII. proposes decolonial theory as an approach that must be taken when addressing global mental health. Finally, Section VIII. applies CBDR, the Montreal Protocol, and decolonial theory to the shortfalls of the CMAP30 to suggest how the WHO could restructure the CMAP30 to more effectively improve global mental health.
II. Background of the WHO
Though the effects of poor mental health are widespread, there is still a wide gap in the worldwide provision and promotion of mental health treatment as well as a lack of significant action by policymakers to bridge this gap. Only 29% of people with psychosis, one third of people with depression, and less than one fifth of people with substance use disorders have received adequate treatment globally, if at all.[36] To resolve this gap, the United Nations (UN) has been working to improve global mental health. Specifically, the UN Charter states that the UN shall promote a higher standard of living; solutions to health-related problems; and universal respect for human rights for all; and to that end, the UN may establish specialized agencies in health.[37] The UN addresses many health-related matters through the General Assembly and the Economic and Security Council, but the leading specialized agency for health is the WHO.[38]
The WHO is composed of three main branches: the Secretariat, member states, and the World Health Assembly.[39] The Secretariat is made up of experts, staff, and field workers who collaborate in the WHO’s headquarters in Geneva, six regional offices, and other stations located in over 150 other states.[40] Member states include 194 states who work with and are advised by the WHO to reach global health goals.[41] The World Health Assembly is the highest decision-making forum in the WHO where delegates from member states meet annually to set the priorities and outline the steps to achieve the WHO’s goals.[42] In addition, the WHO is helmed by the Director-General, who is elected by the member states and who leads the WHO in achieving its goals.[43]
Established in 1948 by the UN, the WHO’s initial priorities included malaria, women’s and children’s health, tuberculosis, venereal disease, nutrition, and environmental pollution.[44] While these priorities generally still remain at the top of the WHO’s docket today, the WHO also continues to address emerging health issues, such as HIV/AIDS, diabetes, cancer, severe acute respiratory syndrome (SARS), Ebola virus, zika virus, and, most recently, the Coronavirus (COVID-19) pandemic.[45] In the decades since its creation, the WHO has been at the forefront of many campaigns against global health issues. The same year it was created, the WHO established the International Classification of Diseases, which is now the international standard for defining and reporting on health conditions.[46] Other contributions to global health by the WHO include advising states on the use of antibiotics beginning in 1950; successfully eradicating smallpox in 1979; nearly eradicating polio beginning in 1988; reducing the prevalence of tuberculosis (TB) beginning in 1995; significantly reducing child mortality rates by 2006; and treating the 2014 Ebola outbreak in West Africa so that by 2016, no new cases were found.[47]
The WHO’s objective is for all people to obtain the highest possible level of health.[48] The WHO’s functions include acting as the leading authority in the field of international health, aiding state governments in strengthening health services, working to eradicate diseases, proposing agreements and making recommendations on international health matters, conducting research in health and medicine, promoting improved health standards, providing information to states and the public, and standardizing diagnostic procedures.[49] The WHO promotes health through its core principles, including: (1) “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being;” (2) “the achievement of any state in the . . . protection of health is of value to all;” (3) “the extension to all of the benefits of . . . psychological . . . knowledge is essential;” (4) the “informed opinion and active cooperation . . . of the public are of the utmost importance in the improvement of health;” and (5) the “governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.”[50] One of the WHO’s specific goals is to improve mental health by strengthening governance; providing community-based care; implementing promotion and prevention strategies; and strengthening information systems, evidence, and research.[51] To achieve this goal, the WHO employs cross-disciplinary specialists nearly worldwide. The WHO is staffed by medical doctors, public health specialists, scientists, and epidemiologists in 149 states who advise ministers of health and aid in the prevention and treatment of diseases.[52] The WHO is also key in developing international health regulations used by states to identify, prevent, and stop the spread of diseases.[53]
III. The WHO’s Comprehensive Mental Health Action Plan 2013-2030
From its inception, fostering activities in mental health has been included in the functions of the WHO.[54] Because the WHO has determined that there is “no health without mental health,” the WHO has been taking increasing steps to improve global mental health.[55] In the following subsection, this paper will review how the WHO has addressed mental health. This paper will then analyze why the WHO’s CMAP30 is not meeting its goals as expected.
