Mental health, migration and the megacity

This International Health supplement reports results and perspectives from an in-progress international and interdisciplinary collaboration investigating the mental health of rural–urban migrant communities in contemporary megacities. The majority of the authors are collaborators on one project, shared between a set of institutions and funders in the UK and China, that uses evidence and approaches from epidemiology, the psychological and psychiatric sciences, the qualitative social sciences, as well as novel digital tools, to produce an individually textured yet clinically relevant picture of mental illness among migrant communities in Shanghai. That endeavour, which is still under way, is now extending into new collaborations with researchers in comparator migrant megacities—in particular, São Paulo, Brazil and Toronto, Ontario, Canada. In this introduction to the supplement, we will set out the background for this research programme in terms of contemporary patterns of urbanization and their relationship to mental health; we will then situate these issues in relation to migration, and especially to Shanghai as a new kind of migrant city. But we will also, in necessarily abbreviated form, make the case for a wider argument that underpins this ongoing endeavour. Our argument is that making sense of what it is like to develop, experience, live with and ameliorate a mental health problem, as a migrant, in a city like Shanghai or São Paulo or Toronto, requires perspectives and methods from a set of disciplines that do not make obvious bedfellows—it requires new forms of collaboration, and indeed new forms of thought, across the social sciences, epidemiological sciences and psychological sciences. Why focus on mental health in megacities? First, because any researcher today, focused on any complex problem in international health, almost certainly needs to consider how that problem plays out in cities. If human life, globally, was to be to reduced to just one social and economic phenomenon, that phenomenon might well be urbanization. For example, in the most recent revision to its report on World Urbanization Prospects, the UN has shown that the percentage of people around the world living in urban areas, having been around 30% in 1950, has reached 55% today and is projected to be about 68% by 2050.1 Indeed, the recitation of such numbers has now become something of a cliché—at any contemporary scholarly or policy event on global health or healthy cities, almost all speakers will likely find themselves at some stage reminding the audience that the world will be two-thirds urban by the middle of this century. But what lies under the skin of this much-repeated statistic, and how do the health consequences of this phenomenon, especially the mental health consequences, differ from patterns of urbanization in earlier eras?2 Among the many factors that stand out, three are especially relevant for our research: Whereas, in previous centuries, Europe and North America accounted for much of the global pattern of urbanization, today the centre of gravity has shifted to Asia, Latin America and Africa. The region of eastern Asia alone, which has been our own focus, has moved from having less than 18% of its population residing in urban areas in 1950 to a projection of more than 80% by 2050. To take only the case of China, which now has more than 100 cities with a population greater than 1 million, that country has moved from having just slightly more than 11% of its population living in cities in 1950 to more than 60% today.3 At the same time, in these same regions, a kind of massification is taking place, in which a general pattern of urbanization is also visible in the specific phenomenon of the megacity, which is in turn a complex, often poorly defined agglomeration, often made up of an extensive network of metropolitan areas, satellite towns and newly connected hinterlands. In São Paulo, Brazil, for example, the population has grown from less than a quarter of a million in 1900 to more than 20 million today—representing 10% of the entire Brazilian population—but with much of that growth in the peripheral areas radiating away from the centre.4,5 Shanghai, which according to one figure had a population of about 5 million in 1950, today has a population of more than 26 million, making it the world’s third largest city.6,7 The megacity, as a very specific kind of social and economic space, thus needs to be considered in its own terms, not least in relation to the literatures on the relationship between density, overcrowding and mental health.8 If much of the growth in the urban population in previous eras came from ‘natural’ population increases (i.e. higher birth rates and lower death rates), for much of the process of urbanization today, and especially so in the megacities of Asia and Latin America, it is inward migration to the cities from the countryside and smaller towns that is the key factor. Indeed, there are 140 million rural–urban migrants today in China alone—a number that is expected to increase even as the Chinese government moves to limit the populations of its largest cities.9 In Brazil, the distinctive pattern of favelas surrounding many major cities equally reflects informal settlements largely erected by rural–urban migrants.10 The articles in this supplement are all concerned with the health consequences of these features of contemporary urbanization, which have thus far been little researched—there has been relatively little attention paid to how health problems play out in the growing megacities of Asia and Latin America, and even less attention to how they play out in the lives of rural migrants in those cities. Moreover, whereas previous work has looked at, for example, environmental health, food security and related topics in megacities, these articles focus only on one emergent, vital and yet understudied feature of these metropolises—the relationship of their growth to the mental health of their inhabitants.11 There is good reason to think there may be particular issues of mental health in these new urban formations. Certainly it has been known since the birth of the industrial cities of the eighteenth and nineteenth centuries that there is a relationship between ordinary life in those cities and the mental health of the cities’ inhabitants—and especially those inhabitants who happen to have been born elsewhere. Research in this vein has progressed from studies of what precisely is wrong with foreign-born inmates in the hastily established asylums in mid-nineteenth century New York, to accounts of overexcited and overstressed psychiatric patients in turn-of-the century London, to more sophisticated attempts to separate congenital from environmental factors in urban migrants experiencing psychosis in the half-urban/half-rural spaces of the American Midwest.12,–14 And yet, despite the long time period over which the relationship between mental health and the city has been observed, questions of its precise character and specificity remain unresolved, at both the biological and social level. Indeed, for many decades scholars debated whether the city was inherently productive of mental illness or whether more people with mental illnesses ended up living in cities through a form of ‘geographical