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Making Knowledge for International Policy

Citation for published version: Sturdy, S, Freeman, R & Smith-Merry, J 2013, 'Making Knowledge for International Policy: WHO Europe and Mental Health Policy, 1970-2008', Social History of Medicine, vol. 26, no. 3, pp. 532-554. https://doi.org/10.1093/shm/hkt009

Digital Object Identifier (DOI): 10.1093/shm/hkt009

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Document Version: Early version, also known as pre-print

Published In: Social History of Medicine

Publisher Rights Statement: This is a pre-copy-editing, author-produced PDF of an article accepted for publication in Social History of Medicine following peer review. The definitive publisher-authenticated version Sturdy, S., Freeman, R., & Smith- Merry, J. (2013). Making Knowledge for International Policy: WHO Europe and Mental Health Policy, 1970-2008. Social History of Medicine, is available online at: http://dx/doi.org/10.1093/shm/hkt009

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Download date: 02. Oct. 2021 Page 1 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 Making knowledge for international policy: 4 5 WHO Europe and mental health policy, 1970-2008 6 7 8 9 10 11 12 Abstract: It is widely agreed that the effectiveness of the World Health Organization 13 14 (WHO) in international policy derives from its reputation as a source of authoritative 15 16 knowledge. However, little has been done to show how WHO mobilises knowledge 17 18 For Peer Review 19 for policy. Commentators tend to assume that WHO is a technocratic organisation, 20 21 which uses technical expertise to define universally-applicable standards on which to 22 23 base policy. This paper tells a more complex story. Looking in detail at the efforts of 24 25 the WHO European Regional Office, since the 1970s, to reform mental health policy 26 27 across the region, it shows that the organisation’s main policy successes in this field 28 29 30 were achieved, not by circulating standardised data or policies, but by creating 31 32 opportunities to share holistic, experience-based knowledge of best practice. We 33 34 analyse our findings using the idea of ‘epistemic communities’, which we show can 35 36 throw new light on the role of knowledge in international policy. 37 38 39 40 41 Keywords: World Health Organization; mental health; policy; knowledge; epistemic 42 43 communities 44 45 46 47

48 49 50 51 52 Introduction 53 54 55 56 57 58 59 60 http://mc.manuscriptcentral.com/(site) Manuscripts submitted to (i)Social History of Medicine(/i) Page 2 of 48

1 2 3 The effectiveness of the World Health Organization (WHO) as a policy body has 4 5 depended from the beginning on its ability to mobilise knowledge. Possessing only 6 7 limited financial resources, and with no powers to compel member states to adopt 8 9 10 any particular course of action, WHO can do little, on its own, to require changes in 11 12 national or local health policy. Consequently, such success as WHO has had in 13 14 promoting and coordinating international health initiatives is generally attributed to its 15 16 reputation as a source of sound and reliable knowledge. As one commentary put it: 17 18 For Peer Review 19 ‘The WHO’s recognised strength lies in its biomedical knowledge, its scientific 20 21 knowledge base, its surveillance and normative regulations, and its data collection ... 22 23 Its perceived weakness lies in its limited ability to apply this knowledge at country 24 25 level’.1 According to another, WHO’s influence is due to its ability to deliver a range 26 27 of ‘international public goods’, including ‘research and development, particularly 28 29 30 regarding problems of global importance ... ; information and databases that can 31 32 facilitate a sustained process of shared learning across countries; harmonised norms 33 34 and standards for national use and ... for regulation of the growing number of 35 36 international transactions; and consensus-building on health policy, which can help 37 38 2 39 mobilise political will within each country’. 40 41 42 43 Such views are broadly consistent with a growing body of academic research that 44 45 seeks to explain the emergence and influence of an increasingly wide range of 46 47 48 ______49 1 Kelley Lee et al., ‘Who Should be Doing What in International Health: A Confusion of Man- 50 51 dates in the United Nations?’, British Medical Journal , 1996, 312 , 302-307, 306. 52 53 54 2 Dean T. Jamison, Julio Frenk and Felicia Knaul, ‘International Collective Action in Health: 55 56 Objectives, Functions, and Rationale’, The Lancet , 1998, 351 , 514-517, 512. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-1- Page 3 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 international organisations since the early twentieth century. There is widespread 4 5 agreement that the production and mobilisation of knowledge is central to the way 6 7 that many international organisations exert an influence in the world. In a widely 8 9 10 cited article, for instance, Barnett and Finnemore argue that international 11 12 organisations derive their power in large part from their ability to ‘(1) classify the 13 14 world, creating categories of actors and action; (2) fix meanings in the social world; 15 16 and (3) articulate and diffuse new norms, principles, and actors around the globe. All 17 18 For Peer Review 19 of these sources of power flow from the ability of [international organisations] to 20 3 21 structure knowledge’. Given this perspective on the power of international 22 23 organisations, and given WHO’s prominence among international organisation, one 24 25 might have expected that academics would have been quick to look in some detail at 26 27 the ways in which WHO generates, structures and mobilises knowledge for policy. 28 29 30 Surprisingly, this does not seem to have been the case. 31 32 33 34 This lack of detailed empirical investigation has not prevented commentators from 35 36 making assumptions about what sort of knowledge politics WHO practices, however. 37 38 39 WHO is widely understood to be a predominantly ‘technocratic’ organisation, in the 40 41 sense that it looks primarily to technical knowledge as a basis for establishing 42 43 normative standards of healthcare practice and provision, which are then universally 44 45 applied and, where possible, enforced across member countries. 4 This assumption, 46 47 48 49 ______50 3 Michael N. Barnett and Martha Finnemore, ‘The Politics, Power, and Pathologies of Inter- 51 52 national Organizations’, International Organization , 1999, 53, 699-732, 710. 53 54 55 4 Philip M. Strong, ‘A New-modelled Medicine? Comments on the WHO's Regional Strategy 56 57 for Europe’, Social Science and Medicine , 1986, 22 , 193-199; John W. Peabody, ‘An Organ- 58 59 60 http://mc.manuscriptcentral.com/(site)-2- Manuscripts submitted to (i)Social History of Medicine(/i) Page 4 of 48

1 2 3 too, is broadly in keeping with the way that academic analysts have tended to think 4 5 about the power of international organisations more generally. Barnett and 6 7 Finnemore, for instance, consider international organisations primarily as 8 9 10 bureaucratic institutions, which exercise power through ‘(1) the legitimacy of the 11 12 rational-legal authority they embody, and (2) control over technical expertise and 13 14 information’.5 The kinds of knowledge practices that Barnett and Finnemore identify 15 16 with this bureaucratic orientation – classification, the fixing of meanings, and the 17 18 For Peer Review 19 articulation and diffusion of norms – are all equally consistent with a technocratic 20 21 approach to policy that other commentators attribute to the World Health 22 23 Organisation. 24 25 26 27 However, our own findings indicate that this is not the only way that WHO works. A 28 29 30 technocratic approach to knowledge and policy may well hold good for large areas of 31 32 WHO’s activities, but we cannot simply assume that it is true of everything the 33 34 organisation does. In the present paper we look in some detail at how, from the 35 36 1970s onwards, WHO’s European Regional Office undertook successive initiatives 37 38 39 to generate and disseminate knowledge of the organisation and effectiveness of 40 41 mental health services within the region, as a basis on which to promote reform of 42 43 those services. To the very limited extent that historians have commented on this 44 45 aspect of WHO’s work, they have assumed that it too was primarily technocratic in 46 47 character, in that it was aimed at setting universal standards of provision: ‘After the 48 49 50 ______51 52 izational Analysis of the World Health Organization: Narrowing the Gap Between Promise 53 54 and Performance’, Social Science and Medicine , 1995, 40 , 731-742. 55 56 5 57 Barnett and Finnemore, ‘Politics, Power, and Pathologies’, 707. 58 59 60 http://mc.manuscriptcentral.com/(site)-3- Page 5 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 Second World War, the World Health Organization (WHO) played an active part in 4 5 generating information about the state of mental health care in various countries, 6 7 largely in order to set international standards for it’.6 Our own findings, based on 8 9 10 detailed examination of WHO documents and on interviews with a number of 11 12 informants involved in WHO Europe’s more recent activities in the field of mental 13 14 health, show that the story is rather more complicated than this technocratic model 15 16 suggests. 17 18 For Peer Review 19 20 21 WHO officers did indeed set out with the aim of collecting standardised data about 22 23 mental health services and their effectiveness, of a kind that was intended to permit 24 25 rigorous comparison between different national mental health systems, and that 26 27 would provide a basis for universal norms and recommendations regarding the kinds 28 29 30 of mental health policies countries should pursue. But we show that these initiatives 31 32 were largely unsuccessful. WHO officers repeatedly failed to establish universally 33 34 applicable standards, not just for the provision of care, but even for the work of data 35 36 collection. In consequence, rigorous international comparison proved impossible, as 37 38 39 did the technocratic aim of setting universal standards of provision. That does not 40 41 mean that WHO Europe has been unable to effect significant advances in regional 42 43 mental health policy; on the contrary, it has achieved some notable successes in this 44 45 regard. But those successes have been achieved through the production and 46 47 mobilisation of a very different kind of knowledge: not standardised and comparative, 48 49 50 ______6 51 Marijke Gijswijt-Hofstra and Harry Oosterhuis, ‘Introduction: Comparing National Cultures 52 53 of Psychiatry’, in Gijswijt-Hofstra et al., eds, Psychiatric Cultures Compared: Psychiatry and 54 55 Mental Health Care in the Twentieth Century: Comparisons and Approaches (Amsterdam: 56 57 Amsterdam University Press, 2005), 9-23, 9. 58 59 60 http://mc.manuscriptcentral.com/(site)-4- Manuscripts submitted to (i)Social History of Medicine(/i) Page 6 of 48

