Redefining the Cultural Norm

by Konyin Adewumi

I have lived under the umbrella of a patriarchal African society all my life.

Chimamanda Ngozi Adichie was the first self proclaimed African Feminist that I had ever encountered. To me, she was a glimmer of hope of what could be. However, I believe the rest of the world needs to reevaluate the reality. It is a dangerous game to look at Africa with a savior complex, deep rooted in the history of the white man’s burden.

My mother is the strongest person I know. Growing up, I learned to fear and admire a woman who was over a foot shorter than me. And though I loved my father with the heart of any young girl whose father has shown her nothing but kindness, I knew that nothing in my life could function without my mother.

My mother could come home from a long day of work, cook my family dinner, drive us anywhere we needed to go, tidy up, adorn herself in anti aging creams, and wake up to do it all over again. She served as both breadwinner to my family and the glue that shouted us all together, because if you have ever encountered an African mother, she was probably shouting.

 I could say the same about many of the African women I grew up around. I had aunties whose strengths and talents were unparalleled. So much so that when I see a picture of an African woman with a basket of yams on her head and baby wrapped in eccentrically colored cloth hanging from her back, I see a woman that can do anything. There is power beyond belief in the African woman, this is what I hope others will one day see.

However, I do not hide behind cultural pride and regional dedication, as a means to ignore a greater issue. Global problems such as the rapid spread of HIV in sub-Saharan Africa have made the problems of patriarchy almost impossible to ignore. HIV disproportionately affects girls and young women throughout Africa, often attributed to the over arching culture of male dominance. Women are less in control of reproductive justice, cliterodectomy are practiced in villages around the continent, female literacy rates continue to be much lower than men, while child marriage remained highly prevalent among young girls.

Women of Africa have historically shown the world what they are capable of. They have played pivotal roles in the ending of apartheid, they have mobilized to end civil wars, they have served as voices to end female genital mutilation, and they have served as powerful heads of states. If global burdens of disease disproportionately affect women, what is the role of women in creating policy, as opposed to men? Audre Lorde once said that the master’s tools will never dismantle the masters house, does this place the burden of change upon the backs of women?

It is not a secret that cultures continue to change. No culture that has refused to adapt has survived the constant transitions and transformations of globalization. So I then pose the question, what would the changing of the gender culture look like in Africa? Can it be implemented into African culture, without breaking down walls of the culture itself? Khadija Gbla, a brilliant African feminist who works to end female genital mutilation, once said that culture is not an excuse for abuse. Do we sacrifice health for the sustainment of a culture or culture to promote health? Are the two mutually dichotomous? I believe we are in a time where women and men of Africa work to cultivate a reality of African Feminism rather than aspire to westernized ideas of female rights.

This begins by asking women of all ethnicities, what does empowerment look like to you and who can help you attain it?

Stereotypes of gender- who said men cannot be good nurses

by Jing Wang

Dr.Watt mentioned in class that: “Gender is the social construction of the biological differences between men and women.”  When I sit down and think about words such as “women,” “female,” “feminist,” “men,” “male,” “patriarchy,” and “masculine,” I feel that yes, gender is “a learned and socially determined behavior.”  Then I start to reflect on how people tend to tag men and women in different countries and cultures.  In fact, it is unfair to both men and women when people assume how men and women should perform regardless of their individual characteristics.

 Adichie talked about the stereotypes that people have for feminists in South Africa: they should look sexless, single, aggressive and not feminine at all, which reminded of people’s attitudes towards feminists in China.  Feminists should be a neutral word but it is more of a negative word in China.  One of the famous sociologists specialized in gender studies in China, who is definitely a feminist, told me that never claim yourself as a feminist if you want to achieve success in this research field.  People will regard you as radical and aggressive and question your work as biased. 

 Another thing that Adichie mentioned was that some of her male friends do not understand why women still think there was gender inequality since the society has given tremendously more rights to women in the past twenty years.   I still remember the student Union election back in high school. Our director said that this school valued gender equality very much so we needed one girl there to show this.    Many people understand gender equality in this way. It is something that we should show and brag about. I do not care who this woman is and what she can do. All that I care about is that she is a woman and be there to show how much I value gender equality.  I am not denying that it has been great progress since the time when women could not vote back in the early 20^th century. But what I am saying is that it is far from enough.  This so-called equality has tricked us and blinded us with ignorance and indifference.   

