Category Archives: International

Mental Illness in Pakistan: The Impacts of Terrorism

BY MAHA CHAUDHRY

In the last decade, the nation of Pakistan has struggled with poverty, faltering power supplies, education inequality, and inflation. However, one of the greatest factors contributing to the nation’s instability is terrorism. A study by the Institute for Economics and Peace ranked Pakistan as third on its Global Terrorism Index, a ranking of the degree to which nations have been affected by terrorism. As a result of the War on Terror, an estimated 80,000 Pakistani civilians have been killed between 2004 and 2013.

As terrorism has become a growing concern in Pakistan, the mental health of its people has also suffered.  From 2001 to 2011, the country witnessed an almost 100% increase in the incidence of mental illnesses, particularly stress-related disorders and depression. Moreover, much research has found a consistent relationship between exposure to terrorism and poor mental health outcomes. A study in Swat Valley, a region in Pakistan especially afflicted by terrorist violence as well as anti-terrorism drone attacks, found severe post-traumatic stress disorder symptoms in a majority of its participants. Another study conducted by Nasim et al. (2014) found a significant association between terrorism and psychiatric morbidity, even among participants who had no direct exposure to terrorism-related violence.

These findings and those of similar studies suggest that living under the threat of a potential terrorist attack is powerful enough to interfere with the daily functioning of the population as a whole, regardless of an individual’s actual exposure to such trauma.

“living under the threat of a potential terrorist attack is powerful enough to interfere with the daily functioning of the population as a whole”

Recognizing the psychological implications of terrorism in Pakistan is of utmost importance, as the growing problems of mental health in the country have already cost it a great deal. The Pakistan Association for Mental Health (PAMH) has highlighted the impacts of poor mental health on “national productivity, creativity, entrepreneurship and personal development”. Severe mental illness has also been associated with health risk factors such as obesity and addiction, to the extent that the World Health Organization has predicted that depression will soon become the second leading cause of death in Pakistan.

While a successful end to the War on Terror would be the ideal solution to its detrimental consequences on the health of Pakistanis, perhaps a more feasible, though challenging, approach would focus on battling the social stigma associated with mental illness in the country, and on increasing the accessibility and quality of mental health services. The increasingly urgent issue of mental illness in Pakistan, exacerbated in the face of terrorism, is one that must be addressed.

[Photo: The family of Zoubair Latif, a seventeen year old student, waits to collect his body after he was killed in a 2014 suicide bombing in Rawalpindi, Pakistan. Source: Dawn News]

References

  1. Global Terrorism Index. Rep. Institute for Economics and Peace, Nov. 2015. Web. 10 Dec. 2015.
  2. Body Count: Casualty Figures after 10 Years of the “War on Terror”: Iraq, Afghanistan, Pakistan. Rep. IPPNW Germany, Physicians for Social Responsibility, Physicians for Global Survival, 19 Mar. 2015. Web. 10 Dec. 2015.
  3. “100 per Cent Rise in Mental Disorders.” Dawn. Dawn Media Group, 09 Oct. 2011. Web. 26 Apr. 2015.
  4. Khalily, Muhammad Tahir. “Mental Health Problems in Pakistani Society as a Consequence of Violence and Trauma: A Case for Better Integration of Care.”International Journal of Integrated Care 11 (2011): e128. Print.
  5. Nasim, Sarah, Mahjabeen Khan, and Sina Aziz. “Impact of Terrorism on Health and Hospital Anxiety Depression Scale Screening in Medical Students, Karachi, Pakistan.” Journal of Pakistan Medical Association 64.3 (2014): 275-80. Journal of Pakistan Medical Association. Journal of Pakistan Medical Association, Mar. 2014. Web. 10 Dec. 2015.
  6. May, Kate T. “Some Stats on the Devastating Impact of Mental Illness Worldwide, Followed by Some Reasons for Hope.” TED Blog. TED, 11 Sept. 2012. Web. 26 Apr. 2015.

Mental health in prisons around the world

BY ANASTASIA REPOULIOU

Show me your prisons and I shall say in which society you live.
~Winston Churchill

The Problem

Let’s start with the numbers: According to the World Prison Population List, 11th edition, by Roy Walmsley, more than 10.35 million people are held in penal institutions throughout the world. Taking into account that figures for Eritrea, Somalia, and the DPRK are not available, that figures for China and Guinea-Bissau are incomplete, and that prisoners held in not fully recognized international jurisdictions and pre-trial prisoners were not included in the report, the total can be estimated to be higher than 10.35 million and may well be in excess of 11 million.