1 2 3 but case-based and holistic, and rooted in personal experience of the peculiarities of 4 5 local mental health systems of a kind that proved difficult to reduce to the 6 7 standardised categories necessary for technocratic policy making. 8 9 10 11 12 Our findings thus present an opportunity to reassess how WHO operates as a 13 14 knowledge-based international policy organisation. We do not presume that our 15 16 findings can be generalised to areas of health policy beyond mental health; it may 17 18 For Peer Review 19 well be the case, for instance, that WHO has succeeded in pursuing a technocratic 20 21 approach to knowledge and policy in more biomedicalised fields of medicine, where 22 23 technical standardisation is more readily achieved and where there may be much 24 25 greater consensus both within and among countries about appropriate forms and 26 27 standards of provision. However, our research makes clear that this is not the only 28 29 30 way that WHO is able to operate, and that other forms of knowledge and policy may 31 32 sometimes prove more practicable or more effective. We therefore need to find 33 34 ways of thinking about WHO’s efforts to produce and mobilise knowledge for policy 35 36 that do not simply presuppose a technocratic orientation. To that end, we go on to 37 38 39 discuss our findings in the light of ideas about ‘epistemic communities’, as 40 41 elaborated by Michael Haas and other writers in the field of policy studies, but also – 42 43 and importantly – as developed within the field of science and technology studies. 44 45 Our analysis suggests not only that thinking about epistemic communities can throw 46 47 valuable light on the role of knowledge in the making of WHO policy, but also that 48 49 50 policy scholars might benefit from incorporating insights from science and technology 51 52 studies into their own understanding of epistemic communities. 53 54 55 56 Methods 57 58 59 60 http://mc.manuscriptcentral.com/(site)-5- Page 7 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 4 5 The research on which this paper is based was conducted as part of a five-year, 6 7 multi-centre research project looking at the role of knowledge in policy for health and 8 9 10 education across twelve European research sites. One work package within that 11 12 project set out to examine how a particular regulatory instrument, WHO Europe’s 13 14 2005 Mental Health Declaration for Europe and its associated Action Plan ,7 was 15 16 adopted and implemented in six different European countries. The authors of the 17 18 For Peer Review 19 present paper were responsible for the Scottish strand of this work package. In 20 21 addition, we undertook to provide contextual information for all six strands of the 22 23 work package by researching the circumstances leading up to the drafting and 24 25 agreement of the Declaration and Action Plan .8 26 27 28 29 30 For the latter part of the project, we conducted a review of the secondary social 31 32 scientific literature on WHO; a review of relevant WHO publications, including all 33 34 reports, papers and other secondary documents on mental health in Europe that 35 36 appeared between 1970 and 2008; and a series of semi-structured interviews with 37 38 39 ten key actors involved in the production and use of the Declaration and Action Plan 40 41 at the international level. Interviewees were identified by referral sampling, and 42 43 included WHO staff (among them the current and two former Regional Advisers for 44 45 ______46 7 WHO Europe, Mental Health Declaration for Europe: Facing the Challenges, Building Solu- 47 48 tions , 2005, WHO EUR/04/5047810/6; WHO Europe, Mental Health Action Plan for Europe: 49 50 Facing the Challenges, Building Solutions , 2005, WHO EUR/04/5047810/7. 51 52 53 8 Richard Freeman, Jennifer Smith-Merry and Steve Sturdy, WHO, Mental Health, Europe . 54 55 Know&Pol Project Report, 2009, available online at 56 57 http://knowandpol.eu/IMG/pdf/o31.who.fabrication.pdf 58 59 60 http://mc.manuscriptcentral.com/(site)-6- Manuscripts submitted to (i)Social History of Medicine(/i) Page 8 of 48

1 2 3 Mental Health), EC officials, project staff, representatives of other international 4 5 organizations and national officials with particular experience of working at 6 7 international level. To ensure that interviewees felt able to speak frankly, it was 8 9 10 agreed at the outset that the interview data should be anonymised; where used in 11 12 the present paper, those data are accordingly referenced by the date on which each 13 14 interview took place. 15 16 17 18 For Peer Review 19 Data analysis took the form of close textual analysis of the various documents and 20 21 interview transcripts. Our aim in the first instance was to provide a detailed account 22 23 of how knowledge of mental health in Europe was gathered, negotiated and agreed 24 25 in the period immediately before and after the signing of the 2005 Declaration and 26 27 Action Plan , with a view to understanding how WHO Europe currently operates as a 28 29 30 knowledge organisation. A rather more cursory analysis of the history of WHO 31 32 knowledge production and mobilisation in this area since the 1970s was included to 33 34 provide institutional context. In the course of the analysis, however, we agreed that 35 36 this longer history warranted more detailed attention for the light it throws on 37 38 39 tensions between WHO’s aspirations and what it has been able to achieve in 40 41 generating and mobilising knowledge about mental health provision in Europe. 42 43 Additional research into the published literature was therefore conducted, and the 44 45 entire corpus of data re-analysed from a historiographical perspective to produce the 46 47 present paper. 48 49 50 51 52 Origins of WHO Europe’s approach to mental health 53 54 55 56 57 58 59 60 http://mc.manuscriptcentral.com/(site)-7- Page 9 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 The years following the Second World War saw dramatic growth in international 4 5 activity around mental health policy,9 including at the newly-established World Health 6 7 Organization. In 1948, a Mental Health Unit (initially a ‘section’ of the Public Health 8 9 10 Division) was created at WHO’s Geneva headquarters, and an Expert Committee on 11 12 Mental Health was convened in 1949, meeting more or less annually thereafter. The 13 14 work of the committee was complemented and supported by the appointment of 15 16 additional study groups, as well as by various ad-hoc seminars and conferences, 17 18 For Peer Review 19 often organized jointly with other bodies including the World Federation for Mental 20 21 Health (formally constituted in London in 1948), ILO, UNESCO and other UN 22 23 agencies. 10 These activities gave rise to a steady stream of publications including 24 25 technical reports and conference proceedings, many of which continue to be cited as 26 27 classics in the field. 28 29 30 31 32 From the start, WHO’s approach to mental health went far beyond conventional 33 34 psychiatry. WHO’s first Director General was Brock Chisholm, a Canadian 35 36 psychiatrist and medical statesman who saw the advancement of mental health as 37 38 39 part of a broad programme of ‘social medicine’ that would deal as much with the 40 41 economic and social dimensions of health and illness as with the biology of 42 43 disease. 11 This expansive understanding of mental health was reinforced when 44 45 46 ______47 9 Gijswijt-Hofstra and Oosterhuis, ‘Introduction’. 48 49 50 10 World Health Organization, WHO and Mental Health 1949-1961 (Geneva: WHO, 1962). 51 52 53 11 John Farley, Brock Chisholm, the World Health Organization, and the Cold War (Vancou- 54 55 ver: University of British Columbia Press, 2008); Ian Dowbiggin, ‘Prescription for Survival: 56 57 Brock Chisholm, Sterilization and Mental Health in the Cold War Era’, in James E. Moran 58 59 60 http://mc.manuscriptcentral.com/(site)-8- Manuscripts submitted to (i)Social History of Medicine(/i) Page 10 of 48

1 2 3 Chisholm appointed Ronald Hargreaves, from the Tavistock Institute in London, to 4 5 set up WHO’s Mental Health Section. According to his obituarist, ‘Hargreaves was 6 7 not concerned so much to establish a division for the furthering of treatment of 8 9 10 mental disorder as to ensure that all the preventive measures undertaken by W.H.O. 11 12 12 had their due mental hygiene component’. Under the leadership of Chisholm and 13 14 Hargreaves, WHO adopted a broadly community-based, preventive approach to 15 16 mental health and mental illness, exemplified by the Expert Committee’s third report, 17 18 For Peer Review 19 the influential WHO Technical Report on The Community Mental Hospital , which 20 13 21 appeared in 1953. At a time when mental health care in developed countries 22 23 remained overwhelmingly organised around the confinement of the mentally ill in 24 25 large psychiatric institutions, WHO’s commitment to preventive and public health 26 27 aspects of mental health was pioneering and distinctly reformist. This approach 28 29 30 remains dominant within WHO to the present day. 31 32 33 34 Seen in wider perspective, however, mental health was a matter of rather peripheral 35 36 concern within WHO, at least during the organisation’s early years. Globally, WHO’s 37 38 39 attention was principally directed to the pressing health problems of the developing 40 41 world, and that tendency only became more marked as growing numbers of newly- 42 43 ______44 45 and David Wright, eds, Mental Health and Canadian Society (Kingston and Montreal: McGill- 46 47 Queen’s University Press, 2006), 176-192. 48 49 50 12 K.S., ‘G.R. Hargreaves, O.B.E., M.R.C.S., L.R.C.P., M.Sc., F.R.C.P.Ed.’, British Medical 51 52 Journal , 5 January 1963, 62-63, 62. 53 54 55 13 World Health Organization, The Community Mental Hospital. Third Report of the Expert 56 57 Committee on Mental Health , WHO Technical Report Series no 73 (Geneva: WHO, 1953). 58 59 60 http://mc.manuscriptcentral.com/(site)-9- Page 11 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 independent countries joined the organisation through the 1950s and 1960s. For 4 5 many of these countries, the most urgent issues revolved around implementation of 6 7 basic sanitary measures, the provision of minimal levels of health care, and efforts to 8 9 10 combat infectious disease. As a result, interest in mental health increasingly shifted 11 12 away from WHO headquarters in Geneva to the organisation’s European Regional 13 14 Office in Copenhagen. 14 As early as 1962, a WHO review of work in the area of 15 16 mental health noted that ‘as the European Office is not so preoccupied with the 17 18 For Peer Review 19 communicable diseases as the other Regional Offices, it is not surprising that it has 20 15 21 given a lead in mental health work of a high standard’. This regional focus was 22 23 formalised in September 1970, when the European Regional Committee approved a 24 25 ‘long-term programme’ in mental health that aimed at replacing narrowly psychiatric 26 27 approaches to mental illness with ‘a new model of care: comprehensive preventive, 28 29 30 treatment and rehabilitation services delivered in the community by multidisciplinary 31 32 teams of health professionals’.16 33 34 35 36 ______37 14 Uniquely in the UN system, WHO is divided into six Regional Offices, the Directors of 38 39 which are primarily accountable to the countries within their respective regions. While the 40 41 European Regional Office enjoys considerable autonomy over policy, however, the fact that 42 43 health systems in the member countries are mostly well developed and effectively university 44 45 means that the Office receives little funding from WHO headquarters. L. Lerer and R. 46 47 Matzopoulos, R. (2000), '"The worst of both worlds": the management reform of the World 48 49 Health Organization', International Journal of Health Services , 2000, 31(2) , 415-438. 50 51 52 15 WHO, WHO and Mental Health 1949-1961 , 6. 53 54 55 16 WHO Europe, Sixty Years of WHO in Europe , (Copenhagen: WHO Regional Office for Eu- 56 57 rope, 2009), 20; Hugh L. Freeman, Tom Fryers, and John H. Henderson, Mental Health Ser- 58 59 60 http://mc.manuscriptcentral.com/(site)-10- Manuscripts submitted to (i)Social History of Medicine(/i) Page 12 of 48