A. The WHO’s Efforts to Address Global Mental Health
While the main focus of this paper is to address the CMAP30, the predecessors to this plan must also be discussed to give it a proper frame. The WHO has identified the need for the accelerated implementation of a plan for mental health due to decades of inattention to and underdevelopment of mental health services as well as human rights abuses and discrimination against people with mental disorders.[56] At the urging of its member states, the WHO has maintained upholding mental health as one of its functions since its inception.[57] However, it was not until 2001 when the WHO began taking public action to promote positive mental health by dedicating its annual report to the subject.[58] The areas covered by that report included the effectiveness of prevention and treatment, service planning and provision, policies to fight stigma and discrimination, and funds for prevention and treatment.[59] The WHO did not establish a program to address global mental health until 2008 with the Mental Health Gap Action Programme (mhGAP), aimed at improving mental health services in LMICs and reducing the gap in treatment between those who need mental health services and those who actually receive them.[60] The mhGAP operated on the claim that if the proper care, psychological treatment, and medication are provided, tens of millions could be treated for depression, schizophrenia, and epilepsy and prevented from attempting or completing suicide, even in areas where mental health resources are severely limited.[61] A four-year analysis of the program gave positive results, indicating that better community awareness allowed 91% of those in the surveyed area to recognize symptoms of mental, neurological, and substance use disorders (MNSs), 67% of those with mental health concerns sought treatment, workers trained in mhGAP regularly implemented it, and providers reported increased mental well-being in the population.[62] With this program, the WHO took its first major step in implementing a program for the improvement of global mental health and showed that aspirational goals were not too high to strive for. This program gave the WHO a foundation on which it would build the CMAP30 in the future.
Due to their complexity, rather than treating the underlying cause with traditional medicine (i.e., taking an antihistamine for allergies or nonsteroidal anti-inflammatory drug (NSAID) for pain), approaches to mental health typically focus on reducing relevant risk factors.[63] In addition, mental health treatment must utilize comprehensive strategies to address such a wide range of factors, and a successful plan must use a whole-of-government approach.[64] A whole-of-government approach is the coordination of government activity across all branches and levels of a government, whereby all parties cooperate on improving policy, efficiently utilizing resources, promoting synergies between the branches, and providing seamless service delivery to its citizens.[65] With an understanding of the complexity of mental health problems and the type of program needed to address them, the WHO at the Sixty-Fifth World Health Assembly in 2012. There, the WHO adopted resolution WHA65,4, which acknowledged the global burden of mental disorders and the need for a comprehensive response at the state level.[66] The WHO analyzed other global-action plans endorsed by the Health Assembly as well as regional mental health action plans and the mhGAP to create a global-action plan that could provide national guidance and address risk factors, promotion, and prevention strategies.[67] After completing this analysis, the WHO developed the Comprehensive Mental Health Action Plan 2013-2020 (CMAP20).[68] All WHO member states are committed to implement the CMAP20, which aims to improve mental health by strengthening governance; providing community-based care; implementing promotion and prevention strategies; and strengthening information systems, evidence and research.[69]
The CMAP20’s vision was to create a world that values, promotes, and protects mental health; where mental disorders are prevented; and where those affected by mental disorders may exercise all human rights and access appropriate mental health care.[70] The goal of the CMAP20 was to “promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights and reduce the mortality, morbidity, and disability for persons with mental disorders.”[71] The CMAP20 identified four objectives: (1) strengthening governance for mental health; (2) providing comprehensive mental health services in community-based settings; (3) implementing strategies for promotion and prevention in mental health; and (4) strengthening information systems, evidence, and research for mental health.[72] The CMAP20 utilizes a cross-section of approaches that includes universal health coverage, human rights, evidence-based practice, a life course approach, a multisectoral approach, and the empowerment of persons with mental disorders, and requires member states to implement it at the regional level and integrated into their national priorities.[73] The WHO measured overall progress toward the CMAP20’s goals by recording what percentage of states have implemented each objective and comparing that against a predetermined goal percentage.[74]
As of the WHO’s 2020 assessment of the CMAP20, the WHO determined that gaps in governance, resources, services, information, and technologies persisted in world mental health systems.[75] This observation prompted the WHO to readdress the comprehensive action plan and built on it. The result was the CMAP30, which revised the indicators, options for implementation, and global targets of the CMAP20 while maintaining the same emphasis on a life-course approach and actions to promote mental health and achieve universal coverage for mental health services.[76] The vision and goal of the CMAP30 remain unchanged from the CMAP20.[77] Objective 1 has been updated to increase the target percentage of states that have updated their laws for mental health.[78] The CMAP30 expanded objective 2 by increasing the target percentage of states that increased service coverage for severe mental disorders and adding new subobjectives for states to double the number of community-based mental health facilities and integrate mental health into primary healthcare.[79] The CMAP30 expanded objective 3 by increasing the target reduction rate of suicide as well as adding a new subobjective of a target percentage of states having a system in place for mental health preparedness in case of emergencies or disasters.[80] Finally, the CMAP30 expanded objective 4 by adding a new subobjective of doubling the output of global research on mental health.[81] The WHO further urges every state to accelerate the implementation of the CMAP30 by deepening the value given to mental health, prioritizing mental health promotion and prevention, and developing networks of community-based services.[82] Aside from the obvious extension of the deadline to meet these objectives from 2020 to 2030, much of the rest of the CMAP30 remains unchanged from the CMAP20.
