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Empire of Madness: Reimagining Western Mental Health Care for Everyone
An urgent rethinking of the Western approach to mental health, which treats the symptoms rather than the exploitative systems causing our distress—by a Rhodes Scholar and Harvard Medical School physician-anthropologist—offering lessons from the rest of the world.
In Empire of Madness, Dr. Khameer Kidia offers a re-evaluation of mental health in the Global North, where the answer to the structural causes of mental distress, like racism and economic inequality, has been to medicate the symptoms rather than revolutionize those causal structures. A clinician and researcher whose own mother suffers from the psychological harm of colonialism, Kidia reports from the front lines of mental health crises at home, in clinical practice and during fieldwork, highlighting the flaws in how we cope with global mental distress.
Western psychiatry, which emerged during nineteenth-century colonialism and expanded under neoliberalism, mollifies the effects—depression, anxiety, hunger, poverty—of oppressive structures rather than fixes them. "Burnout" is just one example of mental distress caused by economic and social conditions but disguised as a medical problem. Clear-eyed and open-hearted, Kidia asks the necessary questions that our current mental health system, pharmaceutically-driven and focused on one-size-fits-all solutions, doesn't address.
How do history, culture, and politics shape mental distress? Is hoarding a medical problem? Why are the outcomes of schizophrenia sometimes better in places without antipsychotics? Can a Zimbabwean grandmother sitting on a wooden "friendship bench" talk through someone's problems better than a Western-trained therapist? For those living in poverty, can cash replace pills?
Empire of Madness sharply intertwines discussions of the colonial origins of psychiatry, the long-lasting and psychological effects of oppression, and the overburdened health professionals striving to heal their patients in rigid, archaic systems to reimagine global mental health as a capacious, inclusive field where our wellbeing is mutual and everyone's voice—patients, caregivers, and health workers alike—matters.
In Empire of Madness, Dr. Khameer Kidia offers a re-evaluation of mental health in the Global North, where the answer to the structural causes of mental distress, like racism and economic inequality, has been to medicate the symptoms rather than revolutionize those causal structures. A clinician and researcher whose own mother suffers from the psychological harm of colonialism, Kidia reports from the front lines of mental health crises at home, in clinical practice and during fieldwork, highlighting the flaws in how we cope with global mental distress.
Western psychiatry, which emerged during nineteenth-century colonialism and expanded under neoliberalism, mollifies the effects—depression, anxiety, hunger, poverty—of oppressive structures rather than fixes them. "Burnout" is just one example of mental distress caused by economic and social conditions but disguised as a medical problem. Clear-eyed and open-hearted, Kidia asks the necessary questions that our current mental health system, pharmaceutically-driven and focused on one-size-fits-all solutions, doesn't address.
How do history, culture, and politics shape mental distress? Is hoarding a medical problem? Why are the outcomes of schizophrenia sometimes better in places without antipsychotics? Can a Zimbabwean grandmother sitting on a wooden "friendship bench" talk through someone's problems better than a Western-trained therapist? For those living in poverty, can cash replace pills?
Empire of Madness sharply intertwines discussions of the colonial origins of psychiatry, the long-lasting and psychological effects of oppression, and the overburdened health professionals striving to heal their patients in rigid, archaic systems to reimagine global mental health as a capacious, inclusive field where our wellbeing is mutual and everyone's voice—patients, caregivers, and health workers alike—matters.
371 pages, Kindle Edition
First published February 3, 2026
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Displaying 1 - 6 of 6 reviews
February 3, 2026
5⭐️
This book validated experiences I’ve had working as an accompagneur in perinatal public health and social work for the past fifteen years.
At its core, this is a book about connection: about how mental wellness is shaped not only by what happens inside us, but by the communities, systems, and supports surrounding us. It challenges the idea that distress is primarily an individual failure and instead asks us to look honestly at isolation, inequality, and social rupture from capitalist, racist and postcolonial influences as central forces affecting mental health.
What resonated most for me was the validation of accompaniment and listening as real forms of care. Walking alongside someone without immediately pathologizing their reactions to very real stressors is often more meaningful than narrowly defined clinical interventions. This book gives language to that reality and grounds it in research, history, and compassion.
This isn’t a light read, but it is an engaging, compelling and affirming one. It confirmed what I have always found to be true from my own field work: community care matters, mental health cannot be separated from public health, and healing is rarely something we do alone.
Highly recommend for anyone working in perinatal health, public health, mental health, or anyone who has ever felt their suffering was treated as a personal problem instead of a collective responsibility.
Greatest thanks to Dr. Kidia, Crown Publishing and NetGalley for the opportunity to review a copy of this book in advance of its publication on 2/3/2026.
This book validated experiences I’ve had working as an accompagneur in perinatal public health and social work for the past fifteen years.
At its core, this is a book about connection: about how mental wellness is shaped not only by what happens inside us, but by the communities, systems, and supports surrounding us. It challenges the idea that distress is primarily an individual failure and instead asks us to look honestly at isolation, inequality, and social rupture from capitalist, racist and postcolonial influences as central forces affecting mental health.