1 2 3 4 5 May’s survey 6 7 8 9 10 This orientation towards comprehensive, multidisciplinary, community-based mental 11 12 health services owed much to the European Office’s first Mental Health Officer, a 13 14 psychiatrist called Tony May. As one of our respondents observed, the effect of 15 16 May’s appointment was essentially ‘to give mental health a public health direction … 17 18 For Peer Review17 19 It’s not psychiatry we’re talking about, it’s mental health’. May regarded the 20 21 collection of systematic information on the state of mental health services as crucial 22 23 if policy was to be reoriented in this way. He accordingly ensured that the first phase 24 25 of WHO Europe’s ‘long term programme’ in mental health was devoted to what 26 27 would later be described as ‘a large-scale “intelligence” operation’,18 that was 28 29 30 intended to provide the first comprehensive survey of mental health services across 31 32 WHO’s European Region. 33 34 35 36 May’s approach to data collection was typically technocratic in its aims. In 1970, a 37 38 39 working group on the classification and evaluation of services had concluded that 40 41 ‘only lip-service was being paid to the scientific planning of mental health services 42 43 44 45 46 ______47 48 49 vices in Europe: 10 Years On (Copenhagen: World Health Organization Regional Office for 50 51 Europe, 1985), 2. 52 53 17 Interview, 23 July 2008. 54 55 56 18 Freeman, Fryers and Henderson, Mental Health Services in Europe , 14. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-11- Page 13 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 through the collection of suitable statistics’.19 May agreed that ‘Efficient organization 4 5 depends on the collection and analysis of uniform data’,20 and he accordingly drew 6 7 up a detailed questionnaire that was eventually sent to each of the thirty countries 8 9 10 that made up the European Region at that time. The survey was conceived as a 11 12 way of ‘documenting aspects of WHO’s long-term programme in mental health’, and 13 14 was intended to identify developments in particular countries ‘which could be useful 15 16 for the Region as a whole’.21 17 18 For Peer Review 19 20 21 In retrospect, May’s survey has assumed considerable historical significance: 22 23 according to one of our interviewees, ‘It was a seminal document in WHO… a 24 25 tabulation of mental health services in Europe’, which demonstrated for the first time 26 27 the need ‘to know where you’re starting from … There were your gaps, there were 28 29 22 30 your challenges’. However, May himself saw his survey as falling rather short of 31 32 what he had hoped. Specifically, it failed to produce the kind of standardised data 33 34 that would enable him to compare the organisation and effectiveness of mental 35 36 health systems in different countries. His questionnaire was designed to ask for no 37 38 39 more than the minimum information that he considered necessary for effective 40 41 administration of mental health services. But even basic information was often 42 43 unavailable. A preliminary study conducted among eight countries quickly revealed 44 45 ______46 19 Ibid. 47 48 49 20 Anthony R. May, Mental Health Services in Europe. A Review of Data Collected in Re- 50 51 sponse to a WHO Questionnaire (Geneva: WHO, 1976), 12, 52 53 54 21 Ibid., 1. 55 56 57 22 Interview, 23 July 2008 58 59 60 http://mc.manuscriptcentral.com/(site)-12- Manuscripts submitted to (i)Social History of Medicine(/i) Page 14 of 48

1 2 3 that ‘there were many gaps in the kind of data which planners might reasonably 4 5 expect to have at their disposal’,23 and this judgement was confirmed when the 6 7 revised questionnaire was eventually sent out to all thirty countries in the region. 8 9 10 11 12 Moreover, such data as were generated by the survey were more effective in 13 14 demonstrating the incommensurability of different national mental health systems 15 16 than in providing a basis for comparing them. Despite May’s care in drawing up the 17 18 For Peer Review 19 questionnaire, and in following up his respondents in the hope of clarifying their 20 21 reports, the data were vitiated by a lack of consistent criteria and terminology of 22 23 reporting. Consequently, the results precluded any possibility of rigorous 24 25 comparative analysis. 24 Later commentators sought to construe May’s survey in a 26 27 more positive light: not only had it demonstrated that international surveys were 28 29 30 possible, but ‘A series of imprecise yet recognizable patterns had emerged, which 31 32 could provide the basis for future policy statements and inquiries’.25 On their own, 33 34 however, such imprecise generalisations were an inadequate basis for technocratic 35 36 policy interventions. 37 38 39 40 41 Henderson’s survey 42 43 44 45 In 1980, May retired from the post of Regional Advisor in Mental Health, and was 46 47 replaced by John Henderson, another psychiatrist with a strong commitment to 48 49 50 ______23 51 May, Mental Health Services in Europe , 1. 52

53 24 54 May, Mental Health Services in Europe , 1-2. 55 56 25 Freeman, Fryers and Henderson, Mental Health Services in Europe , 27. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-13- Page 15 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 community-based mental health services. Henderson shared May’s conviction that 4 5 data collection was the key to reform of mental health services, and in 1982 he 6 7 initiated his own survey to assess what progress had been made in the ten years 8 9 10 since May had undertaken his study of mental health services in Europe. He was 11 12 joined in this endeavour by Hugh Freeman and Tom Fryers, who had pioneered the 13 14 provision of community mental health services in the deprived northern English city 15 16 of Salford during the 1960s. 26 17 18 For Peer Review 19 20 21 Initially, Henderson, Freeman and Fryers sought to revive the kind of explicitly 22 23 comparative and normative approach that May’s survey had failed to achieve. They 24 25 were ambitious to design a survey instrument that would produce data that would be 26 27 ‘consistent’ and ‘comparable’, and they hoped that their survey would ‘not only 28 29 30 illustrate service development – or lack of it – between the beginning of the 1970s 31 32 and the beginning of the 1980s, but will also help to show the way to make it easier 33 34 to undertake a similar review of progress by the beginning of the 1990s’.27 Like May 35 36 before them, however, they quickly realised that patchy data and lack of 37 38 39 standardised reporting criteria would make rigorous comparison of different national 40 41 systems impossible. Inconsistency in the available data in turn reflected deeper 42 43 differences in the conceptual basis of mental health policy in different countries, they 44 45 observed; attempts at comparison would inevitably be confounded by, among other 46 47 48 ______49 26 Valerie E. Harrington, ‘Voices Beyond the Asylum: A Post-war History of Mental Health 50 51 Services in Manchester and Salford’ (unpublished PhD thesis, University of Manchester, 52 53 2008). 54 55 56 27 Freeman, Fryers and Henderson, Mental Health Services in Europe , 4. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-14- Manuscripts submitted to (i)Social History of Medicine(/i) Page 16 of 48

1 2 3 things, divergent ideas about ‘mental health’, prevention, and the respective roles of 4 5 mental health service staff, psychiatric hospitals and community mobilisation. 28 6 7 8 9 10 Consequently, they decided instead to tailor their methods to make the most of such 11 12 data as were readily available. In place of direct measurement, they set out to 13 14 identify ‘general “indicators” of progress in mental illness care’ 29 of a kind ‘that are 15 16 theoretically susceptible to measurement in terms of the accessible information’.30 17 18 For Peer Review 19 The measures they adopted – including metrics such as ‘Reducing the number of 20 21 mental hospitals with more than 1000 beds’, ‘Decreased length of inpatient stay’, and 22 23 ‘Changes in the numbers of nurses’ – reflected their presuppositions about what 24 25 constituted good mental health care, and much of their final report consisted of 26 27 lengthy tabulations of data under these and other heads. Even these surrogate 28 29 30 measures of mental health care proved difficult to interpret, however. Consequently, 31 32 the authors admitted: ‘To try to gain instructive generalizations for many of the 33 34 ‘indicators’ ... we have used various summations, averages, proportions and ratios 35 36 that could not be accommodated in the tables’.31 Repeatedly, they lamented that 37 38 39 their data were ‘far from complete’ and ‘insufficient to permit comparison’, ‘not 40 41 consistent’, incapable of being ‘satisfactorily ... interpreted’, ‘misleading’ and ‘variable 42 43 44 45 46 47 ______48 28 49 Ibid., 3, 44, 97. 50 51 29 Ibid., 4. 52 53 54 30 Ibid., 29. 55 56 57 31 Ibid., 30. 58 59 60 http://mc.manuscriptcentral.com/(site)-15- Page 17 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 in quality’.32 In consequence, only the most limited comparison between countries 4 5 had been possible. 33 6 7 8 9 10 Henderson and his co-authors were also pessimistic about the likelihood that such 11 12 problems would be overcome in future. While urging that ‘the improved collection of 13 14 information on mental health services is an activity deserving collaboration, for which 15 16 WHO is the most appropriate international agency’,34 they saw serious obstacles in 17 18 For Peer Review 19 the way of such initiatives. National governments often lacked the capacity to return 20 21 adequate data, or failed to recognise the value of ‘international knowledge of mental 22 23 health’ for national planning. 35 Even where effective information systems existed, 24 25 governments were often reluctant to harmonise them with one another. Resistance 26 27 to WHO efforts at technocratic standardisation had been voiced as early as 1979, 28 29 30 when mental health advisers from a number of countries had discussed the 31 32 implications of May’s report. While agreeing that the report was a useful ‘yardstick in 33 34 measuring and comparing services in different countries’, ‘At the same time, the 35 36 advisers expressed their resistance to having national information systems bound by 37 38 36 39 any system established by WHO’. Faced with such barriers, and conscious of the 40 41 shortcomings of their own survey, Henderson and his colleagues concluded that 42 43 44 ______45 32 46 Ibid., 31, 49, 55, 64, 65. 47 48 33 49 Ibid., 71. 50 51 34 Ibid., 4. 52 53 54 35 Ibid., 97. 55 56 57 36 Ibid., 98-99. 58 59 60 http://mc.manuscriptcentral.com/(site)-16- Manuscripts submitted to (i)Social History of Medicine(/i) Page 18 of 48