All these stereotypes and tags are unfair to both women and men.  I question why men must be masculine, what is the whole point of this since we are not cavemen and will not starve to death if men did not go hunting.  And I do believe that there should be some cavemen who loved and were better at caring for babies and sewing while they were forced out to hunt.   Just like how people talked about “male nurses” in China. And to be honest, I doubted their ability to be nurses as well because I have been taught and seen a lot how women are born caregivers.  But it turned out they can be great nurses not only in ICU and OR, but also in neonatal department.  I was wondering how many good male nurses we have missed because of the stereotypes and to generalize it, how many good career women we have missed in traditionally men-dominated fields. Almost all of us tend to assume what women and men should do and be like to different extents.  Just to keep in mind, even baby steps from thinking in this way will take us to a better world. 

Bridging the Know-Do Gap

by Alex Whitcomb and Michelle Roberts

“Action without knowledge and knowledge without action means wasted resources and missed opportunities” –Dr. J. W. Lee, WHO Director General

The know-do gap is the chasm between what is known and what is done in practice.  Dr. Paul Farmer frames the know-do gap in terms of infectious disease in saying,

“Simultaneously, rising life expectancy and rapid social change have led to an increasing burden of chronic diseases for which we have effective therapies but inadequate innovation for delivering them efficiently to the neediest people–the so-called know-do, or delivery gap”  (Farmer, 2013). 

This is a fundamental challenge in global health and reducing the global burden of disease.  Though this is a fundamental challenge, it also provides the greatest opportunity for strengthening of health systems.

The gap exists from research and policy to practice as well as the gap between knowledge and awareness to action and behavior change.  Eliminating this gap would mean eliminating preventable deaths.  It is estimated that two-thirds of child deaths worldwide could be prevented by available, effective and cheap interventions.  The World Health Organization estimates that 85.34% of the global disease burden is addressable by already available and cost effective interventions. This is huge.  If this is the case, why isn’t this being done?  Why is this still such an enormous problem?

The challenge remains to synthesis existing knowledge and disseminate this knowledge appropriately.   There is a wealth of information that exists on the Internet, but policy makers, health managers, and service providers are not receiving succinct and synthesized information.  Grimshaw et al. (2004) stated in a review that assessed guideline dissemination and implementation strategies that “despite 30 years of research in this area, we still lack a robust, generalisable evidence base to inform decisions about strategies to promote the instruction of guidelines or other evidence-based measures into practice” (Grimshaw et al., 2004).

Furthermore, care delivery is messy. It isn’t easily studied with a randomized-controlled trial – there are too many variables, too many potential confounders. This is especially true in impoverished settings with endemic inequality. Developing effective care delivery strategies requires observational and qualitative methods and establishing cultural understandings. Despite all of these obstacles, it remains fundamentally true that all our research is for naught if we don’t actually help anyone with it. Isn’t that why we all want to be in global health in the first place anyway?

Policy memos are a tool for bridging the knowledge gap between research and policy.  When done correctly, policy memos provide a concise and comprehensive account a specific problem with an impactful, feasible, cost effective solution.  

Yet, policy memos are only one example of the implementation of public health research. For a new intervention, vaccine, or service to alleviate disease to be effective it must be addressed systematically through policy and programs and services to implement the latest scientific data into patient care.

One of the most poignant examples of the power of care delivery has been the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR was able to do what many thought couldn’t be done - treat a chronic infection with a multidrug regimen poor settings. PEPFAR has made huge strides to diagnose HIV disease, enroll patients, and thus bridge the know–do gap and have a real effect on patients’ lives. Worries about patients in low-income settings ability to follow complex multidrug regimens have been proven surmountable. Dr. Farmer estimated that “in Haiti and Rwanda, so too in South Africa, Kenya, Tanzania, Uganda, Mozambique, and across the continent: more than 7.1 million Africans — nearly half of those who would most benefit from it — are now receiving ART; an estimated 700,000 deaths and more than 200,000 perinatal infections were averted in 2010 alone” (Farmer, 2013). The success in the global effort to combat HIV/AIDS shows what can be done when the know-do gap is addressed effectively and systematically.

The solution lies in figuring out a path to action for each unique situation and replicating a model to scale up.  In order to reduce the know-gap, we must focus on knowledge translation.  We must bring together information from entrepreneurs, basic research and innovation and operations research, and synthesize results to scale up and allow for continuous improvement.  Knowledge translation strategies can harness the power of scientific evidence and leadership to inform and transform policy and practice.