drift’.15 Today, in contrast, much research effort within the life sciences has focused on interactions between the individual and the city, and on specific biological pathways that may mediate or exacerbate the relationship between poor mental health and urban life—with some potentially promising proposals at both the neurobiological and epigenetic levels.16,17 Other strands of research—often situated within the psychological or epidemiological sciences—have explored the range of risk factors and/or the range and weight of different stressors that might account for portions of the differences between rates of mental illness in rural and urban areas: there is now broad consensus, as a recent synthesis of meta-analyses and quantitative studies has shown, that urbanization is a significant risk factor for several major mental illnesses, including psychotic disorders and some mood disorders, and that specific features of the urban social environment associate with poor mental health, including low socio-economic status, low social capital and social segregation, as well as a series of factors in the physical environment, such as physical threat, noise, pollution and some forms of urban design (large, looming towers, for example).18 Within these kinds of studies, among the factors most consistently identified with the risk of developing a mental health problem as an urban dweller are migration and stress.19 Thus, and given the relationship of the megacity to inward migration as well to the often stressful situations in which migrants find themselves, our study has proceeded on the basis that the migrant megacity likely represents a significantly under-researched issue in global mental health. The relationship between migration status and the chance of experiencing significant mental distress is a long-standing theme in psychological research, and there has been much attention over the decades to the role of factors in the place of origin, factors specific to whatever city the migrant has moved to, the actual stress of the journey itself and so on.20 More recent work has shown how migration itself is a manifold experience with distinctive stages and different potential stressors at each stage: that it has different effects across the suite of mental health symptoms and diagnoses, that there are effects through generations and also that many migrants have strategies for resilience and coping.21 Yet two important factors have not been as central to this debate as they might be: first is the distinction between international migration and internal rural–urban migration; while the latter was largely characteristic of patterns of migration that make up the ‘classic’ epidemiological literature on urban mental health, it is not clear that its conclusions will carry with any great fidelity into contemporary internal migration trends, especially in the major cities of the global south. Second is the role of the megacity itself, which, as we note above, is a very specific form of settlement, with again very particular spatial patterns of work, settlement and community, thus presenting to the internal migrant potentially different kinds of stress as well as different affordances for coping.22 This changes things for how we think about the relationship between the city and mental health: indeed, research among rural–urban migrants in China has shown that migrants have both worse and better mental health than their urban counterparts.23,24 What is it then that is so distinctive about migrant life in a city like Shanghai that makes this relationship so complex? What makes Shanghai such a potent site for thinking through the mental distress of the twenty-first century migrant experience? Since 2011, China has been, for the first time in its history, a majority urban nation. And it is migration that is the driving factor.25 We are no longer simply thinking about the city and its relationship to mental health, but to the specific effects on mental life of living in the migrant city, i.e. the mental health consequence of having migrated from a village or town to some major global metropolis. As we noted above, whereas in nineteenth century Europe it was population growth that broadly drove urbanization processes, in twenty-first century China the situation is quite different, with rural–urban migration three times more important for urbanization than population growth in cities.26 It would be an error to think of such a movement only in terms of stress and upheaval: moving to a city such as Shanghai, or Guangzhou, or Shenzhen, presents many opportunities for those who chance it—in terms of material and economic gains, personal and cultural freedoms and simply the opportunity to build one’s own complex, dexterous life, even if on the margins of a major and still-growing megacity.27 Indeed, our own, early quasi-ethnographic forays into the migrant districts and markets of Shanghai during the pilot phase of this project quickly led us into interactions that, while brief, were far from the clichés of migrant hardship—these encounters with rural–urban migrants gave us an image of people who work long hours and face difficulties certainly, but who nonetheless are often in good work, are doing well, who have a sense that they are getting on in life, who are even frequently in the process of putting away money for whatever represents their own vision of the good life, whether in Shanghai or back in their home village.28 This is an important aspect of the migrant experience in contemporary Shanghai, and it will be reflected in the articles that follow. Nonetheless, it is also the case that, for many, urbanization can come at a high price, producing feelings of stress, dislocation, cultural alienation, social defeat and family dispersion, often resulting in elevated rates of illness, and especially mental illness.29 Certainly this is not a story that is unique to China. But there are some features of Chinese urbanization that exacerbate these ills. The most prominent of these is the hukou system—a legacy of the socialist era, now within a (long) process of reform, in which an individual is registered in their place of birth and thereby marked as either urban or rural, with that mark structuring their access to services, especially to where services might be accessed.30 Thus a migrant lacking Shanghai hukou may find their ability to access schooling, health services, good quality housing and so on significantly curtailed in their actual place of residence. Transferring hukou registration remains very difficult, despite ongoing reforms and, while some migrants do strategically wish to retain their rural hukou (to pass onto their children, or because they intend to return to the village in later life), these bureaucratic complexities remain a source of significant stress for many rural migrants—as well as a barrier to seeking help for stress.31 And there are other governance issues that may interact with migrant mental health in a city like Shanghai: for example, China relatively its first mental health with still The of those and especially the of services from a remains it is how such will interact with and it is especially whether will be to the often informal spaces and that are by migrants to with the of megacity way, Shanghai remains a migrant city. and the population from about