1 2 3 there was little point in attempting to pursue further comparative data-gathering 4 5 initiatives. 6 7 8 9 10 Pilot study areas 11 12 13 14 Given the impediments facing comparative surveys, Henderson and his co-authors 15 16 now proposed that WHO Europe’s investigations into mental health services should 17 18 For Peer Review 19 instead concentrate on a ‘different approach’ based on the study of so-called ‘pilot 20 37 21 study areas’. They were referring to a separate programme of investigations that 22 23 began as early as 1973, when May had suggested that, in addition to surveying 24 25 mental health provision across the region’s member states, it would also be worth 26 27 undertaking more detailed, in-depth investigations of much smaller areas. 38 The 28 29 39 30 proposal was subsequently taken up by a WHO Europe working party, and the 31 32 study was eventually expanded to include a total of 21 ‘pilot study areas’ in 16 33 34 countries. 40 35 36 37 38 ______39 37 40 Ibid., 101. 41 42 38 WHO Europe, Mental Health Services in Pilot Study Areas. Report on a Working Group 43 44 45 (Copenhagen: WHO Regional Office for Europe, 1973); WHO Europe, Mental Health Ser- 46 47 vices in Pilot Study Areas. Report on a European Study (Copenhagen: WHO Regional Of- 48 49 fice for Europe, 1987), vii. 50 51 39 WHO Europe, Changing Patterns in Mental Health Care. Report on a WHO Working 52 53 Group (Copenhagen: WHO Regional Office for Europe, 1978). 54 55 56 40 WHO Europe, Mental Health Services in Pilot Study Areas. Report on a European Study . 57 58 59 60 http://mc.manuscriptcentral.com/(site)-17- Page 19 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 The methodology employed to study these areas was quite distinct from that 4 5 adopted in the very broad national and international surveys attempted by May and 6 7 Henderson. ‘Pilot study areas’ were generally quite small – often as small as a 8 9 10 single municipality or district – permitting detailed description of the organisation and 11 12 operation of mental health services in each area. Rather than looking for broad 13 14 comparisons between areas, those involved in the pilot study area project were more 15 16 interested in developing a deep understanding of how each area-based service 17 18 For Peer Review 19 functioned in its own right: ‘The focus of enquiry, in short, was to be fixed not on 20 21 national trends but rather on a number of selected local experiments which might 22 23 serve as demonstration models for future development’.41 This kind of insight into 24 25 the detailed workings of local services could not be gleaned from a standardised 26 27 survey instrument such as a questionnaire. ‘The only way to get to know how a 28 29 30 psychiatric service functions is to work in it for a period of time’, one participant 31 32 observed. ‘Written descriptions, even visits, will not convey the nuances and 33 34 subtleties of administration, organization and function that give each service its 35 36 unique character’.42 37 38 39 40 41 This kind of holistic, case-based knowledge of local services did not lend itself to 42 43 standardised forms of comparison between different areas. Indeed, the pilot study 44 45 area project served to underline that even when apparently similar methods of 46 47 record-keeping were employed in different areas, differences in how those records 48 49 50 ______51 41 WHO Europe, Changing Patterns in Mental Health Care , 2. 52 53 54 42 D. Walsh, ‘A Typical Pilot Study Area’, in WHO Europe, Mental Health Services in Pilot 55 56 Study Areas. Report on a European Study , ch. 4, 73. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-18- Manuscripts submitted to (i)Social History of Medicine(/i) Page 20 of 48

1 2 3 were used and interpreted often meant that they were not strictly comparable. 43 4 5 Freeman and Fryers concluded: ‘With such a wealth of data, and with the range of 6 7 human experience encompassed by mental health services, it is not surprising that 8 9 10 general, overall comparisons of areas were found impossible’. Far from regretting 11 12 the impossibility of general comparisons, however, Freeman and Fryers now saw it 13 14 as confirming what they regarded as an important message about mental health 15 16 service planning: ‘this [i.e. the failure of comparison] reinforced the very proper 17 18 For Peer Review44 19 mistrust of the idea of a “blueprint” for services’. Increasingly, they were moving 20 21 away from a technocratic approach to mental health policy, towards one which 22 23 supposed that services should be organically tailored to meet local needs and 24 25 opportunities. 26 27 28 29 30 This also entailed rather different methods not just of collecting but also of circulating 31 32 the kind of knowledge on which policy should be based. Technocratic approaches to 33 34 policy making tended to suppose that the necessary information could be collected 35 36 and analysed centrally, and that the results could then be disseminated in the form of 37 38 39 standardised data and policy documents. By contrast, the kind of deep personal 40 41 knowledge of local circumstances that Freeman and Fryers had come to prefer 42 43 resisted easy communication in documentary form. Consequently, advocates of the 44 45 46 ______47 43 A. Dupont, ‘Mental Health Information Systems’, in WHO Europe, Mental Health Services 48 49 in Pilot Study Areas. Report on a European Study , ch. 2. 50 51 52 44 Hugh L. Freeman and Tom Fryers, ‘The Pilot Areas Study and the Context of Mental 53 54 Health Care’, in WHO Europe, Mental Health Services in Pilot Study Areas. Report on a Eu- 55 56 ropean Study , ch. 7, 157. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-19- Page 21 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 pilot study areas project urged that publication of written reports should be 4 5 supplemented by opportunities for individuals to meet and share the personal 6 7 knowledge and experience that they embodied: ‘An important feature of the project 8 9 10 was the regular, approximately annual meetings of the pilot study area directors 11 12 and/or their representatives and collaborators,’ which provided ‘an important forum 13 14 for the exchange of information about psychiatric care under greatly varying 15 16 sociocultural and economic conditions, largely inexpressible in statistical terms’.45 17 18 For Peer Review 19 20 21 Participants in the scheme had little doubt that such exchanges had led to real 22 23 improvements in their respective mental health services, even if they could not 24 25 produce statistics to prove it. The work of describing each area ‘must have’ caused 26 27 team members to assess the structure and function of those services, while also 28 29 46 30 making them aware of developments elsewhere, insisted one participant; while 31 32 Freeman and Fryers argued that ‘the evidence suggests that the study itself has 33 34 contributed significantly to progress in most of [the areas]’.47 WHO Europe’s efforts 35 36 to reform mental health by technocratic means might have foundered, but some 37 38 39 actors, at least, were persuaded that more permissive, personally-mediated methods 40 41 of learning by sharing examples of good practice had proved successful. 42 43 44 45 The International Classification of Mental Health Care 46 47 ______48 45 49 R. Giel and J.U. Hannibal, ‘From Phases I and II to Phase III’, in WHO Europe, Mental 50 51 Health Services in Pilot Study Areas. Report on a European Study , ch. 1, 9,11. 52 53 46 Walsh, ‘A Typical Pilot Study Area’, 74. 54 55 56 47 Freeman and Fryers, ‘The Pilot Areas Study and the Context of Mental Health Care’, 160. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-20- Manuscripts submitted to (i)Social History of Medicine(/i) Page 22 of 48

1 2 3 4 5 One final attempt was made during the late 1980s to generate standardised, 6 7 comparable data about different national mental health systems within WHO’s 8 9 10 European region. The impetus on this occasion came not from the Regional Office 11 12 but from the central office in Geneva, who wished to improve knowledge of mental 13 14 health provision worldwide. Knowing how much work had already been done to 15 16 describe the state of mental health services within the European region, in 17 18 For Peer Review 19 November 1988 WHO convened an expert meeting in the Department of Social 20 21 Psychiatry of the University of Groningen, one of the WHO Europe Collaborative 22 23 Centres that had participated in the pilot study areas programme. 48 The meeting 24 25 acknowledged the shortcomings of previous efforts to compile comparative data on 26 27 mental health service provision: May’s and Henderson’s surveys had generated 28 29 30 ‘detailed and reliable’ information that provided a ‘general picture’ of mental health 31 32 services in the countries surveyed, but had failed to achieve the kind of 33 34 ‘standardization’ of data necessary to permit comparison between countries. What 35 36 was needed, the meeting declared, was ‘a classification of services in mental health 37 38 39 care that would facilitate comparisons between care provided in different institutions 40 49 41 and regions’. 42 43 44 45 ______46 48 WHO Europe, The WHO International Classification of Mental Health Care. Report on a 47 48 WHO Meeting, Groningen, Netherlands, 2-3 November 1988 (Copenhagen: WHO Regional 49 50 Office for Europe, 1990); A. de Jong, ‘Development of the International Classification of 51 52 Mental Health Care (ICMHC)’, Acta Psychiatrica Scandinavica , 2000, 102 (Suppl. 405 ), 8- 53 54 13. 55 56 57 49 WHO Europe, The WHO International Classification of Mental Health Care , 1. 58 59 60 http://mc.manuscriptcentral.com/(site)-21- Page 23 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 The meeting suggested that such a classification might be achieved by supposing 4 5 that mental health services were made up of discrete ‘modules of care’. The nature 6 7 and identity of such modules could not be assumed in advance, since mental health 8 9 10 care differed so markedly from one locality to another. But it could be defined 11 12 empirically, for each location, by looking at how staff were organised to deliver 13 14 particular kinds of care. A standardised protocol might then be drawn up to ensure 15 16 that the same kinds of data were collected about every module of care. 50 However, 17 18 For Peer Review 19 the meeting recognised that this standardisation would be harder to deliver in 20 21 practice than on the page, noting that ‘It is not really possible to give strict rules for 22 23 the actual subdivision of an institution into modules of care’. Rather, standardisation 24 25 would depend heavily upon the judgement, skill and experience of the observer. 26 27 Consequently, ‘To guarantee the standardization of the description of mental health 28 29 30 care services using the classification and because this concerns a complex matter 31 32 requiring expertise, the application should be performed by a trained assessor’.51 33 34 Even then, the assessor would probably not have a sufficient understanding of any 35 36 particular institution to ensure accurate classification, and so would need in addition 37 38 39 to draw on the knowledge and experience of ‘representatives of the institution to be 40 52 41 classified’ such as service managers. And since local representatives would be 42 43 concerned to ensure that their institutions were seen in the best possible light, ‘Great 44 45 46 47 48 49 50 ______50 51 Ibid., 4. 52

53 51 54 Ibid. 55 56 52 Ibid., 5. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-22- Manuscripts submitted to (i)Social History of Medicine(/i) Page 24 of 48