The world prison population rate, based on United Nations estimates of national population levels, is 144 prisoners per 100,000 of the national population. Trends vary largely internationally. Since about the year 2000, the total prison population has increased by about 60% in Oceania, 14% in Central America, and 145% in South America.  In Europe it has decreased by 21% largely because of falls in prison populations in Russia and central-eastern Europe.

Now that we’ve established that we are dealing with a large and quickly growing part of the world’s population, let’s look at this population’s profile.

According to the World Health Organization (WHO), there is a disproportionately high rate of mental disorders in prisons. These mental illnesses are often present before admission to prison and exacerbated by the stress of imprisonment, but sometimes they are developed during imprisonment as a consequence of the prison environment and possibly torture or other human rights violations. The main causes identified pertain to:

  • The specific prison environment – overcrowding, violence, enforced solitude, lack of privacy, lack of meaningful activity, isolation, insecurity about future prospects, and inadequate health services (especially mental health services)
  • Societal perceptions affecting the judicial and penal system – the misconception that people with mental disorders are a danger to the public, the intolerance of many societies to difficult or disturbing behavior, the failure to promote treatment, care, and rehabilitation, and the lack of, or poor access to, mental health services
  • The practice of inappropriately locking people with severe mental disorders up in prisons because of the lack of mental health services.
Prisoners suffer disproportionately from mental illness.

The Challenges

Anasseril E. Daniel, a psychiatrist in Columbia, identifies psychotic illness, major depression, personality disorder, psychosis, anxiety disorders including post-traumatic stress disorder (PTSD), organic disorders, suicidal behaviors, and attention deficit hyperactivity disorder (ADHD) as some of the main mental health issues in prisons. Dr. Daniel also identifies some issues that arise when we examine mental health provisions in prisons.

One consideration is the privatization of mental health and medical care, which started due to increasing healthcare costs, staff expense, lack of qualified health care professionals to work in prisons, general lack of visionary correctional leadership, and increasing litigation. There are multiple health care models including services provided by the state, large private vendors providing medical and mental health services, separate small or large specialist mental health vendors, public medical institutions, and medical school-private vendor partnership.

Even though it is unclear which of these models work best, it seems to be true that the profit motive may trump quality and compromise ethics standards and practice.

Another issue that makes mental health in prisons an important issue for the public is that, as Dr. Anasseril puts it: “Compared with the public, offenders may seem less cooperative, less appealing, and even less ‘human.’ Yet U.S. courts have clearly established that prisoners have a constitutional right to receive medical and mental health care that meets minimum standards.”

Finally, pharmaceutical costs are of course a significant component of the overall mental health care costs in corrections, and therefore an important challenge in improving the mental health services in prisons. A tactic we need to put an end to is that of establishing a restricted formulary of older generation psychotropics and generic agents that are less expensive from which formulary physicians are required to preferentially prescribe medications. This is especially important in drug-abusing prisoners, who should be treated with anti-craving and relapse-prevention medications beginning two to four weeks before release and until 30 to 60 days after release.

The Goals

The importance of dealing with these issues should be clear. The WHO summarizes the benefits of responding to mental health issues in prisons in terms of utilitarian calculations with regard to the three main stakeholders:

  1. Prisoners: enhanced health and quality of life, increased probability of successful rehabilitation, and decreased re-offense likelihood
  2. Prison staff: reasonably decreased demands placed upon staff
  3. Society: decreased re-offense incidents, reduced high costs of prisons.

Additionally, the WHO provides a set of possible solutions, including but not limited to diverting people with mental disorders towards the mental health system, access to appropriate mental health treatment, including acute mental health care in psychiatric wards, psychosocial support, and rationally prescribed psychotropic medication, trained staff, information, and education to prisoners and their families on mental health issues, and adoption of mental health legislation that protects human rights.

Assuming a fair and functional judicial system, society through the executive action of the government has the right to restrict the rights of serious offenders, for its own protection, as well as the ultimate goals of deterrence and rehabilitation.