million to in the same the (i.e. Shanghai from million to is to of the population increase in this period was to migration from the In São Paulo, the are very but the patterns of and are metropolitan region of São Paulo has also its population is about 20 million, and this is also by migration from the The largest period of growth came in the and a population of about million in to more than million by with the of growth significantly and almost all of that growth having place away from the centre of the city, in the rural of the urban As we have it is important not to such of population to psychological Nonetheless, given what is known about the city and mental health, and especially given what we about how that relationship is by density, on the one and migration, on the there a case for getting some on what is in terms of the of mental life, in cities like Shanghai and São It be that we are not with early century or early nineteenth century London, cities in which the first of a between city life and mental health known to we are with very different social and epidemiological some on their a and biological of been the central of the We our with the that making sense of what it is like to be a rural migrant in twenty-first century the specific and by people in this producing on the of what kinds of mental health problems people are in their but also the through which migrants in Shanghai had to to make a good life for themselves and their how they on the complex of the city, the and the as of as well as of about how and where they from they if they that and whether it was they be the of the psychological or qualitative social sciences we on the basis that the relationship between urban life and mental health requires a new kind of relationship between these There is no great in such a questions of and the are by having been, for about a century of central to scholars in disciplines that to have very little in from social to studies in urban to some of the very in psychiatric epidemiology, as well as in some of the most in the psychological sciences. of how and urban life and poor mental health to have a of shared attention in the century But while there has been much attention on urban mental health and mental life across these there has been little between at least for some has there been a not only to but to a new kind of research, which would on onto a to the of life in the city, as well as to developing that would produce a epidemiological and picture of urban mental Thus the of this project is not in and epidemiological accounts of migrant life, but it is in for example, and work, as well as digital social tools, all of which help us to some on the migrant experience as it is in the thereby to the epidemiological and other through which we on migrant mental health. What would a new kind of like that the and of qualitative social with the quantitative approaches as well as the and policy of epidemiological The central of this project has been to produce better for the relationship between urban life and mental health, and to do so by a new kind of relationship between the epidemiological and life sciences. The project itself to this by thinking through new kinds of between urban and which in turn was to be a to making sense of the and of migrant life, i.e. forms of and experience that might the epidemiological This vision was to be in research which we have not in a but that through the articles that to produce new on the of mental health problems in a city like Shanghai, especially as those patterns are by migration; to focus on migrant life in Shanghai, with attention to the of migrants in the city and the of new kinds of and new spaces for to at governance and policy that have if significantly the mental health of migrants and other to consider the of new mental health and other relevant in China, especially as these through to policy and and to how these kinds of about Shanghai may mental health research in especially in other megacities of the global where population growth is either or the of significant inward from the were in turn in a and synthesis of the literature on migrant mental health in Shanghai, with particular attention to the of the social and of urbanization in an study on the of migrant and migrant in Shanghai, by an attention to different kinds of and work experience, in migrant communities in the urban centre and in the of the a digital study of the relationship between place, mood and life from migrant the by researchers at and the of a new kind of for migrant mental health in not only in can the of psychiatric symptoms and the experience of social This would be the first for mental health research in Shanghai that not only epidemiological in and international but that is specific to migrant experience in and migrant of that city, and would focus not only on but on social and that this This supplement, which reports of during this project, not report results to all our in what is to report on from our and digital research with a report of the to come in complex aspect of producing that will quickly become to of the articles that while work consistently at least mental distress among migrant communities in Shanghai of the in our were experiencing at least mental our work by contrast, that such distress is often at least well by the strategies that migrants find and make of in their and sense of this whether it even a in the first place may of experience significant mental distress and have good the of ongoing But a to such and to design an that is to live with these even remains the central of this project, and of the that we report for the first The supplement with an of the experience of migration by and on how migrants with the urban environment in life and with attention on the of the migrant and for an account of mental in the of epidemiological that is as to how people in their own lives as it is to their experience of In the and two pilot studies that to epidemiological of migrant mental health with just such an in a that would be to precisely the kinds of in the work and a that uses to produce on in urban the authors these pilot studies the to a new between and biological potentially to a more The then make up a into contemporary work on migrant mental health in Shanghai across a range of First, report on a of mental health among migrant in China, significant to mental health issues among migrant across a range of relevant report on the potentially effects of a for the urban on a new their research an between and a range of and psychological including and the experience of In the a to a relationship between mental health status and a range of factors among migrants in Shanghai. that factors such as and problems are related to the risk of while high is with status, higher and living with then report on a between migrant and in Shanghai, that migrant have only a slightly higher of there is a in those of and particular problems for those in poor work and with low The with a report on the relationship between social and mental health among Shanghai a series of healthy cities to that social and social are significant factors both in migrants sense of and in their mental health authors were in this This research was by the of China and the and Research of UK

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