1 2 3 care should then, however, be taken in guarding the objectivity of the assessment’, 4 5 the authors warned.53 6 7 8 9 10 Following the meeting, the challenge of drawing up a workable and reliable protocol 11 12 for data collection was passed to the Groningen team, who in 1996 published what 13 14 they called the International Classification of Mental Health Care (ICMHC). The 15 16 ICMHC specified that, for the sake of convenience, modules of care might most 17 18 For Peer Review 19 effectively be equated with administrative units of service provision, while the data to 20 21 be collected were categorised into ten possible ‘modalities of care’. Each module of 22 23 care was to be scored in terms of the range and specialisation of the interventions it 24 25 provided under each of those modalities. Field trials showed that the ICMHC 26 27 produced reliably comparable descriptions of services when used by assessors 28 29 54 30 familiar with the services they were assessing. Other researchers agreed that the 31 32 ICMHC was ‘one of the most highly developed of the instruments available for 33 34 classification and description of aspects of services. It allows comparisons between 35 36 37 38 39 40 41 42 43 44 45 46 ______47 53 Ibid., 6. 48 49 50 54 A. de Jong, International Classification of Mental Health Care. A Tool for Describing Ser- 51 52 vices Providing Mental Health Care (Groningen: Department of Social Psychiatry, WHO Col- 53 54 laborating Centre, University of Groningen, 1996); de Jong, ‘Development of the Internation- 55 56 al Classification of Mental Health Care’. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-23- Page 25 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 catchment areas and between countries of the interventions and activities available 4 5 within mental health facilities’.55 6 7 8 9 10 However, there were clear limits to the applicability of the ICMHC. ‘The instrument is 11 12 highly developed as a means of assessing the content of the “package of care” 13 14 provided by a mental health facility, but less developed as a means of classifying 15 16 services into basic types and of describing the set of services available in a 17 18 For Peer Review56 19 catchment area’, noted one group of reviewers. In this regard, the ICMHC might 20 21 be better seen as adding a comparative dimension of the kind of detailed local 22 23 studies undertaken under WHO Europe’s pilot study areas programme than as a 24 25 means of generating broadly comparative knowledge of mental health service 26 27 provision in different countries. Another limitation was acknowledged by the 28 29 30 Groningen team themselves. In compiling the instrument, they had to make certain 31 32 compromises in order to deliver a workable protocol. Most notably, they had decided 33 34 to exclude from their purview ‘those social services which were seen to work more 35 36 and more closely in the community with mental health care services in the process of 37 38 39 delivering care’, since attempting to bring them within the scope of the instrument 40 57 41 ‘would have required resources that were lacking’. The ICMHC thus explicitly 42 43 excluded one of the aspects of mental health provision that most interested policy 44 45 ______46 55 47 Sonia Johnson, Luis Salvador-Carulla and the EPCAT group, ‘Description and Classifica- 48 49 tion of Mental Health Services: A European Perspective’, European Psychiatry , 1998, 13 , 50 51 333-41, 339, 52 53 56 Ibid., 340. 54 55 56 57 de Jong, ‘Development of the International Classification of Mental Health Care’, 9. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-24- Manuscripts submitted to (i)Social History of Medicine(/i) Page 26 of 48

1 2 3 makers at WHO Europe, namely the shift from a predominantly curative approach to 4 5 mental health care towards one characterised by a community-based and preventive 6 7 approach to public mental health. 8 9 10 11 12 These limitations are evident in the way that the ICMHC has since been put to use. 13 14 While it has proved serviceable as a means of conducting detailed comparison 15 16 between local services of a similar kind 58 or in similar localities, 59 it does not appear 17 18 For Peer Review 19 to have been employed in large-scale international surveys of mental health service 20 21 provision more generally. Notably, it was not used in WHO’s own later surveys of 22 23 mental health provision either within Europe or globally (see below). 24 25 26 27 The National Counterparts 28 29 30 31 32 For much of the remainder of the 1990s, the focus of WHO Europe’s mental health 33 34 programme was diverted away from efforts to survey mental health service provision 35 36 across the region, and towards more immediately pragmatic needs. 60 Conferences 37 38 39 and working groups continued to meet and report on a variety of topics, but their 40 41 ______42 58 For instance C. Wright et al., ‘Assertive Community Treatment Teams in London: Models 43 44 45 of Operation. Pan London Assertive Community Treatment Study Part I’, British Journal of 46 47 Psychiatry , 2003, 183 , 132–8. 48 49 59 Grigory Rezvyy et al., ‘The Barents project in Psychiatry: A Systematic Comparative Men- 50 51 tal Health Services Study Between Northern Norway and Archangelsk County’, Social Psy- 52 53 chiatry and Psychiatric Epidemiology , 2007, 42 , 131-139. 54 55 56 60 Interview, 19 January 2009 57 58 59 60 http://mc.manuscriptcentral.com/(site)-25- Page 27 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 activities were guided primarily by the Health For All targets set by WHO in 4 5 Geneva, 61 and by the urgent need to redress the state of mental health services in 6 7 many of the Eastern European countries newly opened up to Western scrutiny and 8 9 62 10 influence. By the end of the decade, however, a number of factors would come 11 12 together to stimulate renewed efforts to build a Europe-wide strategy to review and 13 14 reform mental health services. 15 16 17 18 For Peer Review 19 One factor was the appointment, in 1998, of the Norwegian ex-Prime Minister, Gro 20 21 Harlem Brundtland, as Director General of WHO. Mental health reform was high on 22 23 Brundtland’s list of concerns, and as Director General she would call repeatedly for 24 25 the development of a more preventive, community-based approach to mental health 26 27 worldwide. In keeping with this vision, WHO devoted the World Health Report for 28 29 63 30 2001 to an urgent statement on Mental Health: New Understanding, New Hope , 31 32 ______33 61 On the meaning and context of the Health for All targets, see Ilona Kickbusch, ‘The 34 35 Contribution of the World Health Organization to a New Public Health and Health Promotion’, 36 37 American Journal of Public Health , 2003, 93 , 383-388. 38 39 40 62 World Health Organization, Evaluation of Community-based Mental Health Care Systems: 41 42 Establishment of a Data Bank. Report on a WHO Consultation, Warsaw, 23-24 August 1990 43 44 (Geneva: WHO, 1992); World Health Organization, Quality Assurance Indicators in Mental 45 46 Health Care. Report on a WHO Consensus Meeting, Stockholm, 30-31 August, 1993 (Ge- 47 48 neva, WHO, 1994); World Health Organization, Patient Outcome Measures in Mental Health. 49 50 Report on a WHO Consensus Meeting, Stockholm, 23-24 November, 1995 (Geneva, WHO, 51 52 1996). 53 54 55 63 World Health Organization, World Health Report 2001. Mental Health: New Understand- 56 57 ing, New Hope (Geneva: WHO, 2001). 58 59 60 http://mc.manuscriptcentral.com/(site)-26- Manuscripts submitted to (i)Social History of Medicine(/i) Page 28 of 48

1 2 3 accompanied by an atlas detailing the distribution of mental health resources across 4 5 the world. 64 Meanwhile, concern at the burden of mental ill health was also growing 6 7 outside the WHO, notably within the European Union, and in 1999 a prominent 8 9 10 Conference on the Promotion of Mental Health and Social Inclusion was hosted by 11 65 12 Finland during its tenure of the European Presidency. The need for WHO Europe 13 14 to respond to these pressures was implicitly acknowledged in the following year, 15 16 when Marc Danzon was appointed Regional Director. Danzon had a clinical 17 18 For Peer Review 19 background as a child psychiatrist, and before being appointed overall Regional 20 21 Director of WHO Europe had served as Regional Director of Communications and 22 23 then of Health Services, where he was responsible for overseeing the mental health 24 25 programme. On his appointment, Danzon persuaded the Finnish government to co- 26 27 sponsor what would become the first ever WHO European Ministerial Conference on 28 29 30 Mental Health, to be held in Helsinki in January 2005. 31 32 33 34 The Ministerial Conference provided an opportunity to make a major statement about 35 36 the direction of mental health policy in Europe. In preparing for the Conference, 37 38 39 however, WHO Europe was once again confronted with the paucity of information 40 41 ______64 42 World Health Organization, Atlas: Mental Health Resources in the World, 2001 (Geneva: 43 44 WHO, 2001); World Health Organization, Project Atlas: Information and Evidence for Better 45 46 Decisions (2009), http://www.who.int/mental_health/evidence/atlasmnh/en/index.html, ac- 47 48 cessed 28 February 2010. 49 50 65 51 V. Lehtinen, Action for Mental Health. Activities co-funded from European Community 52 53 Public Health Programmes 1997-2004 , report prepared for the European Commission, 54 55 Health and Consumer Protection Directorate-General (Luxembourg: European Commis- 56 57 sion/STAKES, 2004). 58 59 60 http://mc.manuscriptcentral.com/(site)-27- Page 29 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 about the current state of mental health services in different member countries. 4 5 Fortunately, steps to fill the gap were already being taken by Wolfgang Rutz, who in 6 7 1998 had joined WHO Europe as Regional Advisor in Mental Health. Rutz had set 8 9 10 about compiling information on the condition and effectiveness of mental health 11 12 services within the region. Llike other Regional Advisors before him, he had quickly 13 14 discovered that systematic comparative data were extremely difficult to come by. 66 15 16 Rather than attempt to conduct yet another survey of services, however, Rutz 17 18 For Peer Review 19 instead instituted a network of national ‘counterparts’ – individuals from each country 20 21 within the region who were responsible for liaison between their respective countries 22 23 and the WHO Regional Office. 67 The national counterparts met twice a year to 24 25 discuss the development of mental health services across Europe, and their 26 27 meetings provided a further opportunity to share personal knowledge and experience 28 29 30 of mental health services in different national settings. 31 32 33 34 The nature of the knowledge shared by the national counterparts is apparent from 35 36 the compendium of ‘country reports’ that they wrote to supplement the World Health 37 38 39 40 ______41 66 He did, however, manage to compile provisional figures on the incidence of mental illness 42 43 in different countries, using the Health For All database: Wolfgang Rutz, ‘Mental Health in 44 45 Europe: Problems, Advances and Challenges’, Acta Psychiatrica Scandinavica , 2001, 104 46 47 (suppl. 410 ), 15-20. 48 49 50 67 WHO Europe, Mental Health in Europe. Country Reports from the WHO European Net- 51 52 work on Mental Health (Copenhagen: WHO Regional Office for Europe, 2001); WHO Eu- 53 54 rope, WHO European National Mental Health Counterparts , 2007, 55 56 http://www.euro.who.int/mentalhealth/CtryInfo/20030717_2, accessed 28 February 2010. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-28- Manuscripts submitted to (i)Social History of Medicine(/i) Page 30 of 48