The plan acknowledges that mental-health systems are especially underdeveloped in LMICs.[83] Organizations of people with mental disorders are present in 49% of LICs whereas they are present in 83% of HICs.[84] A trend that is not limited to LMICs is that basic medicines for mental disorders are in low supply globally when compared to medicines available for infectious diseases, and the medicines that are available are often restricted in their use due to a lack of qualified workers who can distribute them.[85] Finally, treatments for mental disorders that do not rely on medications are offered on a limited basis.[86] Because these factors are significant barriers, the CMAP30 acknowledges that providing information and tools is not enough and calls on states to change national mental-health law and policy, reorganize service and expand coverage, development and implement national strategies for suicide prevention, and integrate mental health into the routine health-information system.[87]
B. Why the WHO’s Action Plan Is Not Seeing Significant Results
Since the WHO began working to improve global mental health, many technical advances in the field have been made.[88] Fueled by continuing research, universal interest in and understanding of mental health has increased.[89] Why, then, does the latest analysis by the WHO show that overall state progress under the plan has been slow?[90] Among other indicators of substantial progress, the WHO found that less than 5% of mental health research funding goes to LMICs; only 21% of states have implemented policies that comply with the WHO’s directions; many LMICs continue to lack essential medications, an adequate mental healthcare workforce, and internet access; and 71% of people with psychosis do not receive mental health services.[91] Across nearly all indicators for global progress in mental health, a significant gap continues to exist between the abilities of HICs and LMICs to comply with the CMAP30, and this inherent issue prevents the WHO from meeting the objectives outlined in the CMAP30.
The requirement by the CMAP30 of action by all state governments to effectively implement the plan is a key factor in its downfall.[92] Responses to the plan are expected to be stronger and more effective when mental-health interventions are integrated into a state’s health policy.[93] One reason is that many mental-health systems continue to remain ill-equipped to adequately address the mental health needs of their people, so the state maintains its trajectory without implementation of the plan.[94] Some health systems, especially those in LMICs, have not yet adequately responded to the burden imposed by mental disorders.[95] As a result, their implementation of the improvements called for by the Plan are more difficult when there is no existing policy to use as a foundation.[96] While 92% HICs have enacted mental health legislation, only 36% of LMICs have done the same.[97] The lack of resources for mental-health treatment options for mental disorders as well as the poor quality of care in LMICs further adds to this difficulty.[98] Because the plan seeks global improvement in mental health and mental disorders, little or no improvement across LMICs can hinder that effort. Of 217 member economies of the World Bank, 86 are high income, 105 are middle income, and 26 are low income.[99] This means that HICs make up less than 40% of the world economies, and any inequality that negatively affects LMICs will more significantly affect global change. Under the CMAP30, progress is generally measured by calculating how many states have complied with the requirements of each subobjective without differentiating between the ability of the state to even do so. Because HICs have more resources to implement the required changes and LMICs often lack such resources, the CMAP30 is unfairly favoring HICs over LMICs. Between 76-85% of people with mental disorders in LMICs receive no treatment, compared to 35-50% of those in HICs.[100] Consider the average annual spending on mental health to better highlight this difference. Globally, the average is less than $2.00 USD per person, but this number is reduced to $0.25 USD per person in LICs.[101] On average, this constitutes less than 2% of any given state’s healthcare budget that is spent on mental health.[102] In addition, the number of mental-health workers in LMICs is severely insufficient, especially when considering that half of the world’s population lives in LMICs.[103]
The CMAP30 also implies a call for change by individuals as well to reduce the stigmatization of and discrimination against those with mental disorders.[104] Most societies and their health systems neglect mental health and fail to provide adequate care to those affected, causing millions to suffer alone.[105] Stigmatization and discrimination based on mental health continue to permeate, creating a downward spiral where one experiences a mental disorder but does not seek help, causing the disorder to get worse.[106] To achieve the goals of the CMAP30, humanity as a whole must change its attitude toward mental health to better promote mental well-being and provide adequate care to those affected.[107] Another compounding condition that could in no way have been predicted or prevented by states was the COVID-19 pandemic. Rates of conditions that were already fairly common, such as MDD and anxiety disorders, increased by over 25% worldwide in the first year of the pandemic alone.[108] Finally, the plan is too general and is framed as a blueprint for states to use, and the WHO leaves it up to each state to decide where to focus its efforts to meet the objectives of the plan.[109]
In 2020, the WHO analyzed the progress that member states have made under the plan. The WHO found that the identified targets had not yet been met and that the rate of progress for all targets except the suicide rate have not been satisfactory.[110] Even though member states made progress toward adopting policies and laws regarding mental-health, significant inequalities persist in the availability of mental health resources between LICs and HICs.[111] The WHO also found gaps between policies being in place and the actual allocation of resources as well as in integration into primary healthcare and a lack of states’ abilities to report on some mental-health system indicators.[112] The WHO believed at the time of the 2020 analysis that the plan’s targets can still be met by 2030 but noted that a “collective global commitment . . . to make massive investments and expand efforts at the state level relating to mental health policies, laws, [programs], and services” will be required to do so.[113]