Prisoners lose many of their civil rights such as self-determination and liberty of movement and action. They do however retain their basic rights as human beings.

Prisoners have a right to be healthy and to be provided with adequate treatment. Major steps have been accomplished in that respect when it comes to physical health, but mental health remains a big issue that is largely ignored.

 

References

Daniel, Anasseril E. “Care of the Mentally Ill in Prisons: Challenges and Solutions.” Journal of the American Academy of Psychiatry and the Law Online. American Academy of Psychiatry and the Law., Dec. 2007. Web. 13 Feb. 2016. <http://www.jaapl.org/content/35/4/406.full>.

“Mental health and prisons Information Sheet.” World Health Organization. ICRC. Web. 13 Feb. 2016. < http://www.who.int/mental_health/policy/mh_in_prison.pdf >.

Walmsley, Roy. “World Prison Population List Eleventh Edition.” World Prison Brief (n.d.): n. pag. Institute for Criminal Policy Research, Birkbeck University of London. Web. 13 Feb. 2016. <http://www.icpr.org.uk/media/41356/world_prison_population_list_11th_edition.pdf>.

 

Image Reference

Murray, Stuart J. “Prisons & Mental Health: Violence & Truth-telling.” CHAIM Centre. Carleton University, n.d. Web. 13 Feb. 2016. <http://carleton.ca/chaimcentre/2015/prisons-truth-telling/>.

Humanitarian Response to the Syrian Refugee Crisis

BY ANASTASIA REPOULIOU

no one leaves home unless
home is the mouth of a shark
~Warsan Shire, “Home”

Syrians are fleeing their homes because home is the mouth of a shark. According to a report by the humanitarian organization World Vision, violence caused by the civil war, a healthcare and education infrastructure collapse, and the imminent and exacerbated danger on children, who have suffered physical and emotional injuries, witnessed brutality, and are aggressively recruited in the war, have caused 4.3 million Syrians to flee their country and 6.6 million to become displaced.

Most remain in the Middle East (80,000 in camp Za’atari, 23,700 in Azraq), Turkey (1.9 million), Lebanon (1.1 million, residing in rented abandoned buildings, sheds, garages, tents), Jordan (630,000, residing with host families or in rented accommodations), Iraq (250,000 in the midst of Iraq’s own armed conflict), and Egypt (fully integrated and largely urbanized), and slightly more than 10% of the refugees have travelled to Europe. Syrians, as all refugees fleeing conflict, are in immediate need of all the basics to sustain their lives: water, food, clothing, shelter, health assistance, and hygiene items.

Regardless of whether the refugees are residing in camps, or integrated in cities, they are facing varying levels of severe health risks, lacking access to basic sanitation and adequate health services. The response of both governments and existing health systems and foreign humanitarian aid by governments or organizations like the World Health Organization (WHO) and Médecins Sans Frontières (MSF) have been significant but still largely insufficient. Humanitarian response has also been mostly short-term and concentrated in safer areas and subject to funding cuts.

Untitled
Refugees awaiting care at MSF clinic in Domiz camp. Source: Doctors Without Borders

A joint field assessment by WHO and other humanitarian partners, supported by the Ministry and Departments of Health in Iraq and targeting Syrians residing both inside camps and within the host community in the Anbar and Dohuk governorates, has enabled a better understanding of the health conditions, services provided, and needs of Syrian refugees in Iraq.

The assessment outlined both the short-term and chronic health issues faced by the refugees. There is a significant shortage of chronic disease treatments and of facilities for people with disabilities, even though the children, women, elderly, and disabled were assessed to be at high risk of chronic diseases, and psychosocial and violence-related illnesses. At the same time, it’s of the utmost importance that communicable disease outbreaks are prevented.

A more recent WHO initiative, the Health Working Group in Egypt, co-chaired by WHO Egypt and UNHCR, identifies chronic conditions, like hypertension, diabetes mellitus, and cardiac diseases, as well as serious mental health conditions to be among the most significant health needs of the Syrian refugees. At the same time there is a high risk of communicable disease outbreaks, such as the Middle East respiratory syndrome coronavirus (MERS-cov) and polio. MSF in its fieldwork found most health problems they are dealing with are related to poor medical conditions, including respiratory and urinary infections, gastro-intestinal problems, diarrhea, arthritis, and skin diseases.