1 2 3 Report of 2001. 68 These were two- to three-page ‘briefing contributions’, intended 4 5 primarily for the use of the Regional Adviser and their fellow counterparts, which 6 7 provided ‘unpretentious and informative’ accounts of mental health planning, 8 9 10 legislation and service provision as well as ‘areas of progress’ and issues of concern 11 12 in each of the countries in the region. Like the earlier pilot study area reports, the 13 14 country reports eschewed any attempt at rigorous international comparison, opting 15 16 instead for ‘an impressionistic review describing the relevant efforts and 17 18 For Peer Review69 19 shortcomings as experienced by the counterpart’. Once again, in the absence of 20 21 comparative data about mental health services in different countries, WHO Europe 22 23 had opted for a more case-based, holistic understanding of effective service delivery. 24 25 This kind of knowledge would be crucial to the success of the 2005 Ministerial 26 27 Conference in setting the agenda for mental health policy in Europe. 28 29 30 31 32 The Ministerial Conference 33 34 35 36 The Ministerial Conference of 2005 might be seen as the apotheosis of the case- 37 38 39 based approach to developing mental health policy. Central to the proceedings of 40 41 the Conference were two documents: the Mental Health Declaration for Europe and 42 43 the Mental Health Action Plan for Europe , both of which were prepared before the 44 45 Conference and simply approved there without amendments. The form of these 46 47 documents is worth noting. The Declaration was basically a reassertion of WHO’s 48 49 50 long-standing commitment to community mental health, including the importance of 51 52 ______53 68 WHO Europe, Mental Health in Europe . 54 55 56 69 Ibid., i. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-29- Page 31 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 mental health promotion and other preventive measures, the superiority of 4 5 community-based services over large psychiatric institutions for the mentally ill, and 6 7 the value of NGOs and service user organisations in providing both preventive and 8 9 10 recovery-oriented services. It stressed the need for member countries to develop 11 12 policies ‘aimed at achieving mental well-being and social inclusion of people with 13 14 mental health problems’,70 and committed ministers to pursue implementation of the 15 16 Action Plan across the European Region ‘in accordance with each country’s 17 18 For Peer Review 19 constitutional structures and policies and national and subnational needs, 20 71 21 circumstances and resources’. The Action Plan in turn listed twelve ‘challenges’ 22 23 and a wide range of ‘actions to consider’ as means of addressing those challenges, 24 25 plus a short list of ‘milestones’ against which progress could be measured. 72 Both 26 27 documents were relatively short: the Declaration only six pages in length, and the 28 29 30 Action Plan just twice that. Strikingly, neither the Declaration nor the Action Plan 31 32 cited any evidence in support of the public mental health perspective or the particular 33 34 lines of action that they recommended. Rather, the two documents read more like a 35 36 statement of shared aims and values than an example of evidence-based policy. 37 38 39 40 41 This absence of evidence was partially mitigated by a set of fourteen ‘briefing 42 43 papers’ presented to the Ministerial Conference. 73 These papers served to back up 44 45 ______46 70 WHO Europe, Mental Health Declaration for Europe , 3. 47 48 49 71 Ibid., 4. 50 51 52 72 WHO Europe, Mental Health Action Plan for Europe . 53 54 73 55 Available at http://www.euro.who.int/mentalhealth/Publications/publications, accessed 29 56 57 March 2010. 58 59 60 http://mc.manuscriptcentral.com/(site)-30- Manuscripts submitted to (i)Social History of Medicine(/i) Page 32 of 48

1 2 3 the recommendations of the Declaration and Action Plan by providing empirical 4 5 information on a range of topics, including the mental health of children and young 6 7 people, stigma and social exclusion, and suicide prevention. Insofar as the briefing 8 9 10 papers cited statistical or other quantitative evidence, this was predominantly either 11 12 epidemiological or concerned the availability of psychiatric and other kinds of mental 13 14 health care across the European region. By contrast, information about the nature 15 16 and content of mental health services was chiefly case-based and qualitative in 17 18 For Peer Review 19 character, including brief descriptions of particular initiatives under way in different 20 21 countries. The briefing documents thus did not set out to provide systematic 22 23 evidence for the effectiveness of any particular form of intervention. Rather, the 24 25 initiatives they described served simply to exemplify the kinds of practical ways in 26 27 which the challenges identified in the Declaration and Action Plan might be 28 29 30 addressed; in effect, they were instances of good practice that other countries might 31 32 wish to emulate or adapt for their own purposes. To that end, they were selected 33 34 principally for the way that they embodied and exemplified the general aims and 35 36 values on which the Declaration and Action Plan were founded. 74 37 38 39 40 41 The way in which these examples of good practice were selected is also worth 42 43 noting. The briefing papers were themselves the outcome, not of any systematic 44 45 review of the available evidence, but rather of a whole series of committees, working 46 47 groups and ad hoc meetings that brought together a wide range of interested parties. 48 49 50 Much of the responsibility for planning the conference was delegated to a Steering 51 52 ______53 74 Jennifer Smith-Merry, Richard Freeman and Steve Sturdy, ‘Reciprocal Instrumentalism: 54 55 Scotland, WHO Europe, and Mental Health’, International Journal of Public Policy , in press 56 57 (accepted for publication 14 July 2010). 58 59 60 http://mc.manuscriptcentral.com/(site)-31- Page 33 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 Committee, which met every two or three months from 2002 to 2004, either in 4 5 Brussels or Copenhagen. In the course of its preparations, the Steering Committee 6 7 commissioned and reviewed various working papers and engaged with several other 8 9 10 projects, meetings and networks. It drew in particular on a number of ‘expert 11 12 committees’ that Rutz, as Regional Adviser on Mental Health, had established on 13 14 topics such as children and young people, depression and suicide, alcoholism, and 15 16 stigma and social exclusion. Several of these topics were also explored in a series 17 18 For Peer Review 19 of developmental ‘pre-conferences’ to which representatives of member states were 20 75 21 invited in the months leading up to the Ministerial Conference itself. 22 23 24 25 The whole process was concerned as much with securing a degree of common 26 27 understanding and common purpose between the representatives of different 28 29 30 national mental health systems as with formulating a rigorous, evidence-based policy 31 32 framework. Agreement needed to be reached on such fundamental ideas as what a 33 34 preventive, public-health approach to mental health policy might look like, or how 35 36 community-based mental health services might be organised. As Matt Muijen, who 37 38 39 replaced Rutz as Regional Adviser in May 2004, later recalled: ‘An area that required 40 41 attention at the drafting stage was the scope of mental health care. It proved 42 43 necessary, considering the expansion of responsibilities of mental health well 44 45 beyond the traditional roles of psychiatry in hospitals and outpatient settings, to 46 47 clarify boundaries and to determine priorities’.76 48 49 50 ______51 75 Freeman, Smith-Merry and Sturdy, WHO, Mental Health, Europe . 52 53 54 76 Matt Muijen, ‘Challenges for Psychiatry: Delivering the Mental Health Declaration for Eu- 55 56 rope’, World Psychiatry , 2006, 5, 113-117. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-32- Manuscripts submitted to (i)Social History of Medicine(/i) Page 34 of 48

1 2 3 4 5 Face-to-face meetings, and the opportunity to exchange knowledge of exemplary 6 7 mental health initiatives, were crucial to this process. In the absence of any pre- 8 9 10 agreed model of what constituted an appropriate mental health intervention, practical 11 12 on-the-ground experience of particular initiatives was far more useful than 13 14 centralised, technocratic knowledge of health systems. Indeed, practical experience 15 16 of working examples of community-based mental health care proved to be valuable 17 18 For Peer Review 19 currency in this regard: Scotland, which as a constituent country of the United 20 21 Kingdom did not have official representation within WHO Europe, was able to 22 23 leverage a space in the planning process, and ultimately at the Ministerial 24 25 Conference, on the grounds of having pioneered a number of particularly noteworthy 26 27 lines of community-oriented mental health work. 77 Practical, experience-based 28 29 30 knowledge of mental health service delivery was thus central to the policy process 31 32 that led to the signing of the Mental Health Declaration and Mental Health Action 33 34 Plan for Europe , 35 36 37 38 39 The baseline survey 40 41 42 43 At the same time, however, participants in the Ministerial Conference also reiterated 44 45 a desire for more systematic knowledge of mental health provision, of a kind that 46 47 would permit a more technocratic approach to policy. ‘In spite of rapid development, 48 49 50 the evidence base on preventive activities is still small and needs to be expanded’, 51 52 53 54 55 ______56 77 Smith-Merry, Richard Freeman and Steve Sturdy, ‘Reciprocal Instrumentalism’. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-33- Page 35 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 declared one of the briefing papers.78 ‘Unfortunately, to date, there has been little 4 5 implementation of evidence-based approaches to promotion and prevention across 6 7 Europe’, lamented another. 79 The Mental Health Action Plan for Europe therefore 8 9 10 suggested that relevant data should be collected ‘in order to assist in the effective 11 12 planning, implementation, monitoring and evaluation of an evidence-based 13 14 strategy’.80 15 16 17 18 For Peer Review 19 Contributors to the Ministerial Conference were especially concerned that such 20 21 evidence should be of a kind that would permit comparison between different 22 23 countries and different kinds of interventions. The Declaration accordingly endorsed 24 25 the need to ‘Produce comparative data on the state and progress of mental health 26 27 and mental health services in Member States’.81 WHO Europe quickly took steps to 28 29 30 implement this recommendation. The Regional Office did not have funds of its own 31 32 for this work, so turned to the European Commission for assistance. At the Helsinki 33 34 conference, Matt Muijen had explored with Markos Kyprianou, the European 35 36 Commissioner responsible for Health and Consumer Protection, the possibility that 37 38 39 40 41 42 43 ______44 78 WHO Europe, Mental Health Information and Research , Briefing Paper 4, 2005, 45 46 http://www.euro.who.int/document/MNH/ebrief04.pdf, accessed 30 March 2010. 47 48 49 79 WHO Europe, Mental Health Promotion and Mental Disorder Prevention , Briefing Paper 8, 50 51 2005, http://www.euro.who.int/document/mnh/ebrief08.pdf. 52 53 80 54 WHO Europe, Mental Health Action Plan for Europe . 55