What resonated most for me was the validation of accompaniment and listening as real forms of care. Walking alongside someone without immediately pathologizing their reactions to very real stressors is often more meaningful than narrowly defined clinical interventions. This book gives language to that reality and grounds it in research, history, and compassion.
This isn’t a light read, but it is an engaging, compelling and affirming one. It confirmed what I have always found to be true from my own field work: community care matters, mental health cannot be separated from public health, and healing is rarely something we do alone.
Highly recommend for anyone working in perinatal health, public health, mental health, or anyone who has ever felt their suffering was treated as a personal problem instead of a collective responsibility.
Greatest thanks to Dr. Kidia, Crown Publishing and NetGalley for the opportunity to review a copy of this book in advance of its publication on 2/3/2026.
February 18, 2026
Empire of Madness by Khameer Kidia is a powerful and personal critique of modern psychiatry that asks a big question: what if mental illness is not just a problem in the brain, but a reflection of inequality and oppression? Based on his personal experiences as a son, a physican and a psychiatrists and combining his lived experiences in Zimbabwe, the UK and the US, he writes a book that is personal and universal.
The book is divided into three sections, History, Diagnosis, and Prescription.
In History, Kidia explores how psychiatry has often worked alongside systems of power. He looks at examples like drapetomania, a fake diagnosis once used to pathologize enslaved people who tried to escape, and connects it to present day practices that silence or overmedicate marginalized patients. Drawing on cross cultural research, including studies comparing voice hearing in the United States, Ghana, and India, he shows that experiences we call mental illness are deeply shaped by culture, economics, and politics.
In Diagnosis, Kidia questions the authority of psychiatric labels. He argues that diagnoses are constructed categories that simplify complex human experiences. He challenges the idea that addiction is purely biological and points out how race, class, and power influence who gets labeled “noncompliant” or “disordered.” He introduces ideas like structural violence and epistemic injustice to explain how institutions can dismiss or distort the voices of people who are already marginalized. Throughout this section, he emphasizes that most health outcomes are shaped less by healthcare itself and more by housing, debt, food access, racism, and poverty.
In Prescription, Kidia shifts from critique to possibility. Instead of relying mainly on medication, he advocates for social prescriptions such as stable housing, direct cash transfers, and policies that reduce economic insecurity. He supports a Housing First approach and argues that giving people money can significantly improve depression and anxiety. He also introduces the idea of cognitive liberty, the right to choose whether and how to alter one’s consciousness. Ultimately, the book makes a bold but practical claim: if poverty and oppression drive mental distress, then justice and material support may be the most effective forms of treatment.
I LOVED THIS BOOK!
-
Quotes
empire of madness
“As an American-trained doctor, I've been taught that the key to removing stigma around mental distress is to medicalize it—to call it a disease, to say that it is a fault in your brain, no different from a faulty pancreas in diabetes. But this often has the opposite of the intended effect, both for mental illness and for diabetes. It forces the illness into the individual and private realm, and it says that the problem is within you. It is your fault… I saw that Western medical approaches to mental distress are designed to anesthetize the pain of oppression, not fix it. They are, in other words, tools in an empire of madness… I'm saying that we need to completely reenvision the way we approach the problem of mental distress, thinking of it as a much bigger, structural issue, rather than one that is confined to the individual patient with the illness.”
“For a white woman who'd slept with a Black man, the only culturally legitimate narrative available to her about the experience was one of trauma, even if the relationship had been consensual.
This is how the individual psychology of trauma can become a political force for oppression.”
“To understand how this violent culture derived from profit making can shape our psychology, I turn to Tanya Luhrmann, a psychiatric anthropologist at Stanford who studies how mental illness is influenced by culture. A study she published in 2015 still makes my jaw drop. With a team of psychiatrists, Luhrmann interviewed sixty patients who heard voices and met diagnostic criteria for schizophrenia in three countries: twenty in the United States, twenty in Ghana, and twenty in India. Patients in San Mateo, California, all described the voices they heard in negative terms-intrusive and riddled with vio-lence. "Usually, it's like torturing people," a patient told Luhrmann.
"To take their eye out with a fork, or cut someone's head and drink their blood, really nasty stuff.” In Ghana and India, on the other hand, patients described voices as familiar, usually people the patient already knew, such as a relative.
The voices were mostly peaceful. In Chennai, India, for example, the voices often told patients to complete important chores around the house. "They just tell me to do the right thing," a man from Ghana said. "If I hadn't had these voices I would have been dead long ago."?1 The patients from Ghana and India rarely referred to themselves using diagnostic categories like schizophrenia and were less disturbed by their voices than patients in the United States.”
“The way the global economic system is structured smacks of indirect rule-the more common kind of colonialism where European countries, without establishing settler colonies, extracted wealth, natural resources, and labor from poor countries by co-opting local elites to do their bidding. In the same way, the IMF and the World Bank shape the economies of poor countries to feed into a global system that ultimately benefits Western superpowers and depletes the human and natural resources of poor countries. This is how the French ruled in Algeria, how the Portuguese ruled in Mozambique, how the British ruled in Uganda.”
“Diagnoses themselves are not natural entities but invented categories that help doctors analyze symptoms in their heads-narrowing the complex histories we hear from patients into manageable buckets.”