If you’re interested in learning more about the know-do gap, why it is so problematic, and what has been done to address it, read Dr. Farmer’s article in the New England Journal of Medicine, “Chronic Infectious Disease and the Future of Health Care Delivery.”

The effectiveness of PEPFAR and the Global Fund’s efforts to fight HIV/AIDS was accomplished because of advocacy efforts to overcome the delivery gap. Now, we must engage in advocacy efforts for other disease burdens to develop care delivery systems and meet real need. Doing science isn’t enough. If our work is to have any real impact, we must figure out how to apply it to the lives of those suffering from disease around the world.

  

Farmer, P. E. (2013). Chronic Infectious Disease and the Future of Health Care Delivery. New England Journal of Medicine, 369(25), 2424–2436. http://doi.org/10.1056/NEJMsa1310472

Grimshaw, J., Thomas, R., MacLennan, G., Fraser, C., & Ramsay, C. (2004). Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment, 8(6), 84. http://doi.org/10.3310/hta8060 

Influenza and Epidemic Preparedness

By Hiba Fatima and Leah Watson

We all remember the 2009 swine flu epidemic that caused 14,000 deaths worldwide. Despite only causing cold-like symptoms, the mass panic that surrounded this epidemic was notable, and to an extent, justified. It brought attention to our health system’s ability to cope with an epidemic and shed light on other countries’ healthcare infrastructure. After the epidemic was over, many of our governmental organizations turned their attention to bolstering preparedness for such epidemics. The widespread concern was not if it would happen again, but rather when. This series of events put the spotlight on vaccinations, influenza and the health issues that surround them.

Source: http://www.who.int/csr/don/2009_08_12/en/

Influenza is the most common cause of any respiratory illness as well as the most prevalent, it accounts for 2.7% of global DALYs, 3.9% of death worldwide. The influenza vaccine is very helpful in stopping the spread of influenza in the United States and is renewed every year because the virus undergoes recombination and becomes a new subtype. The pathogenicity of influenza is usually undermined in the United States while in the developing world it is taken much more seriously. This is because the neglect of influenza can very often lead to death. Influenza A and B are the most prevalent, and Influenza A is most commonly responsible for pandemics. This is partly due to its ability to infect and stay in avian and swine species which act as reservoirs for the disease. This gives the virus many opportunities to jump to a human host. Since influenza is an airborne disease, people who work in pig and poultry farms are especially affected, just by being in close contact. Additionally, children ages 5-9 are disproportionately affected compared to the rest of the population. Other high-risk groups for influenza include the elderly living in assisted living institutions, pregnant women and healthcare workers. In many industrialized countries, influenza poses an economic burden as well, many people lose days of work or school and it causes a significant strain on the healthcare system.

Live animal markets are notorious for the spread of influenza from the animals to humans. Prolonged exposure to the hosts causes a high susceptibility to contracting influenza, especially avian and swine influenza. This is exacerbated by the fact that influenza is airborne, making it very easy to spread in a small and confined population. As Dr. Gray mentioned, pigs are the easiest mode of transportation for influenza virus to get to humans. Another point of concern is that the virus undergoes recombination within the animal host and emerges as a novel virus. So by the time it gets to a human host, it is completely new and we have no way of fighting or preventing it.

Source: http://wncn.com/2015/10/07/threat-of-avian-flu-cancels-nc-state-fair-poultry-shows/ 

North Carolina is currently anticipating a potential avian flu epidemic, as Dr. Gray described in his lecture, due to a highly pathogenic avian influenza strain, H5N2, that has already been found in 21 states. Prevention measures are already being taken, such as the cancellation of large poultry-focused events described in the WNCN news headline from October 7th this year (above). The Charlotte Observer reports an $18 billion poultry industry in North Carolina, which may be in jeopardy depending on the progress of the epidemic. Though no cases have yet been reported, a task force has already been formed to ensure effective culling of affected flocks found to be carrying the influenza strain. More than 44 million birds have been killed so far in an attempt to keep this influenza strain under control, and more are projected to be culled as the migration season approaches. This threat may initially seem irrelevant to us humans, until we consider the proximity of vulnerable animals to agricultural workers. While the species barrier between birds and humans may be harder to cross than the species barrier between pigs and humans, close contact with infected birds increases likelihood of passing on the virus from poultry to human.