IV. Analysis of Global Mental Health Under the WHO’s CMAP30
Challenges to mental-health improvement come down to two root causes. First, mental health is overlooked as a true issue.[114] Despite mental health being important to overall well-being, law has historically left it under-addressed.[115] For example, even though numerous international treaties have identified mental health as a human right since the 1960s, 25% of states still have no regulation for it.[116] In addition, the regulation for mental health in 15% of states was passed before 1960 and before most modern treatments were available.[117] The fact that many mental health regulations were passed six decades ago and some states still lack such regulation is often due to the fact that mental health is simply not attributed with the same importance as physical health, causing it to be generally ignored by policymakers.[118] While an increasing number of states have reported improvements in policy, states which report no change in their policies represent the largest body of member states.[119]
The second cause is that mental health is overshadowed by stigma and prejudice.[120] Regardless of the number of international instruments that discuss the rights of those with mental disorders, there continues to be evidence of the infringement of human rights for such people.[121] Additionally, those with disorders that can be easily treated with counseling or inexpensive medications are often misdiagnosed or go untreated altogether.[122] Misdiagnosis and lack of treatment is not a localized issue but can be seen globally, suggesting that simply identifying such rights on paper is not enough to overcome stigma and prejudice.[123] It has been argued that current instruments lay the foundation for addressing global mental health, but true change will not be seen until the way people see mental health changes, and any instrument implemented until that time is a practical failure due to the need to take further steps to meet necessary goals.[124]
However, there is a silver lining. Some states have reported that positive changes in policy are improving mental health outcomes.[125] These improved outcomes indicate that states that are prioritizing mental health by implementing policy changes and creating the necessary infrastructure are seeing positive results.[126] Awareness of mental health by the general public has also steadily been increasing as more advocates and activists continue pushing for change, so there is still hope for humanity to mold its global attitude toward mental health into a more beneficial form.[127] Just because the implementation of a solution is difficult does not mean a problem is unsolvable, just that there is not yet enough international resolve to tackle the problem.[128]
V. CBDR and the Montreal Protocol as Models for Change
The WHO has essentially been given a near-impossible task in that it must develop one single system to evaluate the mental health of all states.[129] While the WHO’s goal to give the highest standard of care for all persons is a noble one, the reality is that this goal is not immune to socioeconomic influences, both nationally and internationally.[130] The WHO’s current approach does not address mental health with a culturally-sensitive lens, but with a western bias that does not consider the fact that no psychological intervention can remedy unemployment, homelessness, hunger, or poverty.[131] The use of common but differentiated responsibility (CBDR), which is used in environmental agreements, is suggested for tackling global problems because it recognizes that though states may have a joint responsibility to act, the obligations of different states will vary based on each state’s circumstances.[132] Additionally, the variation in obligations should be determined mostly by the capabilities of a state to implement such change.[133]
Some variations in obligations that have been successful are a 10-year delay in compliance obligations for developing states and the provision of financial aid and technology transfer from developed states to developing states based on compliance with obligations.[134] This is readily seen in the Montreal Protocol on Substances That Deplete the Ozone Layer (the Montreal Protocol), a treaty that has been described by Former UN Secretary General Kofi Annan as “the single most successful international agreement to date.”[135] The success of the Montreal Protocol is attributed to it being clear with fixed targets, recognizing and accommodating the increased difficulty and cost for developing states to implement it, providing compliance monitoring mechanisms and sanctions for non-compliance where noncomplying states would encounter trade barriers, the addressed problem being immediate with serious consequences, and a low cost of implementation.[136]
Both the CBDR and the Montreal Protocol, when used together, can form the basis of an effective international agreement. The underlying theory of CBDR is that while states work toward a common goal through similar methods, their obligations should not be the same and should instead differ according to each state’s circumstances.[137] In the context of the CMAP30, implementing CBDR would allow the plan to assign different responsibilities to different states that are better able to handle them, rather than requiring the same steps of every state regardless of whether they actually have the resources to implement such changes. Additionally, what made the Montreal Protocol so successful may also be applied to a plan like the CMAP30. Specifically, the WHO should utilize techniques from the Montreal Protocol that include accommodate the fact that LMICs will have a more difficult time enacting change and implement benefits for compliance and sanctions for noncompliance.[138] A delayed time frame during which LMICs may comply, a reward of financial aid and technology transfer from HICs for compliance, and a sanction of reduced financial aid and technology transfer for noncompliance would be beneficial in any future iteration of the CMAP30.[139]
VI. Decolonial Theory
Before addressing how the CMAP30 can be improved, one final theory must be discussed to provide the proper framing of the model agreement: decolonial theory. The WHO’s approach to the CMAP30 has involved developing a one-size-fits-all action plan that was applicable to all states regardless of circumstances.[140] This approach suggests a western bias in which HICs, which are more readily able to implement such changes, are favored over LMICs, which struggle to meet the requirements of the CMAP30.[141] Instead, this approach that contains an inherent western bias must be decolonized.