“In medicine, there are fine lines between drug tolerance, depen-dence, and addiction. Tolerance is when you need increasing amounts of a drug to achieve the same effect. Dependence is when you cannot function without a drug. And addiction is when you are dependent on a drug but cannot function with it. In other words, addiction is when you are not able to live the life you want to live, according to the norms of the society you want to live in, due to the detrimental effects of a drug you have little choice but to take… The line between dependence and addiction is not biological; it is socially con-structed. There is no brain scan or blood test doctors can do that lights up and allows us to say, "Aha, you're an addict." I have patients who are dependent on and take astronomical doses of stimulants and opioid painkillers multiple times a day. They go about their days as usual— performing the responsibilities of the society in which they partici-pate: caring for children, paying their taxes. Unless the drug causes harm in their life, I would not diagnose them with addiction.”
“In my experience as a clinician, immigrant, and mental health researcher trying to understand how poverty affects people's mental wellbeing all over the world, I keep coming back to the diagnosis of debt.”
“Unfortunately, Samuel had developed the worst possible movement side effect of Haldol; tardive dyskinesia, which is an incurable condition characterized by lip smacking and writhing tongue move-ments. Unlike the other movement symptoms, tardive dyskinesia is permanent, even after the drug is discontinued. If you've ever ridden the New York subway on a regular basis, you've probably seen someone suffering from tardive dyskinesia and mistaken their condition for an illness that required medical attention, not an illness caused by medical attention.”
“Gatekeeping is an unusually common function of medicine.”
“This has been happening since the early days of psychiatry. Drap-etomania, for example, was a pseudoscientific mental illness coined by the American physician Samuel A. Cartwright in 1851. It was applied as a diagnosis to Black slaves who tried to escape captivity. To physicians at the time, slaves who tried to escape were considered insane rather than rationally responding to subjugation, deprivation, and violence.”
“I've seen this play out over and over in clinical practice. Black patients like Earl come to the hospital for help, but when they try to advocate for themselves, they instead leave with stigmatizing psy chiatric diagnoses like schizoaffective disorder and coded language in their medical charts that make them sound insane or criminal. "Pa-tient is a frequent flier.""Patient is noncompliant.""Patient with multiple admissions for functional pain, frequently refuses care resulting in AMA [against medical advice] discharge."”
“But history keeps repeating itself because people in the dominant caste truly feel unsafe. They are genuinely terri-fied. They want safe spaces, but they cannot see that they are the safest people in the world.”
“The reason many drugs have such nonspecific effects is that our bodies are full of receptors (alpha 1, alpha 2, beta 1, beta 2, D1, D2, V1, V2, mu-to name a few) that are dispersed throughout our tissues, blood vessels, nerves, and organs. Most medications hit multiple receptors in multiple places causing multiple effects. It's why a couple of doses of an asthma inhaler also increases heart rate or why aspirin treats pain, fever, and heart attacks. It's why minoxidil, the active ingredient in hair loss treatments, is also a potent blood pressure medi-cation. This understanding of pharmacology may be one of the most important ideas I learned in medical school: a schema that goes be yond what you can get on a first-pass internet search—one that helps us understand how to use drugs beyond what they're famous for and to parse the taur bind between therapeutics (how we heal) and intro genesis (how we harm).”
“We do this because we have no choice. It is cheaper for hospital corporations to make us quiet patients with antipsychotics, or even to physically restrain them, than it is to hire more doctors, nurses, and sitters. In the absence of more human capital, antipsychotics allow hospital corporations to extract the most labor from the fewest workers to maximize profit. Without extra workers, we use antipsychotics to keep our patients in line: tucked in, peaceful, wearing gray hospital socks and pajamas— sardines brined in a can of Haldol.”
“To describe this type of oppression, my mentor the late physician anthropologist Pail Farmer popularized the termi "structural violence," the idea that there are institutions and governing structures that obstruct people's ability to access health care, obrain food, and otherwise flourish in life, thus inflicting violence.”
“After all, "healthcare itself," explains Tom Insel, the psychiatrist and former director of the NIMH, "explains only about 10 percent of health outcones." The remaining 90 percent of health outcomes, including mental health outcomes, ure determined by structural facton like access to food, shelter, transport, and oppression due to race, clas gender, sexuality, and disability.”
“Through DNA methylation and demethylation, when a small molecule is added or subtracted from a piece of DNA, the environment and stressful life events can turn a gene on or off without altering the gene itself.”
“This unwillingness to grasp someone else's understanding is called cistemic injustice: the hierarchy in which some people's knowiedge systems are more valuable than other people's knowledge systems. It is a fact, for example, that fewer people would read this book if I were not a physician.
There are two types of epistemic injustice, according to Miranda Fricker, the philosopher who popularized the concept. Testimonial injustice is when we don't believe what people say because of their inferior status in society. Hermeneutic injustice, relatedly, is when we don't have words for people's experiences. "An example of the first," writes Fricker, "might be that the police do not believe you because you are black; an example of the second might be that you suffer sexual
"harassment in a culture that still lacks that critical concept."" Both types of epistemic injustice are involved in trauma: both the inability to believe that some people's responses to trauma are real and the fact that there aren't ways to discuss trauma responses that don't fit a Western narrative of the concept.