There’s an additional layer to the issue. With the threat of the potential influenza A epidemic looming over North Carolina, the scientific community is faced with the challenge of promoting public health measures despite pushback from industries who may face economic damage. The balance of economic and public health issues pervades the issue of global influenza. As Dr. Gray mentioned in class, live animal markets in China have been a foundation of local economies and traditions for thousands of years, and threatening to remove these is unlikely to result in immediate compliance. Similarly, as mentioned, Dr. Gray’s article “Variant Influenza A (H3N2) Virus: Looking Through a Glass, Darkly”, farmers are unlikely to comply with studies on zoonotic influenza transmission if they perceive the success of their businesses to be at risk.

This brings us to areas of pandemic influenza that are hotly contended. How, then, do we propose to unite the efforts of these two sides of the equation? Is legislation the only option - in essence, using the power of the law to initiate compliance among economic stakeholders? Might there be areas of overlap in which both sides can cooperate? These are questions that both the scientific community and those with commercial interests will need to answer, and soon. As migration season for many bird species is rapidly approaching, united strategies will be key to effective prevention of an impending epidemic.

We cannot underestimate the importance of pandemic influenza, and the urgency with which we must handle it. Although we may have only had to deal with inconvenient symptoms like sneezing or a runny nose, this does not mean that influenza isn’t a serious illness; its strains can become deadly when left unchecked, particularly when cultivated in animal reservoirs for extended periods of time. United efforts such as OneHealth here at Duke have made huge headway in bridging the gap between different areas of study of influenza, including medicine, veterinary medicine, and environmental health, and this has greatly helped us to understand different contributors to influenza pandemics. However, true prevention of an epidemic requires further open collaboration among the government, economic stakeholders, the public, and the scientific community, and it is only when we take a multi-perspectival look at the issue that we’ll be able to deal with it this year and in years to come.

Sustainability of Global Health Interventions

by Daphne Wang

One aspect of global health intervention programs highlighted by Dr. Prakalapakorn’s lecture was sustainable development. In the field of global eye health, there is concrete knowledge on the interventions to prevent or treat visual impairment, and the overwhelming cost-effectiveness of these treatments. When tackling such global health challenges with known effective treatments, it is even more imperative to focus efforts on creating intervention programs that are locally sustainable, for both cost-effective and ethical reasons.

A common theme observed across many organizations that provide ophthalmological care in low-income settings is a focus on training local eye care professionals. The Aravind Eye Care System is one of the most productive eye care center and teaching facility in the world. In order to help replicate the radical “McDonald” model of eye care elsewhere, Aravind offers both clinical and non-clinical courses on topics such as management, community outreach, and instrument maintenance. In this way, Aravind not only trains the local workforce to sustain the growth of the institute itself, but also encourages the development of similar facilities in other underserved areas. Another organization, Orbis International, is well-known for their Flying Eye Hospital, a fully equipped eye hospital and surgical teaching facility. Orbis targets the adequate training for healthcare professionals to build eye care capacity in the places that it works. By providing the training from a team approach, Orbis improves the efficiency of the surgical team and the health outcomes for the patients. Education and training are essential aspects for creating a sustainable global health intervention by building the local workforce and sharing proven methods for increased healthcare efficiency and better patient outcomes.

Another consideration when creating a sustainable healthcare model in a low-resource setting is the acquisition and management of donated goods. Many instruments required during vision exams and surgeries are expensive and complex. To ensure that donated instruments have the most benefit, the Community Eye Health Journal developed guidelines: “Donations of consumables and surgical instruments: how to ensure you really benefit.” One informing principle is to consider the standards of eye care and the ease of maintaining the donated goods. Donated medicine should be of comparable quality to those used in other parts of the country. Eye care facilities receiving donated instruments should be able to maintain, fix, and use the instruments. It is not sustainable to simply accept items unless these items will be used and maintained reliably, and that the healthcare outcomes of the donated medicine are comparable to the results of medicines in the native country.

Perhaps even more importantly compared to concerns of cost-effectiveness, sustainable global health interventions have ethical impacts. Would an intervention provide more harm than good if a patient was diagnosed with a treatable condition, but was unable to receive treatment due to program sustainability reasons? If the benefits of the short-term intervention end with the end of the intervention, is the program still beneficial to the local population? If a donated medication arrives only intermittently, should this treatment be offered to the patients? There are fewer ethical concerns if treatments are sustainable and available in the long-term. Until additional guidelines can be developed for sustainable eye care in low-resource settings, interventions that provide training for local eye care professional and practice effective management of donated resources are crucial aspects of a sustainable program targeting the reduction of visual impairment in underserved regions.

Reference

Cordero, I. (2011). Donations of consumables and surgical instruments: how to ensure you really benefit. Community Eye Health,24(76), 41.