Decolonization is the “process by which a colonial power divests itself of sovereignty over a colony so that the colony is granted autonomy and . . . attains independence.”[142] In the context of international agreements, especially those in which western states hold disproportionate power, decolonization theory requires agreements to shed this western bias by challenging Eurocentrism, disrupting intellectual routines, and repositioning oneself in the world and history.[143] In fact, “there is painfully little discussion about legal cultures outside of Europe.”[144] In doing so, those drafting such agreements are able to resist nationalizing and universalizing the agreements, instead allowing them to be flexible and consider the circumstances of nonwestern states.[145] Rather than treat all states as equal in all aspects, decolonialization embraces the disparateness of states as beneficial and relevant.[146] Maintaining colonialism is to suppress history and culture and to demand respect for a governing authority rather than consider the expression of those who are governed.[147] Decolonization also requires policymakers to utilize encultured interpretation, a technique by which expressions by nonwestern states are given meaning by the language, culture, and experiences of those people.[148] In the context of mental health, encultured interpretation means that global mental health cannot simply be approached with a western bias, but must be considered through the eyes of the people who will be affected. This makes policymakers uncomfortable because the meaning of such expressions is not black and white but are influenced by the experiences of the interpreter.[149] Only by collectively reshaping understanding what the law is, and only when the minority is allowed to participate equally in policymaking, can justice be had on an international level.[150]
Once international health law (IHL), including international mental health law, is decolonized, it can be classified as global health law (GHL). GHL is a set of instruments adopted by the WHO that interact with other branches of international law.[151] GHL differs from IHL because, while IHL is focused on health alone, GHL exists as only one branch of international law that interacts with the other branches.[152] Additionally, the term “international health law” was coined in relation to cross-border epidemic control, a system deeply rooted in colonialism.[153] Because IHL was more connected to the protection of home states from the diseases of “others,” moving past IHL to GHL signifies a concern for the health of all of humanity rather than just western states.[154] One key advantage is that because GHL is one part of a body of international law, it considers other factors and addresses local issues that may not be as prevalent in western states.[155] For example, the advanced development in HICs has shifted their concern away from infectious disease to focus more on NCDs thanks to the availability of clean water, sanitation services, and medical technologies, privileges that are not available in many LMICs that are still fighting infectious diseases.[156] Because HICs do not have to worry as much about infectious diseases, they have the liberty to focus on other issues, but it is unfair to expect LMICs to effectively adopt the same approach without possessing the same privileges and resources. When addressing a crisis such as global mental health, it is not enough to focus only on the crisis itself, but the biases that define what a crisis is must also be considered.[157] When infectious diseases are still so prevalent, NCDs do not meet the requirements of a public health emergency of international concern (PHEIC), and any action plans are thus nonbinding.[158] LMICs are still suffering from infectious diseases as well as NCDs, and in many cases, the issue of infectious diseases can create a cycle that worsens mental disorders.[159] As a result, if mental health is to be addressed globally, it must be considered in-context in LMICs rather than assuming that the idea of mental health in LMICs mirrors the same in HICs.
VII. How the WHO can Improve its Mental Health Action Plan
The WHO’s CMAP30 is a noble effort to address mental health on a global scale, but the umbrella approach that it takes to the varying concept of mental health between states is insufficient to meet its goals. A decolonized approach must be utilized if the WHO hopes to see any meaningful results. In effect, any mental health action plan cannot contain a western bias and differences in the abilities of member states to adopt and implement any policy changes must be considered and accounted for in the plan itself. To address this, the specific policymakers of the plan must be addressed, a CBDR approach modeled on the Montreal Protocol should be utilized, and the objectives and indicators of the CMAP30 must be reviewed.
To help eliminate western bias, the group of policymakers who draft the action plan cannot all be from HICs. Diversity in each member’s background will help break up any inherent bias when drafting the action plan. Therefore, some members may be from HICs, but a variety of LMICs must also be significantly represented. Because there are so many states that may have various needs and views, but a drafting committee can only be so big, delegates from each state should meet with a member of the drafting committee to provide insight on the action plan from their respective state and thus allow the drafting committee to factor each state’s needs in drafting the most widely-applicable, comprehensive plan possible.
The drafters do not need to start with a blank slate when drafting the action plan because an efficient plan can be created by draping the façade of the CMAP30 over the structure of the Montreal Protocol using a CBDR approach. Now that the drafting committee has input from each member state, a CBDR approach would allow the drafting committee to consider factors such as available resources and infrastructure when deciding what obligations each state should be assigned. Under a CBDR approach, member states would be grouped into categories based on the ease with which they will be able to implement the suggested changes for improving global mental health. For example, the requirements of HICs could look very similar to those of the CMAP30. Because of its inherent western bias, the CMAP30 was drafted primarily with HICs in mind, and the availability of resources in HICs makes them more likely to be able to implement policy changes as they are.