Actions are of course being taken both by humanitarian organizations and governments to offer assistance and health infrastructure to the refugees. WHO in Iraq, for example, has provided the Directorate of Health medications covering their needs for three to five months, as well as wheel chairs and other medical supplies, such as health and hygiene kits, vaccination services, and health education, and has contributed towards the establishment of clinics and the building of medical staff capacity.

WHO in Egypt is supporting the Ministry of Health and Population through building primary health care capacity, helping develop an Early Warning and Response Network for communicable diseases (EWARNS), detecting and managing non-communicable diseases, and integrating mental health services.

Responding to the polio outbreak in Syria, WHO is assisting with national immunization for polio across Egypt, including in the refugee communities. MSF’s actions in response to the crisis in Iraq include carrying out 126,722 medical consultations in Iraq, deploying mobile medical teams for remote and hard-to-reach areas, providing general health care with focus on chronic diseases, reproductive health, and mental health, and – in response to increasing needs – opening a maternity unit where women can deliver babies safely. MSF has also been working to contain the cholera outbreak in the Baghdad district and the governorates of Diwaniya, Najaf, and Babil.

As humans witnessing the violent uprooting of fellow humans we should be concerned and active in ensuring an improvement in the health conditions of the Syrian refugees.

But even disregarding our humanitarian obligations, it is of the utmost importance that we prevent the spread of especially communicable diseases that is made more likely through the mass displacement and bad living conditions of the refugees, since it can cause another world epidemic that will affect all of us in a very concrete way.

 

 

Sources:

“Iraq.” MSF USA. Medecins Sans Frontieres, 24 Dec. 2013. Web. 12 Dec. 2015. <http://www.doctorswithoutborders.org/country-region/iraq>.

“Providing Health Care to Syrian Refugees in and outside the Camps.” Iraq | News.World Health Organization, 2012. Web. 12 Dec. 2015 <http://www.emro.who.int/irq/iraq-news/syrian-refugees-in-iraq.html>.

“Syrian Refugee Response.” Egypt | Programme Areas | Syrian Refugee Response.World Health Organization, 2015. Web. 12 Dec. 2015 <http://www.emro.who.int/egy/programmes/syrian-refugee-response.html>.

 

 

 

Polio outbreak in Ukraine: consequences and lessons

BY AVA TORJANI

Beginning September 2015, two cases of polio were reported in southwestern Ukraine, paralyzing a 4-year old and 10-month old, according to the Global Polio Eradication Initiative. After its first occurrence in Europe over the last five years, polio has stirred significant distress amongst healthcare officials and the Ukraine government due to the alarmingly low population of vaccinated children, which is currently at fifty percent. The World Health Organization (WHO) has urged Ukraine to declare a state of emergency in order to avoid further spread of the disease to bordering countries including Romania, Hungary, Poland, and Slovakia.

Polio is a highly infectious disease caused by poliovirus, which can be transmitted from person to person via ingestion of infected feces. It predominantly affects children under the age of five and is characterized by symptoms of fever, headache, and vomiting. Initially replicating in the intestine, the virus can invade the immune system and cause paralysis.

Thankfully, several vaccines against polio exist. So how exactly did this menacing disease reappear? The vaccine itself contains a weakened form of the virus, which boosts our immune system so that we can fight off the real virus if we ever catch it. However, the weakened virus may undergo mutation and grow stronger—a problem for those who are not vaccinated, but not for those who are.

Up until now, there have been no new reported cases of Polio, according to the Global Polio Eradication Initiative. However, the World Health Organization is still urging Ukraine to declare a state of emergency for several reasons. Firstly, there is no cure to polio, which makes it very difficult to treat successfully if contracted. Also, an outbreak can have devastating consequences due to the large number of countries bordering Ukraine.

As a result—with the aid of WHO, CDC, UNICEF, Gates Foundation and Rotary International—the Ukrainian government launched a polio vaccine campaign in October, whose initial goal was to vaccinate ninety percent of children aged five and under. Unfortunately, only sixty percent of these children were vaccinated by early November.

What is obstructing the campaign’s path towards this goal?