Eye Health Disparity

by Yujung Choi

What I loved about Dr. Prakalapakorn’s guest lecture was her incorporation of the anatomy and physiology of the eye to describe how certain dysfunctions of the eye can lead to different ophthalmological diseases. And of course, listening to her incredible experiences with the Orbis Flying Eye Hospital was inspiring, too!

During her lecture, Dr. Prakalapakorn mentioned some statistics regarding the global burden of ophthalmological disease. I think it is worth mentioning them again to reiterate how the burden of eye disease disproportionately affects the global poor especially in the time of significant population growth and aging worldwide. According to the WHO, about 285 million people are visually impaired around the world. Of those, over 90% live in low and middle income countries. More disconcertingly, about 80% of all visual impairment can be prevented or cured (WHO, 2014).

Although most ophthalmological diseases such as cataract, uncorrected refractive error, glaucoma and age related macular degeneration are not life threatening conditions, they remain serious global health problems as poor eye health affects people’s income, livelihoods, nutrition, development and access to basic services such as education and healthcare. Jaggernath et al. further argue that eye diseases are both the cause and consequence of poverty; a lack of sanitation, poor or inadequate water supply, malnutrition and a lack of education cause the majority of preventable vision impairment and blindness while severely vision impaired and blind individuals are also limited from accessing and utilizing available public services (Jaggernath et al., 2014).

As with many diseases around the world, women bear the additional burden of health inequalities of eye diseases. Women suffer from visual problems at rates about 1.5 times greater than men, adjusted for age and irrespective of biological attributes (Stevens et al., 2013; See Fig. 1). This gender disparity can be explained by frequent exposure to causative factors such as infectious diseases and malnutrition as well as less access to treatment and care for women when compared to men. For instance, women were found to utilize eye care services 40% less than men (Fouad et al., 2004). How do we explain this phenomenon? A couple reasons may include: 1) women tend to have less control of finances than men. This makes the cost of surgery and transportation to the hospital more prohibitive for women. Not to mention the financial burden from the loss of work while staying in the hospital and/or accompanying the patient; 2) women may be less likely than men to travel outside of their village for a surgical facility; 3) women may perceive that there is a higher value for men to have surgery than for themselves because men are the breadwinners of households; 4) there is a lack of access to information and resources because community-based education about eye care has not been initiated in many areas (Lewallen and Courtright, 2002); 5)  there could be a fear of a poor outcome.

Figure 1. Bar graph of the ratio of female-to-male age-standardized prevalence of blindness and of moderate and severe vision impairment (MSVI) in adults 50 years of age and older.

Stevens, G. A., White, R. A., Flaxman, S. R., Price, H., Jonas, J. B., Keeffe, J., ... & Vision Loss Expert Group. (2013). Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990–2010. Ophthalmology, 120(12), 2377-2384.

Because women are less likely to seek ophthalmological care than men, they are more negatively affected in school participation and literacy levels. Women also experience higher rates of violence and less assistance with abuse and have limited decision making power in and outside household. More importantly, women’s low status in low and middle income countries—as evidenced by lower levels of education, literacy and income—is the root cause of the gender disparities in ophthalmological health. Some questions I have are: how well do you think the trend of women playing more prominent roles in household and society in the future will decrease the gap of prevalence of blindness and of MSVI between women and men? Looking at Figure 1, how do you explain the female-to-male prevalence of blindness in high-income and Central/Eastern Europe compared to the one in Sub-Saharan Africa? Why is there such a big difference between the blindness ratio and of MSVI ratio in East and Southeast Asia and Oceania? What factors contribute to this difference? And why is there hardly any difference between blindness ratio and of MSVI ratio in Sub-Saharan Africa?

Fortunately, visual impairment worldwide has decreased since the 1990s despite the aging population. The WHO states that this is because of overall socioeconomic development in low and middle income countries, concerted public health action, increased availability of eye care services and awareness of general population about solutions such as surgery and refraction devices to the visual impairment problems (WHO, 2014). Globally, there has also been an increase in telemedicine. Taking advantage of the increase in access to mobile phones in low and middle income countries, eye surgeons such as Dr. Andrew Bastawrous created Peek, a smart phone app into a comprehensive, easy-to-use, accurate eye-exam device. Perhaps this app can bridge the gaps in eye health disparity and gender inequality in eye health. Moreover, perhaps the WHO’s multidisciplinary methods to combat eye diseases can serve as a good model for prevention and control of other diseases around the world.  