Some key features from the Montreal Protocol will also help the action plan excel. Because it will be more difficult for LMICs to implement the required policy changes than it will be for HICs, the deadlines for such changes to be enacted should be more lenient. The Montreal Protocol allowed for a 10-year delay for states that were parties to the agreement to become compliant with the agreement.[160] The CMAP20 was only a seven-year plan, but the CMAP30 extended the timeframe to 17 years. If benefits or sanctions were to be dependent on compliance with required policy changes, the deadline for member states to become compliant should be extended if a state is likely to encounter difficulty in enacting those changes. Alternatively, if one single deadline is to be established rather than deadlines based on states, that deadline should be the farthest out to provide the most accommodation to states that need it the most. Benefits and sanctions dependent on compliance with the action plan would act as positive and negative reinforcement for implementing such changes, respectively. Providing benefits such as financial aid and the transfer of technology to states who comply by the deadline is likely to encourage states to enact the required changes. Alternatively, withholding such benefits if states are not in compliance by the deadline is also likely to encourage states to make such changes by the deadline.
Finally, the CMAP30 can also be used as part of the foundation for a new action plan. The CMAP30’s vision of a world that values, promotes, and protects mental health, and its goal of promoting good mental health and preventing mental disorders are ideal and need not be changed.[161] In addition, the objectives of the CMAP30, strengthening leadership, providing community services, implementing promotion and prevention strategies, and strengthening information systems and research, are also ideal, but the details of these objectives is when the CMAP30 begins running into a western bias. Because these objectives require changes at the policy and infrastructure level, LMICs are going to be less likely to implement these objectives. Because of this, the objectives should be broken down into stepwise subobjectives that place member states on a scale based on the beginning compliance of mental health policy in the state and the ease at which the state can implement such changes. The pitfall that the CMAP30 falls into is that it identifies objectives and identifies what states should do to become compliant, but progress is not measurable. The action plan should utilize SMART goals, which are specific, measurable, attainable, relevant, and time-bound.[162] The objectives of the CMAP30 are specific, relevant, and time-bound, but there is no way to measure progress toward meeting the objectives. Additionally, because LMICs are unable to enact the necessary changes, the objectives are not attainable either. The action plan should have steps that, upon completion, move member states closer to compliance. Such steps should reflect the abilities of member states to meet the objectives and will give states some direction as to how to proceed if resources are limited and achieving the objective outright is not possible.
Ultimately, mental health is a matter that takes influence from multiple sources and the western concept of mental health cannot be effectively applied to nonwestern states. As a result, the action plan should be revised to allow more flexibility for states that are not able to come into compliance as easily as HICs are. If the drafting committee for an action plan includes delegates from varied backgrounds that include LMICs in the drafting of the action plan, decolonization and CBDR approaches are utilized, the Montreal Protocol is used as a foundation, and the objectives are revised to be SMART and allow more leniency for LMICs, an effective action plan can be created that will see more positive results than the CMAP30 has thus far.
VIII. Conclusion
As the leading authority regarding global health law, the WHO plays a major role in fostering good mental health worldwide. To do so, the WHO implemented the CMAP30 to encourage member states to enact policy changes to improve global mental health. However, due to a gap in the abilities of HICs and LMICs to implement such changes, a lack of available resources and sufficient infrastructure in LMICs, and an inherent western bias in the WHO’s interpretation of mental health and its associated treatment, progress toward meeting the CMAP30’s objectives has been slow, especially in LMICs. The result is that the umbrella approach that the CMAP30 utilizes is insufficient to adequately address the mental health needs of every member state and is instead drafted in a way that makes it easier for HICs to comply than LMICs. Instead of this broad approach, an action plan that can be individually applicable to each member state needs to be created. To achieve this, a decolonization approach must be utilized to properly consider the concept of mental health in each member state and the availability of resources and infrastructure in the implementation of the action plan. The action plan must be drafted in a way that places states on steps that guide them toward meeting the action plan’s objectives. The objectives must also be updated to be SMART goals that are broken down into steps, measurable, and attainable by all member states and not just HICs. A truly effective comprehensive mental health action plan would allow the teenage girl in the introduction to seek effective treatment regardless of her location, for good mental health, as a human right, should be available to all.
[1] Study Reveals Lack of Access as Root Cause for Mental Health Crisis in America, National Council for Mental Wellbeing (October 10, 2018), https://www.thenationalcouncil.org/news/lack-of-access-root-cause-mental-health-crisis-in-america/#:~:text=The%20large%20majority%20of%20Americans,and%20paying%20for%20daily%20necessities.
[2] María I. Jiménez Chafey et al., Clinical Case Study: CBT for Depression in a Puerto Rican Adolescent: Challenges and Variability in Treatment Response, 26 Depression and Anxiety 98, 98 (January 15, 2009).
[3] Id. at 99.
[4] Id. at 99—101; Institute for Quality and Efficiency in Health Care, In Brief: Cognitive Behavioral Therapy (CBT), National Center for Biotechnology Information (June 2, 2022), https://www.ncbi.nlm.nih.gov/books/NBK279297/#:~:text=Cognitive%20behavioral%20therapy%20(CBT)%20is%20problem%2Doriented.,mainly%20deal%20with%20the%20past.
[5] Jiménez Chafey, supra note 2, at 101.
[6] Id.
[7] Atalay Alem et al., Community-Based Mental Health Care in Africa: Mental Health Workers’ Views, 7 World Psychiatry 54, 54 (2008).