As scholars of epistemic injustice point out, some voices simply aten't taken seriously, in part because they do not appeal to Western ideas of what a voice can say and how a voice can speak."
“Living bisected between worlds an ocean apart has made me interrogate how this universalizing tone flattens the multiplicity. of trauma; how it forces an overly simplistic conception of well-being. and suffering in places where such a conception may not be useful or welcome.”
“A social prescription could be a gym membership or a
1950s
dance class. It could be a housing voucher or food stamps. It could be a nature walk, or even much needed, hard cash. But Jack Geiger (1950s) believed, as do I, that social prescribing is about not only individual-level prescriptions for structural problems faced by patients but also structural prescriptions (such as the pit latrines in South Africa) that build healthier environments to improve the well-being of many individual patients at scale.”
“Because of this, housing is one of the most potent social prescriptions for mental illness and should be the first step in mental health care, a principle called Housing First, which espouses getting patients into housing before any of their other problems can be dealt with.”
“A 2019 study in Biological Psychiatry showed that in the first year of residency medical trainees had significant shortening of their telomeres, which are the protective bits of DNA at the ends of our chromosomes that hold them together and prevent them from unraveling.® Each time a cell divides, its telomeres shorten, until eventually the telomeres can no longer protect our chromosomes and the cell "dies" or becomes
"senescent." When the rate of telomere shortening is normal, this process is protective; it kills off cells that could otherwise become cancer-ous. But when the rate of telomere shortening is more rapid than normal, as it was for medical trainees in this study, senescent cells from chronic stress can cause inflammation throughout the body, which is associated with premature aging and early mortality.”
“In the United States, people spend their lives in the pursuit of happiness, but it is a cultural assumption that happiness is the best way of being. It is almost impossible for us to imagine that our patients wouldn't always prefer to feel happy.
What this projection of our own emotional ideals does, intentionally or not, is invalidate people's suffering and potentially worsen their mental health. It says to patients that the way they are feeling when they are sad or anxious or paranoid is not warranted, even when it is a rational response to a toxic environment.
To maximize autonomy and limit projecting our normative emotions onto our patients, a helpful framework for clinicians and patients in mental health is cognitive liberty, a twofold idea that argues that everyone should have the right to "mental self-determination." First, everyone should be able to alter their own consciousness however they see fit, whether through drugs, therapy, medications, or yoga. Second, everyone should be free from coercive efforts by others to alter their consciousness; in other words, people should not be coerced or forced into taking psychotropic medications.”
“Indigenous Zimbabwean knowledge explains mental health proba lems in spiritual terms, most commonly through ngozi, angered spir-its.' People experiencing madness are suffering the consequences of angry spirits who demand retribution for wrongdoing. There are f range of offenses that might create this situation: livestock theft, mur der, domestic violence, unpaid dowry. And, while the wrongdoing might have been committed by a single person a long time ago, misfortune due to ngozi reverberates throughout the kinship system and across generations.”
“I'm not saying that we should recode all instances of ngozi as
"trauma," but there is a broad parallel: In both ngozi and trauma, a bad thing happens, and people suffer intergenerational distress because of it. This tells me that the phenomena might be related but have different cultural explanations, what medical anthropologists call explanatory models.”
“But researchers throughout the world have demonstrated that cash transfers improve people's physical health, depression, anxiety, school attendance, maternal-child health, nutrition, and even mortal-ity. People who receive cash transfers are less likely to murder, be incarcerated, die of overdose, transmit HIV, commit domestic vio-lence, and visit the emergency department. In a large meta-analysis pooling more than twenty-six thousand participants, researchers at Oxford looked specifically at the impact of cash transfers on depression and anxiety in poorer countries. They found, unsurprisingly, that giving people free cash significantly reduced symptoms of mental ill-ness? "Financial insecurity," explains the psychiatrist-anthropologist Eric Reinhart, "is a major driver behind cycles of poor mental health, disease, violence, crime, and incarceration-all of which, in turn, further entrench poverty, destabilize families, undercut public health and childhood education, and constrain people's life opportu-nities."
“When people are living in poverty, what actually helps their mental health is the most obvious but least often prescribed: cash.”
“If depression gets better when you give someone money. and rets worse when you take it away, this is even stronger evidence that the cause of depression is a lack of money, otherwise known as poverty.”
“If you are paid to do something, you have the option to stop that job and forfeit your pay.
That freedom is good for mental well-being. (Labor specialists call this
"job control," which is associated with better mental health.)" But if you do something purely out of moral obligation, or, as women have been socialized to do, out of "love," that care work is harder to escape, making it more likely to worsen the carer's mental health.”
The book is divided into three sections, History, Diagnosis, and Prescription.
In History, Kidia explores how psychiatry has often worked alongside systems of power. He looks at examples like drapetomania, a fake diagnosis once used to pathologize enslaved people who tried to escape, and connects it to present day practices that silence or overmedicate marginalized patients. Drawing on cross cultural research, including studies comparing voice hearing in the United States, Ghana, and India, he shows that experiences we call mental illness are deeply shaped by culture, economics, and politics.