      

For your reference, here is the link to Dr. Bastawrous’ TedTalk discussing his eye exam smart phone app: http://www.ted.com/talks/andrew_bastawrous_get_your_next_eye_exam_on_a_smartphone?language=en

References

Fouad, D., Mousa, A., & Courtright, P. (2004). Sociodemographic characteristics associated with blindness in a Nile Delta governorate of Egypt. British Journal of Ophthalmology, 88(5), 614-618.

Jaggernath, J., Øverland, L., Ramson, P., Kovai, V., Chan, V. F., & Naidoo, K. S. (2014). Poverty and eye health. Health, 2014.

Lewallen, S., & Courtright, P. (2002). Gender and use of cataract surgical services in developing countries. Bulletin of the World Health Organization, 80(4), 300-303.

Stevens, G. A., White, R. A., Flaxman, S. R., Price, H., Jonas, J. B., Keeffe, J., ... & Vision Loss Expert Group. (2013). Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990–2010. Ophthalmology, 120(12), 2377-2384.

World Health Organization. (2014). Visual impairment and blindness. Fact sheet, (282), 2009-2010.

A Brief History of Mental Illness

By Taylor Haynes

Mental illness and the concept of mental health are not new. They have existed as long as we have. There exist accounts from as early as the third century CE of the confinement of mentally ill people in Syrian Catholic churches. Institutional care for the mentally ill can be traced back as early as the 1400s, and the first psychiatric hospital in North America opened in 1773 in the colony of Virginia¹.

One would think that this history, along with the later development of effective pharmacological and psychosocial interventions for a range of conditions, might have resulted in the recognition that mental disorders were a public health priority. This, unfortunately, is not true. The key impetus for the emergence of the field of global mental health did not come until the publication of the World Development Report 1993. This report featured the initial findings of the Global Burden of Disease study, the first study to use DALYs to measure the global burden of disease. Much to the surprise of many people, computation with DALYs showed that approximately 8% of the global burden of disease was due to mental health problems². Several other publications followed, culminating with the publication of the Lancet series on global mental health in September 2007. Only then was the global mental health movement officially launched.

In the eight years since the Lancet series, the field has experienced a surge of attention, research, and public support. One of the most interesting, and most controversial, pieces of literature to come out of this surge is the 2010 New York Times piece by Ethan Watters entitled “The Americanization of Mental Illness.” In the piece, Watters suggests that a kind of psychiatric-cultural imperialism has been foisted on other countries and cultures by “the West.” Specifically, Watters claims that, “For more than a generation now, we in the West have aggressively spread of our modern knowledge of mental illness around the world… There is not good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments, but also the expression of mental illness in other cultures³.”

Though the Watters thesis has its merits, it is also shallow and simplistic in many of its assumptions and conclusions. I found it hard to agree completely in light of several unfounded claims. In discussing anorexia in Hong Kong, for example, Watters fails to consider alternative explanations for the rise in “westernized” anorexia presentation. Could it perhaps be attributed to better understanding and recognition of a disorder that had not been fully studied or appreciated in the past? Considering the history of PTSD in the United States, wherein clinical presentation has been described for centuries, while the diagnosis has been clarified and categorized only recently (the 1980s)⁴, this is certainly possible. Additionally, I found Watters’ claim that a biological interpretation of mental illness results in harsher treatment of the mentally ill shortsighted. Were those thought to have a biological determinant of disease really treated more harshly, or were they treated like someone without a mental illness? It is important to consider this control (or lack thereof) in analyzing his claim.

The rise of the global mental health movement has greatly helped to publicize, personify, and reduce global suffering due to mental illness. It has also, however, shown the limitations of the current approach to global mental health care. There is thus an urgent need for continuing research, in low-/middle-income and high-income countries alike, that addresses the questions of etiology, treatment, and cultural variations that scholars such as Watters have brought to light.

References 

1. Cohen, A., Patel, V., and Minas, H. (2014). A brief history of global mental health. In V. Patel, H. Minas, A. Cohen, and M. Prince (Ed.), Global Mental Health: Principles and Practice (pp. 3-26). New York: Oxford University Press.
2. World Bank. (1993). World development 1993: Investing in health. New York: Oxford University Press.
3. Watters, E. (2010, Jan 8). The Americanization of mental illness. The New York Times. Retrieved from http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html
4. Friedman, M.J. (2013). History of PTSD in veterans: Civil War to DSM-5. Retrieved from http://www.ptsd.va.gov/public/PTSD-overview/basics/history-of-ptsd-vets.asp

Living in the Shadows

by Phoebe Huo

41% of countries do not have a mental health policy.