[8] Id. at 54—55.
[9] Oye Gureje et al., The Role of Global Traditional and Complementary Systems of Medicine in Treating Mental Health Problems, 2 Lancet Psychiatry 168, 171 (2015).
[10] Id. at 172.
[11] Id. at 171.
[12] The World Bank, Getting to Know the World Bank, World Bank Group (Jul. 26, 2012), https://www.worldbank.org/en/news/feature/2012/07/26/getting_to_know_theworldbank#:~:text=The%20World%20Bank%20is%20an,finance%20much%2Dneeded%20development%20projects.
[13] The World Bank, The World Bank in Middle Income Countries: Overview, World Bank Group (2024), https://www.worldbank.org/en/country/mic/overview#:~:text=The%20world’s%20Middle%20Income%20Countries,major%20engines%20of%20global%20growth.
[14] Pim Cuijpers et al., Psychotherapies for Depression in Low- and Middle-Income Countries: A Meta-Analysis, 17 World Psychiatry 90, 90 (2018).
[15] Institute for Global Health and Infectious Diseases, A Path for Scaling Mental Health Treatment in Low-Income Countries: Results from the SHARP Trial, UNC School of Medicine (Apr. 2, 2024), https://globalhealth.unc.edu/2024/04/a-path-for-scaling-mental-health-treatment-in-low-income-countries-results-from-the-sharp-trial/#:~:text=The%20World%20Health%20Organization%20estimates,of%20other%20mental%20health%20professionals.
[16] Id.
[17] Caitlin White, Investing in a Diverse Mental Health Workforce is Critical in This Moment, HealthCity (Aug. 10, 2021), https://healthcity.bmc.org/investing-diverse-mental-health-workforce-critical-moment/#:~:text=The%20U.S.%20has%20an%20average,even%20lower%20in%20rural%20communities.
[18] Cuijpers, supra note 14.
[19] Id.
[20] World Health Organization, World Health Statistics 2023: Monitoring Health for the DGSs, Sustainable Development Goals 64 (May 19, 2023).
[21] Id.
[22] Id.
[23] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030 1 (2021), https://iris.who.int/bitstream/handle/10665/345301/9789240031029-eng.pdf.
[24] Id.
[25] Id.
[26] Id. at 2—3.
[27] Id.
[28] Id. at 1.
[29] Id.
[30] Id.
[31] Id. at 1—2.
[32] Id. at 2.
[33] Id. at 1—2.
[34] Arthur Wilson & Abdallah S. Daar, A Survey of International Legal Instruments to Examine Their Effectiveness in Improving Global Health and in Realizing Health Rights, 41 J.L. Med. & Ethics 89, 89 (2013).
[35] Const. of the World Health Org. art. 2, July 22, 1946, T.I.A.S. 1808, 14 U.N.T.S. 185.
[36] World Health Organization, Mental Health Atlas 2020, 1 (2021), https://iris.who.int/bitstream/handle/10665/345946/9789240036703-eng.pdf; World Health Organization, World Health Statistics 2023: Monitoring Health for the DGSs, Sustainable Development Goals, supra note 20.
[37] U.N. Charter art. 55; id. art. 57.
[38] Global Issues: Health, United Nations, https://www.un.org/en/global-issues/health (last visited Nov. 29, 2024).
[39] Who We Are, World Health Organization (2024), https://www.who.int/about/who-we-are.
[40] Id.
[41] Id.
[42] Id.
[43] Id.
[44] Global Issues: Health, supra note 38.
[45] Global Issues: Health, supra note 38.
[46] Global Issues: Health, supra note 38.
[47] Global Issues: Health, supra note 38.
[48] Const. of the World Health Org. art. 1, July 22, 1946, T.I.A.S. 1808, 14 U.N.T.S. 185.
[49] Const. of the World Health Org. art. 2, supra note 35.
[50] Const. of the World Health Org. ¶ 1, July 22, 1946, T.I.A.S. 1808, 14 U.N.T.S. 185.
[51] Mental Health: WHO Response, World Health Organization (2024), https://www.who.int/health-topics/mental-health#tab=tab_3.
[52] Global Issues: Health, supra note 38.
[53] Global Issues: Health, supra note 38.
[54] Const. of the World Health Org. art. 2, supra note 35.
[55] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23.
[56] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at v.
[57] José Bertolote, The Roots of the Concept of Mental Health, 7 World Psychiatry 113, 114 (2008).
[58] Id. at 115.
[59] Id.
[60] Mental Health: WHO Response, supra note 51.
[61] Mental Health, Brain Health and Substance Use: Mental Health Gap Action Programme (mhGAP), World Health Organization (2024), https://www.who.int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme.
[62] mhGAP in Uganda – Bringing Treatment, Dignity, and Real Change, World Health Organization (Nov. 2, 2020), https://www.who.int/news-room/feature-stories/detail/mhgap-in-uganda-bringing-treatment-dignity-and-real-change#:~:text=Better%20community%20awareness%20has%20enabled,than%20someone%20giving%20me%20money!.