In Diagnosis, Kidia questions the authority of psychiatric labels. He argues that diagnoses are constructed categories that simplify complex human experiences. He challenges the idea that addiction is purely biological and points out how race, class, and power influence who gets labeled “noncompliant” or “disordered.” He introduces ideas like structural violence and epistemic injustice to explain how institutions can dismiss or distort the voices of people who are already marginalized. Throughout this section, he emphasizes that most health outcomes are shaped less by healthcare itself and more by housing, debt, food access, racism, and poverty.
In Prescription, Kidia shifts from critique to possibility. Instead of relying mainly on medication, he advocates for social prescriptions such as stable housing, direct cash transfers, and policies that reduce economic insecurity. He supports a Housing First approach and argues that giving people money can significantly improve depression and anxiety. He also introduces the idea of cognitive liberty, the right to choose whether and how to alter one’s consciousness. Ultimately, the book makes a bold but practical claim: if poverty and oppression drive mental distress, then justice and material support may be the most effective forms of treatment.
I LOVED THIS BOOK!
-
Quotes
empire of madness
“As an American-trained doctor, I've been taught that the key to removing stigma around mental distress is to medicalize it—to call it a disease, to say that it is a fault in your brain, no different from a faulty pancreas in diabetes. But this often has the opposite of the intended effect, both for mental illness and for diabetes. It forces the illness into the individual and private realm, and it says that the problem is within you. It is your fault… I saw that Western medical approaches to mental distress are designed to anesthetize the pain of oppression, not fix it. They are, in other words, tools in an empire of madness… I'm saying that we need to completely reenvision the way we approach the problem of mental distress, thinking of it as a much bigger, structural issue, rather than one that is confined to the individual patient with the illness.”
“For a white woman who'd slept with a Black man, the only culturally legitimate narrative available to her about the experience was one of trauma, even if the relationship had been consensual.
This is how the individual psychology of trauma can become a political force for oppression.”
“To understand how this violent culture derived from profit making can shape our psychology, I turn to Tanya Luhrmann, a psychiatric anthropologist at Stanford who studies how mental illness is influenced by culture. A study she published in 2015 still makes my jaw drop. With a team of psychiatrists, Luhrmann interviewed sixty patients who heard voices and met diagnostic criteria for schizophrenia in three countries: twenty in the United States, twenty in Ghana, and twenty in India. Patients in San Mateo, California, all described the voices they heard in negative terms-intrusive and riddled with vio-lence. "Usually, it's like torturing people," a patient told Luhrmann.
"To take their eye out with a fork, or cut someone's head and drink their blood, really nasty stuff.” In Ghana and India, on the other hand, patients described voices as familiar, usually people the patient already knew, such as a relative.
The voices were mostly peaceful. In Chennai, India, for example, the voices often told patients to complete important chores around the house. "They just tell me to do the right thing," a man from Ghana said. "If I hadn't had these voices I would have been dead long ago."?1 The patients from Ghana and India rarely referred to themselves using diagnostic categories like schizophrenia and were less disturbed by their voices than patients in the United States.”
“The way the global economic system is structured smacks of indirect rule-the more common kind of colonialism where European countries, without establishing settler colonies, extracted wealth, natural resources, and labor from poor countries by co-opting local elites to do their bidding. In the same way, the IMF and the World Bank shape the economies of poor countries to feed into a global system that ultimately benefits Western superpowers and depletes the human and natural resources of poor countries. This is how the French ruled in Algeria, how the Portuguese ruled in Mozambique, how the British ruled in Uganda.”
“Diagnoses themselves are not natural entities but invented categories that help doctors analyze symptoms in their heads-narrowing the complex histories we hear from patients into manageable buckets.”
“In medicine, there are fine lines between drug tolerance, depen-dence, and addiction. Tolerance is when you need increasing amounts of a drug to achieve the same effect. Dependence is when you cannot function without a drug. And addiction is when you are dependent on a drug but cannot function with it. In other words, addiction is when you are not able to live the life you want to live, according to the norms of the society you want to live in, due to the detrimental effects of a drug you have little choice but to take… The line between dependence and addiction is not biological; it is socially con-structed. There is no brain scan or blood test doctors can do that lights up and allows us to say, "Aha, you're an addict." I have patients who are dependent on and take astronomical doses of stimulants and opioid painkillers multiple times a day. They go about their days as usual— performing the responsibilities of the society in which they partici-pate: caring for children, paying their taxes. Unless the drug causes harm in their life, I would not diagnose them with addiction.”
“In my experience as a clinician, immigrant, and mental health researcher trying to understand how poverty affects people's mental wellbeing all over the world, I keep coming back to the diagnosis of debt.”
“Unfortunately, Samuel had developed the worst possible movement side effect of Haldol; tardive dyskinesia, which is an incurable condition characterized by lip smacking and writhing tongue move-ments. Unlike the other movement symptoms, tardive dyskinesia is permanent, even after the drug is discontinued. If you've ever ridden the New York subway on a regular basis, you've probably seen someone suffering from tardive dyskinesia and mistaken their condition for an illness that required medical attention, not an illness caused by medical attention.”
“Gatekeeping is an unusually common function of medicine.”
