Comment
employment programmes provide on-the-job training
to prepare participants for more sophisticated jobs.
We believe that increasing individuals’ career prospects
requires formal opportunities for higher education,
combined with enhanced on-the-job training, to help
people learn new ways to complete essential tasks more
efficiently, communicate with others more effectively,
organise multiple activities, adjust to changing demands
from the job, and learn new work skills relevant to the
evolving needs of employers.
Few higher-education institutions around the world
accommodate the unique impairments and learning needs
of people with severe mental illness. Advanced learning
programmes tailored for people with mental illness, such
as supported education, have neither been widely tested
nor widely adopted in the USA and elsewhere.6 Perhaps
the time has come for studies on the career development
of people with severe mental illness. Such studies could
aim to restore social inclusion and citizenship rights
through higher education and career development.
Every nation faces the challenge of developing human
capital, yet people with severe mental illness have not
generally been regarded as an asset, even though several
studies show a capacity to contribute.7 People with
mental illness strive for self-determination through work
just as passionately as people in good health. We believe
that developing an empowered, educated, healthy,
and skilled labour force could reduce the economic
and social marginalisation of people with mental
illness. At present we know little about how to apply
evidence-based practices in supported employment5 to
countries with developing market economies. Similarly,
in more regulated economies than in the USA, such as
Australia, Canada, and Europe, we know little about the
extent to which established evidence-based practices can
be implemented with high fidelity, and whether the active
ingredients need further development in local contexts.
Despite international differences in labour markets, health
Mental health and global movement of people
Migration is a key part of globalisation,1 and the social,
cultural, economic, and political forces of globalisation
have substantially changed the determinants and
consequences of migration. 170 million people live
outside their country of origin, and every year more
www.thelancet.com Vol 370 September 29, 2007
and welfare systems, employment outcomes from Burns
and colleagues’ study warrant optimism that high rates
of competitive employment could be achievable in more
regulated economies and lead to increasingly viable
career prospects for people with histories of lengthy
unemployment,8 such as those with severe mental illness.
Further progress will inevitably require new international
partnerships, funding from a wide variety of sources,
different research designs, a long-term focus to track
vocational recovery, and inclusive communities prepared
to restore equal rights of citizenship and value human
strengths over deficits. Equally important will be the need
for researchers to produce evidence for immediate use in
developing policy and in sponsoring local evidence-based
programmes.
Paul B Gold, *Geoff Waghorn
Department of Psychiatry and Behavioral Sciences, Medical
University of South Carolina, SC, USA (PBG); and School of
Population Health, University of Queensland, and the Queensland
Centre for Mental Health Research, Park Centre for Mental Health,
Richlands, QLD 4076, Australia (GW)
geoff_waghorn@qcmhr.uq.edu.au
We declare that we have no conflict of interest.
1 Burns T, Catty J, Becker T, for the EQOLISE Group. The effectiveness
of supported employment for people with severe mental illness:
a randomised controlled trial. Lancet 2007; 370: 1146–52.
2 Crowther RE, Marshall M, Bond GR, Huxley P. Helping people with severe
mental illness to return to work: a systematic review. BMJ 2001; 322: 204–08.
3 Cook JA, Leff HS, Blyler CR, et al. Results of a multi-site randomized
implementation effectiveness trial of supported employment interventions
for individuals with severe mental illness. Arch Gen Psychiatry 2005; 62:
505–12.
4 Latimer EA, Lecomte T, Becker DR, et al. Generalisability of the individual
placement and support model of supported employment: results of a
Canadian randomised controlled trial. Br J Psychiatry 2006; 189: 65–73.
5 Bond GR. Supported employment: evidence for an evidence-based practice.
Psychiatr Rehabil J 2004; 27: 345–59.
6 Mowbray CT, Collins ME, Bellamy CD, et al. Supported education for adults
with psychiatric disabilities: an innovation for social work and psychosocial
rehabilitation practice. Soc Work 2005; 50: 7–20.
7 World Health Organization. The world health report 2001. Mental health:
new understanding, new hope. Geneva: WHO, 2001.
8 Organisation for Economic Co-operation and Development. OECD
employment outlook 2006—boosting jobs and incomes. Paris: OECD, 2006.
than 700 million people cross national boundaries.2 The Published Online
September 4, 2007
public-health importance of this massive movement DOI:10.1016/S0140-
of people is apparent for communicable diseases, and, 6736(07)61249-5
although less visible, is no less important for mental
health.
1109
 Comment
Although globalisation promises universal economic
and social benefits, it leads to increased marginalisation,
unemployment, erosion of job security, increased poverty,
reduced access to health care and education, and reduced
social provision for people who are ill or unemployed. Many
factors that lead to permanent and temporary migration
are products of globalisation, and are determinants of
mental health and illness.3,4 Rapidly emerging market
economies need cheap labour, which might involve
women from rural areas with poor education who have
been separated from their family and who have access to
few legal protections. High-income countries (ie, those in
Europe, North America, and Australia and New Zealand)
with declining and ageing populations need immigrants,
but are often ambivalent about them when they come.
Complex emergencies and human-rights abuses produce
large flows of asylum seekers and refugees, mostly into
neighbouring low-income countries that have little
capacity to receive and to care for them. Poverty fuels
the deadly trade of people-trafficking, and is the major
engine for undocumented immigration. The decline of
rural economies everywhere and rapidly escalating global
The printed journal
includes an image merely
for illustration
Corbis
1110
ecological problems will substantially increase the pressure
on people to move.