25% of countries have no legislation on mental health.

28% have no separate budget for mental health.

37% of countries do not have mental health community care facilities.

These statistics present the current situation of global mental disease burden. However, behind the statistics, the reality shows more cruel pictures: discrimination and stigmatized images around people with mental disorders and shortage of mental health professionals lead the marginalized population to live in the shadow.

Like the person who has been locked in the wood house for ten years in the video we showed in the class, many people with mental disorders are victimized for their illness, and become the target of discrimination. Some stigma are from general population, as Dr. Maselko mentioned in her lecture, because the definition of mental illness is so vague and incomplete in developing countries, people may hesitate to search for help because they do not even have the knowledge of the symptoms. Therefore, due to inaccurate information of mental disorders, many people believe that the disease is untreatable, and the person with the disease needs to be excluded from population. On the other hand, abundant evidence from Western countries indicates that people with mental disorders are stigmatized and discriminated against by health professionals. Specifically in developing countries, treatment suggestions from health professionals to those with mental disorders include a wide range of proposals, some of them are punitive and discriminatory, and far from official guideline recommendations. These negative social attitudes towards people with mental disorders have an adverse effect on prevention and early treatment. And these attitudes are pervasive even though the United Nations has provided a basic standard for people with mental disorders:

All person with a mental illness, or who are being treated as such person, shall be treated with humanity and respect for the inherent dignity of the human person. All person with mental illness, or who are being treated as such person, have the right to protection from economic, sexual and other forms of exploitation, physical or other abuse and degrading treatment.

United Nations Principles for the Protection of Persons with Mental Illness

However, most countries of the world are far from complying with this principle.

As Dr. Maselko and Dr. Shirey mentioned in their lecture, there is a global disparity of receiving mental health care between high-income and low or middle-income counties. For over 30 years, international organizations such as World Health Organization have been encouraging developing countries to increase their mental health facilities, however, the progress in achieving well-equipped facilities for the care of mental disorders has been slow. Almost one-fourth of developing countries have no system for providing basic mental health treatment for citizens. Even among countries that have such a system, the health facilities lack trained professionals who can provide good mental health services. Most of the facilities contain few doctors and many non-professional health workers. The doctors are usually too busy for managing patients who need specialized care, and have no time to supervise other health workers. 

“ Where is the mental health hospital I can go for help? ” asked by the father in the video. He is still searching for a mental hospital that can provide accurate information and appropriate treatments for her daughter.  As well as the father, we still have a long way to go to bring people with mental disorders fully out of the shadows.  

Global Surgical Burden

by Joe Incorvia and Ben Kuo

Today, we’d like to tell you the story of two mothers, Mary and Awusi, who are both incredibly driven to give the best lives to their families. Hailing from Cary, NC and Anomabo, Ghana, respectively, their access to medical care differ greatly, therefore impacting their decisions.

Let’s see what’s going on with Mary first. It is a brisk Sunday morning around 10 am and Carter, Mary’s 17 year-old son has been complaining about his stomach all morning. He describes a strong pain in his abdomen, to which his mother gives him some Tums and tells him to lay down and rest... Just over 5300 miles away, Awusi notices that Coffie, her eldest son (19 years-old) is unusually tired from his day. He’s sitting outside and clutching his side, telling her he has been in serious pain all day. She tells him to go find Appiah, who takes the role as the community’s healer when the medical brigades aren’t near...

Back stateside, it’s now 1pm and Carter’s pain has gotten to the point of unbearable, he’s vomited multiple times and has a low grade fever. Worried, Mary decides to take him to the hospital. She helps Carter uncomfortably walk to the car and takes off for Duke Medical Center... Appiah has been with Coffie for about a few hours now, Awusi arrives as well to see that her son is writhing in pain. She is told that he needs more help and should head to Finney Hospital in Accra, nearly 100 kilometers away. She hopes she can find Owusu who has a car and can drive her there…

Arriving at Duke Medical Center, Mary and Carter sign in and wait. After about 40 minutes, Carter is taken back for a CT scan diagnosing his ailment as appendicitis. He is scheduled for surgery for the next open slot and will receive it in about 4 hours, he is put on medication to help his pain while he waits… Every bump in the road aggravates Coffie as the pain continues to get worse, he’s nauseous and clutching his side in the back seat of the truck. It’s been 7 hours since he went to see Appiah and the remedy he was given has not helped since leaving. Upon arriving at Finney, they see many people lined up inside the hospital. They go inside explaining their problem and are told that hospital staff will keep checking in, but they most likely won’t have any beds available until morning…