“This has been happening since the early days of psychiatry. Drap-etomania, for example, was a pseudoscientific mental illness coined by the American physician Samuel A. Cartwright in 1851. It was applied as a diagnosis to Black slaves who tried to escape captivity. To physicians at the time, slaves who tried to escape were considered insane rather than rationally responding to subjugation, deprivation, and violence.”
“I've seen this play out over and over in clinical practice. Black patients like Earl come to the hospital for help, but when they try to advocate for themselves, they instead leave with stigmatizing psy chiatric diagnoses like schizoaffective disorder and coded language in their medical charts that make them sound insane or criminal. "Pa-tient is a frequent flier.""Patient is noncompliant.""Patient with multiple admissions for functional pain, frequently refuses care resulting in AMA [against medical advice] discharge."”
“But history keeps repeating itself because people in the dominant caste truly feel unsafe. They are genuinely terri-fied. They want safe spaces, but they cannot see that they are the safest people in the world.”
“The reason many drugs have such nonspecific effects is that our bodies are full of receptors (alpha 1, alpha 2, beta 1, beta 2, D1, D2, V1, V2, mu-to name a few) that are dispersed throughout our tissues, blood vessels, nerves, and organs. Most medications hit multiple receptors in multiple places causing multiple effects. It's why a couple of doses of an asthma inhaler also increases heart rate or why aspirin treats pain, fever, and heart attacks. It's why minoxidil, the active ingredient in hair loss treatments, is also a potent blood pressure medi-cation. This understanding of pharmacology may be one of the most important ideas I learned in medical school: a schema that goes be yond what you can get on a first-pass internet search—one that helps us understand how to use drugs beyond what they're famous for and to parse the taur bind between therapeutics (how we heal) and intro genesis (how we harm).”
“We do this because we have no choice. It is cheaper for hospital corporations to make us quiet patients with antipsychotics, or even to physically restrain them, than it is to hire more doctors, nurses, and sitters. In the absence of more human capital, antipsychotics allow hospital corporations to extract the most labor from the fewest workers to maximize profit. Without extra workers, we use antipsychotics to keep our patients in line: tucked in, peaceful, wearing gray hospital socks and pajamas— sardines brined in a can of Haldol.”
“To describe this type of oppression, my mentor the late physician anthropologist Pail Farmer popularized the termi "structural violence," the idea that there are institutions and governing structures that obstruct people's ability to access health care, obrain food, and otherwise flourish in life, thus inflicting violence.”
“After all, "healthcare itself," explains Tom Insel, the psychiatrist and former director of the NIMH, "explains only about 10 percent of health outcones." The remaining 90 percent of health outcomes, including mental health outcomes, ure determined by structural facton like access to food, shelter, transport, and oppression due to race, clas gender, sexuality, and disability.”
“Through DNA methylation and demethylation, when a small molecule is added or subtracted from a piece of DNA, the environment and stressful life events can turn a gene on or off without altering the gene itself.”
“This unwillingness to grasp someone else's understanding is called cistemic injustice: the hierarchy in which some people's knowiedge systems are more valuable than other people's knowledge systems. It is a fact, for example, that fewer people would read this book if I were not a physician.
There are two types of epistemic injustice, according to Miranda Fricker, the philosopher who popularized the concept. Testimonial injustice is when we don't believe what people say because of their inferior status in society. Hermeneutic injustice, relatedly, is when we don't have words for people's experiences. "An example of the first," writes Fricker, "might be that the police do not believe you because you are black; an example of the second might be that you suffer sexual
"harassment in a culture that still lacks that critical concept."" Both types of epistemic injustice are involved in trauma: both the inability to believe that some people's responses to trauma are real and the fact that there aren't ways to discuss trauma responses that don't fit a Western narrative of the concept.
As scholars of epistemic injustice point out, some voices simply aten't taken seriously, in part because they do not appeal to Western ideas of what a voice can say and how a voice can speak."
“Living bisected between worlds an ocean apart has made me interrogate how this universalizing tone flattens the multiplicity. of trauma; how it forces an overly simplistic conception of well-being. and suffering in places where such a conception may not be useful or welcome.”
“A social prescription could be a gym membership or a
1950s
dance class. It could be a housing voucher or food stamps. It could be a nature walk, or even much needed, hard cash. But Jack Geiger (1950s) believed, as do I, that social prescribing is about not only individual-level prescriptions for structural problems faced by patients but also structural prescriptions (such as the pit latrines in South Africa) that build healthier environments to improve the well-being of many individual patients at scale.”
“Because of this, housing is one of the most potent social prescriptions for mental illness and should be the first step in mental health care, a principle called Housing First, which espouses getting patients into housing before any of their other problems can be dealt with.”
“A 2019 study in Biological Psychiatry showed that in the first year of residency medical trainees had significant shortening of their telomeres, which are the protective bits of DNA at the ends of our chromosomes that hold them together and prevent them from unraveling.® Each time a cell divides, its telomeres shorten, until eventually the telomeres can no longer protect our chromosomes and the cell "dies" or becomes
"senescent." When the rate of telomere shortening is normal, this process is protective; it kills off cells that could otherwise become cancer-ous. But when the rate of telomere shortening is more rapid than normal, as it was for medical trainees in this study, senescent cells from chronic stress can cause inflammation throughout the body, which is associated with premature aging and early mortality.”