The most significant explanation corresponds to anti-vaccination attitudes amongst Ukrainians, in particular a Ukrainian lobby group that claims the vaccines against polio are unsafe and should be destroyed. In addition, the majority of parents are not well informed about the disease, with only eighteen percent of Ukrainian mothers knowing that polio is actually dangerous. Physicians are also liable to the potential consequences of vaccines and are therefore reluctant to administer them; if a child dies within thirty days of receiving the vaccine, it is considered as the sole cause of death. In Ukraine, the physician who administered the vaccine can consequently have their license suspended or can be sent to jail. However, the driving reason for low immunization rates for polio is the insufficient supply of its vaccines. According to the Global Alliance Vaccine Initiative, Ukraine buys these vaccines locally rather than internationally, which means that the supply is generally low and the costs are accordingly much higher.

These obstructions are yet another driving reason for WHO’s insistence that Ukraine declares a state of emergency. “The declaration would mobilize other government divisions to support the vaccination campaign,” claims Oliver Rosenbauer, a spokesperson for the WHO polio eradication program. Nevertheless, the vaccine campaign has created a greater public awareness of the importance of immunizing against polio and other infectious diseases.

Although it’s a costly lesson, this incident teaches us all about the importance of public health awareness for diseases, their treatments and their cures. The optimistic outlook of this incident focuses on the long-term goal of improving Ukraine’s immunization system in order to prevent future outbreaks of disease.

The Spread of Chagas Disease: One of the Leading Causes of Heart Failure in Latin America

Although Chagas disease has only recently emerged as a possible public health concern in some southern states of the U.S., this infectious disease has been a major threat of high priority for health officials throughout many nations of Latin America for many years.

Prevalent in countries such as Mexico and Brazil, Chagas disease, also known as American trypanosomiasis, is a potentially life-threatening tropical parasitic infection caused by the protozoan parasite Trypanosoma cruzi (T. cruzi) found mostly in endemic areas of Central and South America. Continue reading The Spread of Chagas Disease: One of the Leading Causes of Heart Failure in Latin America

The Spread of Chagas Disease in Latin America

By Francisca Bermudez

Although Chagas disease has only recently emerged as a possible public health concern in some southern states of the U.S., this infectious disease has been a major threat of high priority for health officials throughout many nations of Latin America for many years.

Prevalent in countries such as Mexico and Brazil, Chagas disease, also known as American trypanosomiasis, is a potentially life-threatening tropical parasitic infection caused by the protozoan parasite Trypanosoma cruzi (T. cruzi) found mostly in endemic areas of Central and South America. According to the Center for Disease Control and Prevention (CDC), it is estimated that as many as 8 million people suffer from this disease worldwide, many of whom are unaware of their condition.

Most victims are infected by this parasite in the same way: through contact with the feces of triatomine bugs, also known as “kissing bugs”. As described by the CDC, they are known as “kissing bugs” because they tend to feed on people’s faces; after they ingest blood, they defecate on the person, infecting them with the T. cruzi parasite. While usually transmitted to animals and people by insect vectors, Chagas disease can also spread through congenital transmissions, contaminated blood transfusions, infected organ transplants, or even laboratory accidents.

Chagas disease has spread quickly over the years and has recently become so widespread in areas of Latin America that many now feel it has become a “public health emergency”6.This is because Chagas disease, in its later stages, can often result in chronic diseases and even death.

In an interview, Dr. Juan Mejia, Secretary General of the Latin American Society of Cardiovascular and Thoracic Surgery, explains that besides causing gastrointestinal disease such as “megacolon” or “megaesophagus,” Chagas disease can also lead to severe cardiac disease and can “cause acute myopericarditis as well as chronic fibrosing myocarditis”.

According to Dr. Mejia, “Chagas myocarditis is the most common cause of non-ischemic cardiomyopathy in Latin America”. In fact, of the people suffering from Chagas disease, according to the World Health Organization, approximately 30% of chronically infected people develop cardiac abnormalities7.

These cardiac abnormalities, Dr. Mejia states, can often include “cardiac arrhythmia, left ventricular enlargement, and chronic heart insufficiency”. In addition, Chagas disease often leads to cardiomyopathy as a result of “chronic myocardial aggression” along with “chronic inflammation and fibrosis of the heart,” he adds.