[63] World Health Organization, World Health Statistics 2023: Monitoring Health for the DGSs, Sustainable Development Goals, supra note 20.
[64] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 2.
[65] Org. for Econ. Coop. and Dev., Estonia: Towards a Single Government Approach, 116 (2011).
[66] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23.
[67] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23.
[68] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23; Mental Health: WHO Response, supra note 51.
[69] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at v; Mental Health: WHO Response, supra note 51.
[70] World Health Organization, Comprehensive Mental Health Action Plan 2013-2020 9 (2013), https://iris.who.int/bitstream/handle/10665/89966/9789241506021_eng.pdf.
[71] Id.
[72] Id. at 10.
[73] Id.
[74] Id. at 20.
[75] World Health Organization, World Mental Health Report: Transforming Mental Health for All 51 (2022), https://iris.who.int/bitstream/handle/10665/356119/9789240049338-eng.pdf.
[76] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at v.
[77] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 4.
[78] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 7.
[79] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 10.
[80] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 12.
[81] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 14.
[82] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xx.
[83] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 4.
[84] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 4.
[85] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 4.
[86] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 4.
[87] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 4; World Health Organization, Mental Health Action Plan 2013-2030 Flyer: What Member States Can do, 3 (2021), https://cdn.who.int/media/docs/default-source/campaigns-and-initiatives/world-mental-health-day/2021/mental_health_action_plan_flyer_member_states.pdf.
[88] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xiii.
[89] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xiii.
[90] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at 52.
[91] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xiii.
[92] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 6.
[93] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 7.
[94] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xiii.
[95] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[96] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[97] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[98] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[99] World Bank Country and Lending Groups, The World Bank (2024), https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.
[100] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[101] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[102] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xv.
[103] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[104] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[105] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at vi.
[106] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at 23.
[107] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at vi.
[108] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at vi.
[109] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xx.
[110] World Health Organization, Mental Health Atlas 2020, supra note 36, at 2.
[111] World Health Organization, Mental Health Atlas 2020, supra note 36, at 2.
[112] World Health Organization, Mental Health Atlas 2020, supra note 36, at 2.
[113] World Health Organization, Mental Health Atlas 2020, supra note 36, at 2.
[114] Mara Howard-Williams, Policy Proceeds Law: A Global Analysis of Mental Health as a Human Right, 65 How. L. J. 417, 419 (2022).
[115] Id. at 417 (2022).
[116] Id.
[117] Id. at 420.
[118] Id.
[119] Id. at 474.
[120] Id. at 419.
[121] Wilson, supra note 34, at 96.
[122] Wilson, supra note 34, at 96.
[123] Wilson, supra note 34, at 96.
[124] Wilson, supra note 34, at 96.
[125] Howard-Williams, supra note 114, at 421.
[126] Howard-Williams, supra note 114, at 421.
[127] Wilson, supra note 34, at 96.
[128] Wilson, supra note 34, at 99.
[129] Howard-Williams, supra note 114, at 429.
[130] Wilson, supra note 34, at 90.
[131] Howard-Williams, supra note 114, at 423, 426, 428.
[132] Wilson, supra note 34, at 91.
[133] Wilson, supra note 34, at 91.
[134] Wilson, supra note 34, at 97.
[135] Wilson, supra note 34, at 97.
[136] Wilson, supra note 34, at 97—98.
[137] Wilson, supra note 34, at 91.
[138] Wilson, supra note 34, at 97—98.
[139] Wilson, supra note 34, at 97—98.
[140] World Health Organization, World Mental Health Report: Transforming Mental Health for All, supra note 75, at xiii.
[141] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 3.
[142] Decolonization, Black’s Law Dictionary (12th ed. 2024).
[143] Sherally Munshi, Comparative Law and Decolonizing Critique, 65 Am. J. Comp. L. 207, 207, 212 (2024).
[144] Id. at 225.
[145] Id. at 212.
[146] Id. at 212—213.
[147] Id. at 214, 216.
[148] Id. at 217.
[149] Id. at 213.
[150] Id. at 218.
[151] Aeyal Gross, The Past, Present, and Future of Global Health Law Beyond Crisis, 115 Am. J. Int’l L. 754, 757 (2021).
[152] Id.
[153] Id.
[154] Gross, supra note 151, at 757—58.
[155] Gross, supra note 151, at 759.
[156] Gross, supra note 151, at 764.
[157] Gross, supra note 151, at 767.
[158] Gross, supra note 151, at 767.
[159] Gross, supra note 151, at 768.
[160] Wilson, supra note 34, at 97.
[161] World Health Organization, Comprehensive Mental Health Action Plan 2013-2030, supra note 23, at 4.
[162] Malinda Dokos et al., SMART Goals & Mental Health, Mental Health and Developmental disabilities National Training Center, https://www.mhddcenter.org/wp-content/uploads/2021/01/SMART-Goals-Mental-Health.pdf (last visited Dec. 1, 2024).