“In the United States, people spend their lives in the pursuit of happiness, but it is a cultural assumption that happiness is the best way of being. It is almost impossible for us to imagine that our patients wouldn't always prefer to feel happy.
What this projection of our own emotional ideals does, intentionally or not, is invalidate people's suffering and potentially worsen their mental health. It says to patients that the way they are feeling when they are sad or anxious or paranoid is not warranted, even when it is a rational response to a toxic environment.
To maximize autonomy and limit projecting our normative emotions onto our patients, a helpful framework for clinicians and patients in mental health is cognitive liberty, a twofold idea that argues that everyone should have the right to "mental self-determination." First, everyone should be able to alter their own consciousness however they see fit, whether through drugs, therapy, medications, or yoga. Second, everyone should be free from coercive efforts by others to alter their consciousness; in other words, people should not be coerced or forced into taking psychotropic medications.”
“Indigenous Zimbabwean knowledge explains mental health proba lems in spiritual terms, most commonly through ngozi, angered spir-its.' People experiencing madness are suffering the consequences of angry spirits who demand retribution for wrongdoing. There are f range of offenses that might create this situation: livestock theft, mur der, domestic violence, unpaid dowry. And, while the wrongdoing might have been committed by a single person a long time ago, misfortune due to ngozi reverberates throughout the kinship system and across generations.”
“I'm not saying that we should recode all instances of ngozi as
"trauma," but there is a broad parallel: In both ngozi and trauma, a bad thing happens, and people suffer intergenerational distress because of it. This tells me that the phenomena might be related but have different cultural explanations, what medical anthropologists call explanatory models.”
“But researchers throughout the world have demonstrated that cash transfers improve people's physical health, depression, anxiety, school attendance, maternal-child health, nutrition, and even mortal-ity. People who receive cash transfers are less likely to murder, be incarcerated, die of overdose, transmit HIV, commit domestic vio-lence, and visit the emergency department. In a large meta-analysis pooling more than twenty-six thousand participants, researchers at Oxford looked specifically at the impact of cash transfers on depression and anxiety in poorer countries. They found, unsurprisingly, that giving people free cash significantly reduced symptoms of mental ill-ness? "Financial insecurity," explains the psychiatrist-anthropologist Eric Reinhart, "is a major driver behind cycles of poor mental health, disease, violence, crime, and incarceration-all of which, in turn, further entrench poverty, destabilize families, undercut public health and childhood education, and constrain people's life opportu-nities."
“When people are living in poverty, what actually helps their mental health is the most obvious but least often prescribed: cash.”
“If depression gets better when you give someone money. and rets worse when you take it away, this is even stronger evidence that the cause of depression is a lack of money, otherwise known as poverty.”
“If you are paid to do something, you have the option to stop that job and forfeit your pay.
That freedom is good for mental well-being. (Labor specialists call this
"job control," which is associated with better mental health.)" But if you do something purely out of moral obligation, or, as women have been socialized to do, out of "love," that care work is harder to escape, making it more likely to worsen the carer's mental health.”
Review of advance copy received from Netgalley
Thanks to NetGalley & Crown Publishing for the ARC!
Dr. Khameer Kidia’s Empire of Madness: Reimagining Western Health Care for Everyone is a research-backed, memoir-hued book with a simple premise: “That suffering, though it is internally experienced, is externally determined.”
To put it another way, mental illness is revealed in the individual, but it is rooted in—and resolved through—the community.
To put it a third way, maybe you’re depressed because you can’t afford your groceries. Maybe you have ADHD only because productivity is elevated as gospel.
For readers familiar with social theory, much of what Kidia says here isn’t anything new—Western capitalism medicalizes and individualizes social ills, and then it stigmatizes those who experience them. Coincidentally, those who are sickest often look the least like those in power. The author’s vital addition to care-related discourse is, perhaps, his positionality as much as his message. He isn’t an “anti-medicine hippy” or a political mouthpiece. He’s a Princeton-educated doctor saying, “Hey, we are under-serving people when we aren’t also looking at the circumstances causing their problems.”
By looking outside of the patient, Kidia invokes the concept of ubuntu in a call for deeper focus on “ministering to suffering.” With this emphasis on practice, the politics of the book feel accessible, which is so important for a project as topically far-reaching as Empire of Madness.
Kidia’s writing lives in nuance. He writes about how he happily helped a trans woman get top surgery before recognizing that the requirement of diagnosed gender dysphoria codifies stigma. He describes the impact of care facilities that mirror prisons and questions what “the carceral nature of mental health” says about our beliefs surrounding recovery. He explores how COVID stimulus checks functioned as a “social prescription” that alleviated mental stress. Above all, the author writes with a willingness to learn, and one of the pleasures of Empire of Madness is that it isn’t didactic—it's personal.
Throughout the book, Kidia is remarkably focused, and a key reason for that is his use of auto-ethnography as a scaffold for his arguments. Born to Indian parents in Zimbabwe and educated in the US, he has seen and experienced the disconnect between Western talking points and the way they inflict harm. He has witnessed how a decimated economy impacted his mother; how his community couldn’t get COVID vaccines because the American government stockpiled them; how US sanctions on Zimbabwe prevented him from crowdfunding medical access to people who had already suffered at the hands of their government. The author writes all of these critiques with grace and humility, identifying his past mistakes and using them as the foundation for reflection. It’s a generous approach to such a heavy topic.