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1 2 3 the Commission might support a survey of mental health provision in Europe; funds 4 5 for this purpose were subsequently written into EC grant funding for mental health. 82 6 7 8 9 10 Preparation of the survey questionnaire was led by the European Regional Office. 11 12 However, it is notable that the initial design of the survey questionnaire was not 13 14 based on the ICMHC, which as we saw above had been developed by WHO Europe 15 16 to permit strict comparisons between specific mental health services within the 17 18 For Peer Review 19 region. Rather, it was based on the Assessment Instrument for Mental Health 20 21 Systems, developed by WHO in Geneva as a tool to identify and assess the main 22 23 components of mental health systems in low and middle-income countries. 83 24 25 Evidently the Regional Office recognised that efforts to gather the kind of fine- 26 27 grained data specified by the ICMHC were likely to be self-defeating, and a more 28 29 30 broad-brush approach should be adopted, at least in the first instance. 31 32 33 34 A key concern throughout the drafting process was the desire to generate viable 35 36 indicators by which different national systems and different interventions could be 37 38 39 measured. As one of our informants put it, the drafting process was informed by 40 41 consideration of ‘what is it that can be turned into a variable and to an indicator 42 43 ______44 82 Interview, 18 November 2008. 45 46 47 83 Michelle Funk, Natalie Drew and Benedetto Saraceno, ‘Global Perspective on Mental 48 49 Health Policy and Service Development Issues: The WHO Angle’, in Martin Knapp et al., 50 51 eds, Mental Health Policy and Practice Across Europe (Maidenhead: Open University Press, 52 53 2007), 426-440; Shekhar Saxena et al., ‘WHO’s Assessment Instrument for Mental Health 54 55 Systems: Collecting Essential Information for Policy and Service Delivery’, Psychiatric Ser- 56 57 vices , 2007, 58 , 816-821. 58 59 60 http://mc.manuscriptcentral.com/(site)-35- Page 37 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 eventually’.84 Considerable care was therefore taken to design the instrument so as 4 5 to produce comparable results when applied in different national and regional 6 7 settings. Language was one obvious concern, and most countries translated the 8 9 10 questionnaire into their own languages. But technical vocabulary posed an 11 12 additional challenge; consequently the questionnaire was accompanied by a 13 14 glossary drawn from a range of other WHO documents, specialist publications and 15 16 expert advice. It was also crucial that the questionnaire should be equally applicable 17 18 For Peer Review 19 to different national mental health systems. Consequently, national counterparts 20 21 were closely involved in the later stages of drafting the questionnaire, scrutinising 22 23 and amending the questionnaire at two consultative meetings in March and October 24 25 2006. A participant recalled that at the second of these meetings, ‘We again had the 26 27 text of the questionnaire on the big screen and went through it question by question, 28 29 30 participants made comments that were added with track-changes and after the 31 32 meeting we produced an updated questionnaire incorporating the comments’.85 The 33 34 outcome was a significantly enlarged questionnaire, running to nearly 50 pages and 35 36 covering approximately 1,000 variables. The final version was ready for distribution 37 38 39 to national coordinators – usually the counterparts themselves – in March 2007. 40 41 42 43 In all, forty two member states took part in the survey; of the ten that did not, seven 44 45 were newly independent states in Eastern Europe, while the remainder – Iceland, 46 47 Monaco and Andorra – were very small. The survey generated an enormous 48 49 50 amount of data. Making sense of those data remained a challenge, however, as the 51 52 ______53 84 Interview, 18 November 2008. 54 55 56 85 Interview, 25 February 2009. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-36- Manuscripts submitted to (i)Social History of Medicine(/i) Page 38 of 48

1 2 3 resulting report made clear. The report was frank about the difficulties that 4 5 confronted any attempt to survey mental health services across so diverse a region, 6 7 acknowledging from the start that ‘A challenge in its own right was whether this 8 9 86 10 survey could meaningfully be conducted and what the next steps should be’. The 11 12 authors were particularly circumspect about the possibility of drawing any clear 13 14 comparative conclusions, dwelling at some length on the tension between diversity 15 16 and convergence in comparative observation. Gaps in the available information 17 18 For Peer Review 19 were exacerbated by difficulty in developing common definitions and internationally 20 21 compatible data. Perhaps surprisingly, comparison had proved particularly difficult in 22 23 the most developed Western European countries, where de-institutionalisation and 24 25 diversification of services had progressed furthest: ‘Services in the EU 15 countries 26 27 [i.e. not including the mainly Eastern European countries that have joined since April 28 29 87 30 2004] appear to be so differentiated that any comparison is haphazard’. 31 32 33 34 The report was also cautious about the normative conclusions it felt able to draw. 35 36 There are indications within the survey instrument itself that WHO initially hoped to 37 38 39 be able to define a minimum standard of provision that countries might be expected 40 41 to achieve. Thus the preamble to the survey instrument stated that ‘This is a WHO 42 43 benchmarking project supported by the European Commission’, and that ‘This 44 45 questionnaire will offer us an insight into the activities of Member States at this point 46 47 in time, and a benchmark point as compared to milestones in the Declaration and 48 49 50 ______51 86 WHO Europe, Policies and Practices for Mental Health in Europe: Meeting the Challenges 52 53 (Copenhagen: WHO Regional Office for Europe, 2008), 2. 54 55 56 87 Ibid., 89. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-37- Page 39 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 Action Plan’.88 As preparations for the survey progressed, however, participants 4 5 became increasingly cautious: ‘We didn’t feel that we were in the position to 6 7 establish benchmarks already – we needed to have a baseline first’.89 The survey 8 9 90 10 instrument was accordingly circulated as a ‘Baseline Assessment Questionnaire’, 11 12 and the final report avoided any suggestion that it was concerned with 13 14 benchmarking, presenting itself simply as a first step towards a more comparative 15 16 assessment of progress in the reform of mental health provision: ‘This report is the 17 18 For91 Peer Review 19 first stage, a baseline’. Nearly forty years after Tony May embarked on the first 20 21 systematic survey of mental health services in Europe, hopes of generating the kind 22 23 of data that would permit rigorous comparison of different countries, and that might 24 25 provide a basis for setting international standards, continued to be deferred. 26 27 28 29 30 Discussion 31 32 33 34 Since the 1970s, WHO’s European Regional Office has repeatedly attempted to 35 36 compile the kind of data on mental health services that would permit rigorous, 37 38 39 systematic comparison between different national systems and different kinds of 40 41 mental health intervention. The impetus behind such efforts has been essentially 42 43 ______44 88 WHO Europe, Baseline Assessment Questionnaire: based on milestones, responsibilities 45 46 and actions in the WHO Mental Health Declaration and Action Plan (Copenhagen: WHO 47 48 Regional Office for Europe, 2007). 49 50 51 89 Interview, 18 November 2008. 52 53 90 54 WHO Europe, Baseline Assessment Questionnaire . 55

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1 2 3 technocratic – rooted in the expectation that such knowledge would ultimately make 4 5 possible the establishment of universal, normative standards of provision against 6 7 which different countries could be measured and judged. In the event, the 8 9 10 necessary knowledge has so far proved elusive: the disparate ways in which mental 11 12 health systems have evolved in different countries, and the different understandings 13 14 of mental health care that obtain in those settings, have defied reduction to the kinds 15 16 of standardised categories that would permit direct comparison and universal 17 18 For Peer Review 19 standard-setting. 20 21 22 23 This does not mean that WHO Europe has failed in its aim of generating and 24 25 mobilising knowledge as a means of developing and promoting new mental health 26 27 policies; on the contrary, it has been quite successful in achieving that aim. But our 28 29 30 study makes clear that the kind of knowledge that has proved most effective as a 31 32 basis for WHO Europe’s policy initiatives in the area of mental health consists, not of 33 34 standardised comparative data about national systems of mental health care, but 35 36 rather of case-based knowledge of particular local interventions. As we indicated in 37 38 39 our introduction, this sits uneasily with the widely-held view of WHO as a 40 41 technocratic institution which exercises power through the diffusion and enforcement 42 43 of universal norms and standards. It also challenges us to reconsider the way that 44 45 academics have tended to think about the role of knowledge in the work of 46 47 international policy organisations more generally. As we have seen in the case of 48 49 50 the widely-cited work of Barnett and Finnemore, much academic thinking in this field 51 52 assumes a similarly technocratic or beureacratic perspective, attributing the 53 54 influence of international organisations in large part to their control over the 55 56 epistemic work of classification, the fixing of meanings, and the articulation and 57 58 59 60 http://mc.manuscriptcentral.com/(site)-39- Page 41 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 diffusion of norms.92 If we are to understand WHO Europe’s success in the field of 4 5 mental health policy, it appears that we need to expand the way we think about the 6 7 role of knowledge in the development of international policy beyond this narrowly 8 9 10 technocratic frame. 11 12 13 14 One way of doing so is by looking at how policy knowledge originates in and is 15 16 mobilised by particular epistemic communities. The idea of epistemic communities 17 18 For Peer Review 19 has its roots in the sociology of scientific knowledge, where it has developed as a 20 21 useful tool for of thinking about the collective nature of the work of scientific 22 23 knowledge production, and about the social organisation of the communities of 24 25 practitioners who undertake that work.93 But it has been adopted with particular 26 27 enthusiasm by scholars of international policy, beginning with Peter Haas in a much- 28 29 30 cited 1992 paper on how epistemic communities help to secure international policy 31 32 coordination.94 33 34 35 36 37 38 39 ______40 92 Barnett and Finnemore, ‘Politics, Power, and Pathologies’, 707. 41 42 43 93 For a useful recent review, see Morgan Meyer and Susan Molyneux-Hodgson, 44 45 ‘Introduction: The Dynamics of Epistemic Communities’, Sociological Research Online , 46 47 2010, 15 (2) 14. 48 49 50 94 Peter M. Haas, ‘Epistemic Communities and International Policy Coordination’, 51 52 International Organization , 1992, 46 , 1–35; see also Mai’a K. Davis Cross, ‘Rethinking 53 54 epistemic communities twenty years later’, Review of International Studies , FirstView Article, 55 56 DOI: 10.1017/S0260210512000034, published online 11 April 2012. 57 58 59 60 http://mc.manuscriptcentral.com/(site)-40- Manuscripts submitted to (i)Social History of Medicine(/i) Page 42 of 48