Due to these mentioned cardiac complications, Chagas disease, throughout the Americas in recent years, has emerged as one of the leading causes of heart disease in the region.

According to Dr. Mejia, this epidemic of Chagas disease – one of the leading causes of heart failure in Central and South America – has quickly spread throughout Latin America and is “typical of Andean, semi, and tropical countries”. Noting that “the transmission of Chagas disease is related to the insect family of Triatominae,” he explains that these insects usually “live in hovels where they are able to multiply without the risk of predators.” For this reason, we commonly see the spread of Chagas disease in places where “kissing bugs” thrive, which is mostly in mud dwellings in undeveloped areas in Latin America.

While this epidemic has mainly affected those living in Central and South America, the CDC has recently reported that Chagas disease is now progressively spreading to other areas of the world9. As a result, due the mentioned serious cardiac complications, it appears that Chagas disease will continue to be a major public health concern in the long run. However, it is possible that it will now have an impact not only in the lives of people in Latin America, but also in the lives of people in many other parts of the world as well.

Lessons from Polio in Nigeria

By: Tristan Lim

At the end of the twenty-fifth year of the Global Polio Eradication Initiative, only three polio-endemic countries remain in the world – a drastic difference from the more than 125 countries struggling to control polio in 1988. One of these remaining countries is one of the most populous in the world: Nigeria.

Located in West Africa, Nigeria has made ongoing efforts to eradicate polio since 1988 as part of the Global Polio Eradication Initiative. As of 2014, the Nigeria Polio Eradication Emergency Plan (NPEEP) has identified six strategic priorities in eradicating polio: enhancing the quality of supplemental immunization activities, implementation of special strategies to reach underserved populations, adoption of special approaches for security challenges areas, improving outbreak responses, enhancing routine immunization and in-between round activities, and enhancing surveillance.

The NPEEP’s efforts have brought about important achievements in the ongoing battle to eradicate polio. In 2013 alone, Nigeria saw a marked reduction of at least 56% in Type 1 wild polio virus cases compared to those in 2012 and witnessed the disappearance of Type 3 wild polio virus with no cases in 2013. However, Nigeria’s six-pronged plan has led to an unexpected outcome in regards to another nearby epidemic.

In recent months, the Ebola epidemic has ravaged countries in West Africa such as Sierra Leone, Liberia, and Nigeria. On July 20th, Nigeria’s Ebola outbreak began when Liberian-American Patrick Sawyer flew into Lagos. Nineteen confirmed cases and one probable case stem from Sawyer’s case, the most recent of which was detected August 31. As of October 20th, the World Health Organization has officially declared Nigeria Ebola-free after having passed the mandatory period of forty-two days after the last confirmed case of the virus being discharged from the hospital.

The World Health Organization Country Representative, Dr. Rui Gama Vaz, highlighted the importance of having an established public health infrastructure system by observing that, “As the most populous country in Africa and its newest economic powerhouse, Nigeria stands at a high risk for the spread of the Ebola virus disease”.

With the construction of public health infrastructure to battle polio, Nigeria has developed a more centralized approach to handling health crises that provided the country a head start over other West African countries. The NPEEP’s strategies such as instituting a centralized National Polio Eradication Emergency Operations Center and improving strategies to reach underserved populations have effectively created a surveillance system that was easily implemented to monitor new Ebola cases.

Many lessons concerning emergency responses and decision-making can be learned from Nigeria’s success in containing Ebola. As the world continues to watch the Ebola health crisis take place in West Africa, Nigeria is a prime example of the importance of public health infrastructure. Development of emergency operations centers and surveillance systems in the rest of the West African countries may lend themselves to further preventing the spread of Ebola. While these lessons from Nigeria may be late to the war on Ebola, they still provide a resounding model of centralized public health infrastructure that may prevent future epidemics from occurring.

Lessons from Polio in Nigeria

At the end of the twenty-fifth year of the Global Polio Eradication Initiative, only three polio-endemic countries remain in the world – a drastic difference from the more than 125 countries struggling to control polio in 1988. One of these remaining countries is one of the most populous in the world: Nigeria.

Located in West Africa, Nigeria has made ongoing efforts to eradicate polio since 1988 as part of the Global Polio Eradication Initiative. Continue reading Lessons from Polio in Nigeria