How well do you think the prognosis will be for our two suspected appendicitis patients? Well, based on our talk from Dr. Rice and the theme of this section, there are some important points to consider. Before even talking about possible appendectomies, we need to consider the events leading up to diagnosis (or in Coffie’s case, getting to the hospital). Much of the global surgery burden comes from a disparity in access in many Low-Middle Income Countries (LMICs). Road infrastructure, cultural attitudes toward surgical intervention, and financial constraints all play a role in making medical decisions. In the United States, we may be fortunate enough to be able to hop in a car and head quickly to the nearest major medical center for emergency care, knowing that we may be able to have the fund to cover care as well as faith in the medical system to help out ourselves or our loved ones. However, 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed. Access is worst in low-income and lower-middle-income countries, like Coffie’s home nation of Ghana, where nine of ten people cannot access basic surgical care (Meera et al, 2015).

It’s simply not just a point of disparity of access, but also disparity of capacity of surgical care. In fact, 143 million additional surgical procedures are needed in LMICs each year to save lives and prevent disability. Of the 313 million procedures undertaken worldwide each year, only 6% occur in the poorest countries, where over a third of the world’s population lives. Low operative volumes are associated with high case-fatality rates from common, treatable surgical conditions (Meera et al, 2015). That could mean that a procedure we take for granted as being simple and commonly nonfatal, such as an appendectomy, could prove to be an issue for LMICs to diagnose or treat well. And even if the diagnosis is correct, there may not be the ability for a health center to be able to provide the proper surgical care needed, increasing mortality and disability rates.

So let’s venture back to our story one more time. Hypothetical, yes, but it still brings up a point about access to basic surgical care. It appears to be much easier for Carter to get access to proper surgical care at a health center able to provide it than Coffie can. That is unfortunately the case in many LMICs when compared to HICs like the United States. Now, while Carter could have complications and end up having a negative outcome and Coffie could end up getting a bed and being treated without issues, the chance of those alternative scenarios happening are directly correlated to the access and capacity disparities talked about in the literature, and the disparities increase when talking about more complicated procedures like cesarean section and neurosurgical care. 

Disparity in Surgical Need across different regions

United States
Surgical Unmet Need per 100,000	0
Surgical Rates per 100,000	>20,000
Ratio of Met to Total Need	4.01
Global Target	5,000

Sub-Saharan Africa (western)
Surgical Unmet Need per 100,000	5,625
Surgical Rates per 100,000	<100
Ratio of Met to Total Need	0.11 (1/9)
Global Target	5,000

Rose et al., 2015, Estimated need for surgery worldwide based on prevalence of

diseases: a modelling strategy for the WHO Global Health Estimate.

The Lancet Global Health

Global surgery burden is exactly what it sounds like: a global issue. Today’s surgical workforce would need to increase by 2.2 million to be able to reach the target of 80% coverage for timely access of primary surgical care for 2030. The cost of surgical expansion would be around $350 billion and the lost output will cost LMICs $12.3 trillion (Meera et al, 2015). The conversation around increasing care can be done in an affordable way that can help not only save money, but save lives. A solution to this problem could help create positive outcomes for individuals like Carter and Coffie across the entire Earth.

High Priority Intervention Areas

Area in Need	2030 Global Lancet Commission Targets
Access to timely essential surgery	80% coverage of essential surgical and anesthesia services per country
Surgical workforce density	100% of countries with at least 20 surgical, anesthetic, and obstetric physician per 100,000 population
Surgical Volume	A minimum of 5,000 procedures per 100,000 population
Perioperative Mortality	100% of countries tracking perioperative mortality
Protection against catastrophic expenditure	Systems to protect out-of-pocket payments for surgical and anesthesia care

Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. a., … Yip, W. (2015). Global Surgery 2030: 

Evidence and solutions for achieving health, welfare, and economic development. Surgery, 3–6. 

Things to Ponder:

With these proposed targets that are collaborative in nature, how do we ensure accountability between healthcare professionals, governments, global organizations (WHO, World Bank), and other stakeholders? Do you all think that these goals are feasible? Let us know in the comments below.

-       Ben and Joe

All figures from: Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. a., … Yip, W. (2015). Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Surgery, 3–6