1 2 3 Like many with only passing familiarity with the sociology of scientific knowledge, 4 5 however, Haas tends to think of knowledge production and mobilisation, and the 6 7 epistemic communities that conduct it, in primarily intellectualist terms. Thus he 8 9 10 defines epistemic communities as ‘networks of knowledge-based experts’ whose 11 12 ‘control over knowledge and information’ enables them to shape policy by 13 14 ‘articulating the cause-and-effect relationships of complex problems, helping states 15 16 identify their interests, framing the issues for collective debate, proposing specific 17 18 For Peer Review95 19 policies, and identifying salient points for negotiation’. And he emphasises the 20 21 shared normative and causal beliefs, criteria for judging epistemic validity, and ideas 22 23 about the framing of policy problems that he takes to be constitutive of ‘community’. 96 24 25 26 27 However, work in science and technology studies (STS) also highlights other 28 29 30 aspects of epistemic communities that may be valuable for thinking about the role of 31 32 knowledge in policy. Thus STS scholars make clear that the work of knowledge 33 34 production depends not just on shared intellectual commitments, but also on the 35 36 establishment of agreed practices and agreed forms of social order, including shared 37 38 39 conventions for collaboration, communication, and the distribution of authority and 40 41 credit. Crucially, work in STS also emphasises that all these aspects of the 42 43 intellectual, practical and social organisation of knowledge production may differ 44 45 quite markedly from one field of science to another. 97 This appreciation of the 46 47 48 ______49 95 Ibid., 2. 50 51 52 96 Ibid., 3. 53 54 55 97 See for instance Peter L. Galison and David J. Stump (eds), The Disunity of Science: 56 57 Boundaries, Contexts, and Power (Stanford: Stanford University Press, 1996); Karin Knorr- 58 59 60 http://mc.manuscriptcentral.com/(site)-41- Page 43 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 diversity of epistemic cultures, and hence of the epistemic communities that those 4 5 cultures serve to constitute, can be particularly valuable in helping us to understand 6 7 the very different ways in which knowledge may be organised in relation to policy. 8 9 10 11 12 Of course, policy-oriented epistemic communities will often – perhaps even usually – 13 14 tend to evolve in concert with technocratic approaches to policy, or in connection 15 16 with policy issues that lend themselves to technocratic interventions.98 Indeed, the 17 18 For Peer Review 19 present paper documents the efforts of WHO Europe to create just such a 20 21 technocratically-oriented epistemic community in the field of mental health policy. 22 23 Specifically, it shows how WHO officers repeatedly attempted to build an 24 25 international network of mental health experts, united by shared use of standardised 26 27 data collection instruments, and reporting to a single central authority that would 28 29 30 ensure the quality of the resulting data then use it to create a single coherent body of 31 32 comparative knowledge of mental health provision across Europe. 99 33 34 35 36 To date, as our study makes clear, this project has been seriously compromised by 37 38 39 serious technical and practical difficulties. However, our study also shows that WHO 40 41 Europe has been considerably more successful in fostering the development of a 42 43 rather different epistemic community in this area of mental health policy, 44 45 ______46 47 Cetina, Epistemic Cultures: How the Sciences Make Knowledge (Cambridge: Harvard 48 49 University Press, 1999). 50 51 52 98 Cross, ‘Rethinking Epistemic Communities’, 9. 53 54 55 99 Cf. Saul Halfon, ‘The Disunity of Consensus: International Population Policy Coordination 56 57 as Socio-technical Practice’, Social Studies of Science , 2006, 36.5 , 783-907. 58 59 60 http://mc.manuscriptcentral.com/(site)-42- Manuscripts submitted to (i)Social History of Medicine(/i) Page 44 of 48

1 2 3 incorporating very different practices of knowledge production and forms of work 4 5 organisation. This alternative epistemic community has evolved around the 6 7 production and circulation, not of standardised forms of data, but of context-sensitive 8 9 10 knowledge of particular cases of exemplary mental health interventions. Moreover, 11 12 that knowledge is in large part generated, not through the deployment of centrally 13 14 managed and standardised survey instruments (though survey data may sometimes 15 16 be employed in building such knowledge), but through face-to-face discussion, 17 18 For Peer Review 19 negotiation and sharing of personal experiences and understanding of relevant 20 21 interventions. 22 23 24 25 Over the past forty years, WHO Europe has created a wealth of opportunities for 26 27 such discussions to take place: at the workshops organised under the pilot study 28 29 30 areas scheme, through the regular meetings of the national counterparts and, most 31 32 visibly, at the many workshops and conferences that culminated in the Ministerial 33 34 Conference in Helsinki and the signing of the Mental Health Declaration and Mental 35 36 Health Action Plan for Europe . In so doing, WHO Europe has done much to create 37 38 39 the conditions under which the emergent epistemic community has been able to 40 41 negotiate and define its own objects of knowledge and standards of knowledge 42 43 production. 44 45 46 47 That is not to suggest that WHO officers did not play an active role in determining 48 49 50 what kinds of interventions would be considered appropriate for study, or what 51 52 aspects of those interventions should receive particular attention. Nonetheless, the 53 54 degree of decentralised autonomy enjoyed by the various parts of this epistemic 55 56 community stands in marked contrast to the kind of strict centralised disciplinary 57 58 59 60 http://mc.manuscriptcentral.com/(site)-43- Page 45 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 control that WHO Europe sought to exert in its efforts to generate systematic 4 5 comparative knowledge of mental health provision. In terms of the standards and 6 7 practice of knowledge production it employs and the way the work of knowledge 8 9 10 production is organised, the epistemic community that has grown up around the 11 12 production and circulation of case-based knowledge of exemplary mental health 13 14 interventions is thus very different from that which WHO initially sought to build 15 16 around the conduct of systematic surveys. 17 18 For Peer Review 19 20 21 This decentralised approach to epistemic authority is also apparent in the particular 22 23 style of policy making that WHO Europe adopted when it decided to create the 24 25 Mental Health Declaration and Action Plan . Given the difficulties they had 26 27 encountered in trying to conduct systematic surveys of mental health provision 28 29 30 across Europe, WHO officers were well aware that mental health systems had 31 32 evolved in different ways and faced different opportunities and constraints in different 33 34 national settings. If it was impossible even to establish universal standards of 35 36 measurement and comparison across these different settings, there was plainly little 37 38 39 to be gained by trying to define, let alone impose, universal standards of service 40 41 provision. Instead, in organising the Helsinki conference, the WHO officers and their 42 43 European Commission colleagues engineered a situation in which policy actors from 44 45 across Europe were able to agree on a rather general orientation and set of values 46 47 that they felt should inform mental health practice, and on a wide-ranging set of 48 49 50 examples of good practice that they regarded as embodying and exemplifying those 51 52 values. And by inscribing those values and examples, not in a set of precise 53 54 technical standards of performance, but in the much more open-ended format of the 55 56 Declaration and Action Plan , WHO gave national and local policy makers and 57 58 59 60 http://mc.manuscriptcentral.com/(site)-44- Manuscripts submitted to (i)Social History of Medicine(/i) Page 46 of 48

1 2 3 service providers considerable interpretative freedom to decide just what kinds of 4 5 initiatives might be regarded as successfully implementing WHO policy. 6 7 8 9 10 In the event, insofar as the WHO policy has actually led to action, much of the work 11 12 of interpreting and implementing it has been undertaken or at least championed by 13 14 members of the same epistemic community of practitioners and policy makers as 15 16 was responsible for drafting the Declaration , Action Plan and associated briefing 17 18 For Peer Review 19 documents; and it has involved much the same kind of discussion and negotiation of 20 21 what counts as appropriate action in particular contexts as characterised the 22 23 selection of the exemplary cases that were incorporated in those policy documents. 24 25 In effect, the work of implementing WHO Europe’s policy on mental health can thus 26 27 be seen as a direct continuation of the work of formulating that policy. Moreover, 28 29 30 WHO itself has had very little involvement in such decisions about how to implement 31 32 that policy as have been taken at national or local level. At most, its presence in 33 34 those decisions appears to be chiefly symbolic, with the Declaration and Action Plan 35 36 being invoked to lend additional authority to a wide range of national and local policy 37 38 39 initiatives, many of which were already under way or mooted well before the Helsinki 40 100 41 conference. This is a long way from a technocratic or bureaucratic approach to 42 43 44 ______45 100 Smith-Merry, Richard Freeman and Steve Sturdy, ‘Reciprocal Instrumentalism’; Freeman, 46 47 Smith-Merry and Sturdy, WHO, Mental Health, Europe , 67f; Didier Vrancken, Frédéric 48 49 Schoenaers and Gaëtan Cerfontaine, ‘The WHO in Belgium: Cross-level Networking’, 50 51 Know&Pol Project Report, 2009, http://knowandpol.eu/IMG/pdf/o31.who.belgium.pdf ; 52 53 Gunnar Vold Hansen, Marte Feiring, Marit Helgesen, Helge Ramsdal, ‘Norway, Mental 54 55 Health and WHO’, Know&Pol Project Report, 2009, 56 57 http://knowandpol.eu/IMG/pdf/o31.who.norway-2.pdf ; Bori Fernezelyi and Gábor Eröss, ‘Lost 58 59 60 http://mc.manuscriptcentral.com/(site)-45- Page 47 of 48 Manuscripts submitted to (i)Social History of Medicine(/i)

1 2 3 policy. WHO’s aspirations may have been technocratic, as indeed may those of 4 5 many who have contributed to the development of its mental health policy; but it 6 7 would appear that the field of mental health does not lend itself to technocratic 8 9 10 intervention, and WHO has consequently had to pursue a very different policy style. 11 12 13 14 This in turn requires us to rethink the nature of the relationship between WHO’s 15 16 European Regional Office and the epistemic community that has grown up around 17 18 For Peer Review 19 that Office’s mental health policy initiatives. WHO has played an active role in the 20 21 creation and orientation of that epistemic community, by identifying individuals with 22 23 roughly similar interests in mental health, creating opportunities for networking and 24 25 communication, setting a general agenda for discussion, and granting the imprimatur 26 27 of WHO policy to the outcomes of those discussions. But in terms of making 28 29 30 knowledge for policy, and in terms of deciding how to implement that policy, the 31 32 resulting epistemic community has in large part been left to exercise its own 33 34 collective judgement, independently of official interference from WHO influence. 35 36 Indeed, in this respect, that epistemic community might perhaps be better regarded 37 38 39 as a network of practitioners and policy makers united by a set of general values and 40 41 an interest in mutual learning about best practice in mental health than as an organ 42 43 of WHO policy. Happily, the concerns and interests of WHO Europe and those of 44 45 the members of the epistemic community that it has fostered are generally in 46 47 alignment with one another, to the extent that it makes little sense to ask if the 48 49 50 epistemic community has developed to serve WHO’s policy purposes or vice versa. 51 52 ______53 54 in Translation: From WHO Mental Health Policy to a non-Reform of Psychiatric Institutions’, 55 56 Know&Pol Project Report, 2009, http://knowandpol.eu/IMG/pdf/o31.who.hungary.pdf 57 58 59 60 http://mc.manuscriptcentral.com/(site)-46- Manuscripts submitted to (i)Social History of Medicine(/i) Page 48 of 48

1 2 3 4 5 Whether similar conclusions might be drawn about other areas of WHO policy, or 6 7 indeed about the work of other international policy organisations, is a matter for 8 9 10 empirical investigation. Mental health is clearly a particularly diverse and contested 11 12 area of social and medical provision, and may represent an especial challenge to 13 14 technocratic forms of policy. Whatever the specifics of the case, however, there is a 15 16 more general conclusion that we can draw from our study of WHO Europe’s efforts 17 18 For Peer Review 19 to make knowledge for mental health policy – namely: that policy studies has much 20 21 to gain from recognising that epistemic communities are characterised as much by 22 23 the particular epistemic practices and forms of social order they embody as by 24 25 generalised forms of expertise and authority. As our case study demonstrates, 26 27 attention to the particular ways in which specific epistemic communities are 28 29 30 constituted in the field of policy can also throw valuable light on the different ways in 31 32 which policy itself may be pursued. 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 http://mc.manuscriptcentral.com/(site)-47-