If there is a critique to be made, it’s that the final “prescription” for change rings a little hollow, losing the specificity of earlier chapters in favor of limp suggestions that there should be less stigma and less punitive debt. Yes, one thinks, but how? Ultimately, it highlights just how vast these structural issues are— it’s hard to know where to even begin tackling them. By the end of the book, I felt very sure of the diagnosis but uncertain if it could be treated.
Despite this small complaint, I think Empire of Madness is excellent, and for readers who are interested in what it means to be well, the book might be just what the doctor ordered.
Dr. Khameer Kidia’s Empire of Madness: Reimagining Western Health Care for Everyone is a research-backed, memoir-hued book with a simple premise: “That suffering, though it is internally experienced, is externally determined.”
To put it another way, mental illness is revealed in the individual, but it is rooted in—and resolved through—the community.
To put it a third way, maybe you’re depressed because you can’t afford your groceries. Maybe you have ADHD only because productivity is elevated as gospel.
For readers familiar with social theory, much of what Kidia says here isn’t anything new—Western capitalism medicalizes and individualizes social ills, and then it stigmatizes those who experience them. Coincidentally, those who are sickest often look the least like those in power. The author’s vital addition to care-related discourse is, perhaps, his positionality as much as his message. He isn’t an “anti-medicine hippy” or a political mouthpiece. He’s a Princeton-educated doctor saying, “Hey, we are under-serving people when we aren’t also looking at the circumstances causing their problems.”
By looking outside of the patient, Kidia invokes the concept of ubuntu in a call for deeper focus on “ministering to suffering.” With this emphasis on practice, the politics of the book feel accessible, which is so important for a project as topically far-reaching as Empire of Madness.
Kidia’s writing lives in nuance. He writes about how he happily helped a trans woman get top surgery before recognizing that the requirement of diagnosed gender dysphoria codifies stigma. He describes the impact of care facilities that mirror prisons and questions what “the carceral nature of mental health” says about our beliefs surrounding recovery. He explores how COVID stimulus checks functioned as a “social prescription” that alleviated mental stress. Above all, the author writes with a willingness to learn, and one of the pleasures of Empire of Madness is that it isn’t didactic—it's personal.
Throughout the book, Kidia is remarkably focused, and a key reason for that is his use of auto-ethnography as a scaffold for his arguments. Born to Indian parents in Zimbabwe and educated in the US, he has seen and experienced the disconnect between Western talking points and the way they inflict harm. He has witnessed how a decimated economy impacted his mother; how his community couldn’t get COVID vaccines because the American government stockpiled them; how US sanctions on Zimbabwe prevented him from crowdfunding medical access to people who had already suffered at the hands of their government. The author writes all of these critiques with grace and humility, identifying his past mistakes and using them as the foundation for reflection. It’s a generous approach to such a heavy topic.
If there is a critique to be made, it’s that the final “prescription” for change rings a little hollow, losing the specificity of earlier chapters in favor of limp suggestions that there should be less stigma and less punitive debt. Yes, one thinks, but how? Ultimately, it highlights just how vast these structural issues are— it’s hard to know where to even begin tackling them. By the end of the book, I felt very sure of the diagnosis but uncertain if it could be treated.
Despite this small complaint, I think Empire of Madness is excellent, and for readers who are interested in what it means to be well, the book might be just what the doctor ordered.
December 8, 2025
Empire of Madness is perhaps the most affirming, revolutionary book I have read as a mental health scientist and clinician. Dr. Khameer Kidia's brilliant, humanistic case for decentering Western perspectives in mental health is at once a comprehensive accounting for capitalist mental health industry as a tool of empire and oppression, a poignant reflection on their own personal and professional journey, and a masterful case for radical empathy and the healing power of community. I firmly believe this text should be required reading in all mental health training programs. Full review to come after publication.
Also: seeing a methods and position section in a nonfiction text warmed my qualitative heart and participatory action researcher soul :)
Also: seeing a methods and position section in a nonfiction text warmed my qualitative heart and participatory action researcher soul :)
February 13, 2026
I agree with about 95% of the book, however I do think the author’s attitude is a bit too idealistic.
As someone that has been working in public mental health for over 10 years now (Australia) I think there’s a risk that someone may read this book and believe that psychosocial economic factors are the only causes for mental health issues.
The existing system is not perfect, I am fully aware. However we have come a long way. We also can’t forget that medication and inpatient/ community treatment are necessary for a reason.
As someone that has been working in public mental health for over 10 years now (Australia) I think there’s a risk that someone may read this book and believe that psychosocial economic factors are the only causes for mental health issues.
The existing system is not perfect, I am fully aware. However we have come a long way. We also can’t forget that medication and inpatient/ community treatment are necessary for a reason.
February 5, 2026
5⭐️
Soft 5 stars. Intriguing analysis of psychiatry and mental health
Soft 5 stars. Intriguing analysis of psychiatry and mental health
Displaying 1 - 6 of 6 reviews