The encounter between people and cultures is medi-
ated by a global flow of commodities,5 information,
and, increasingly, direct contact between people. Most
migration occurs from poor, generally sociocentric
(ie, collectivist) cultures to those that are richer and
egocentric (ie, individualist).4 Acculturation, which
occurs when different cultural groups are in sustained
contact with one another,6 might lead to distress and
dysfunction in some individuals and to tension between
cultural groups. The power of institutional or individual
racism over the mental health of immigrants must not
be ignored. Fragmentation and erosion of identity, the
loss associated with displacement from familiar contexts
and support networks, the difficulties of settlement,
and the pressures on accustomed family structures and
relationships can increase vulnerability to mental illness.7
Sociocentric individuals who migrate from socio-
centric societies to those that are egocentric are likely to
develop distress—especially if they do not have access
to a community of people with similar backgrounds.8
www.thelancet.com Vol 370 September 29, 2007

An additional source of stress on immigrants is that host
societies have generally failed to respond effectively to
the reality of ethnic, cultural, and linguistic diversity.9
Pilot programmes that show effective delivery of a
mental health programme to immigrants who are in the
minority have little effect on mainstream mental health
services.10
The effect of movement of trained and professional
individuals and their families around the world cannot
be underestimated. The cost of training a doctor or an
engineer in a low-income country may be proportionately
low, but the brain drain can cost millions of dollars,
especially in countries that can ill afford to lose such skills.
Therefore the treatment gap in low-income countries
will probably widen, and there have been recent calls for
developed countries to refund donor countries.11 The
money that migrants send back to their country of origin
may compensate, but this is not the full story. The mental
health of people who are left behind and who have poor
resources, the potential resulting resentment, and the role
of acculturation on the health of migrants need urgent
wider discussion.
*Dinesh Bhugra, Iraklis Harry Minas
The built environment and health
In a recent British Medical Journal poll,1 the sanitary
revolution that introduced clean water and sewage
disposal was voted the most important medical
advance since the journal was first published. That result
reminds us of the crucial part played by urban planners
and engineers in health improvement 150 years ago.
As the squalor and decay of that time gave way to
improvements in the environment, together with
substantial advances in medicine and improved life
expectancy, the 20th century saw a corresponding
decrease in interest in the effect of the built environment
on health. The automobile was pivotal in the planning
of communities,2 with unforeseen results, such as urban
sprawl and changes in lifestyles, health, and wellbeing.
The damaging social results of urban planning that
ignore lessons from real life have been eloquently
described in a seminal study of American cities.3
Crime, absence of social cohesion, noise, air pollution,
and road-traffic accidents are some of the negative
www.thelancet.com Vol 370 September 29, 2007
Comment
Section of Cultural Psychiatry, Institute of Psychiatry, King’s College
London, London SE5 8AF, UK (DB); and Centre for International
Mental Health, School of Population Health, University of
Melbourne, VIC, Australia (IHM)
d.bhugra@iop.kcl.ac.uk
We declare that we have no conflict of interest.
1 Mignolo W. Globalization, civilization processes and the relocation of
language and cultures. In: Jameson F, Miyashi M, eds. The cultures of
globalization. Durham, NC: Duke University Press, 2001: 32–53.
2 Koehn P. Globalization, migration health, and educational preparation for
transnational medical encounters. Global Health 2006; 2: 2.
3 Minas H. Migration, equity and health. In: McKee M, Garner P, Stott R, eds.
International co-operation in health. Oxford: Oxford University Press, 2001:
151–74.
4 International Organization for Migration. World migration 2005: costs and
benefits of international migration. Geneva: International Organization for
Migration, 2005.
5 Inda J, Rosaldo R. Roving commodities. In: Inda J, Rosaldo R, eds.
The anthropology of globalization. Oxford: Blackwell Publishing, 2001: 231.
6 Berry J. Acculturation and identity. In: Bhugra D, Bhui K, eds. Textbook of
cultural psychiatry. Cambridge: Cambridge University Press (in press).
7 Bhugra D. Migration and mental health. Acta Psychiatr Scand 2004; 109:
243–58.
8 Bhugra D. Cultural identities and cultural congruency: a new model for
evaluating mental distress in immigrants. Acta Psychiatr Scand 2005; 111:
84–93.
9 Minas H. Developing mental health services for multicultural societies.
In: Bhugra D, Bhui K, eds. Textbook of cultural psychiatry. Cambridge:
Cambridge University Press (in press).
10 Fernando S. Multicultural mental health services: projects for minority ethnic
communities in England. Transcult Psychiatry 2005; 42: 420–36.
11 Patel V, Boardman J, Prince M, Bhugra D. Returning the debt: how rich
countries can invest in mental health capacity in developing countries.
World Psychiatry 2006; 5: 67–70.
characteristics that have persisted or even increased, Published Online
September 13, 2007
despite the efforts of well-meaning planners, architects, DOI:10.1016/S0140-
and transportation experts in past decades.3 Related to 6736(07)61260-4
this changed landscape, the causes of disease that were See Series page 1175
prevalent a century ago have been replaced by more
chronic disorders, such as asthma, obesity, and diabetes.
Against this background, a collective recognition of
the crucial relation between the built environment
and health,2,4 particularly within the neighbourhood
as an essential health setting,5–7 is only just beginning
to re-emerge (figure). Furthermore, climate change is
leading to an urgent focus on sustainable building, which
has the potential not only to minimise environmental
degradation but also to improve health.8
Researchers define the built environment as encom-
passing all buildings, spaces, and products that are
created or modified by people. The built environment
affects indoor and outdoor physical environments,
social environments, and subsequently health and
1111