Trauma and Violence

Increased conflict in developing nations has caused a surge in trauma-related mental health issues around the world. With significantly less access to funds and resources, lesser-developed nations are facing a monumental problem in combating the proliferation of mental health issues. A lack of understanding surrounding mental health only exacerbates social issues for patients suffering from mental disabilities in developing countries; they fear speaking out and ultimately receive sub-par care, if they are lucky enough to get any whatsoever.

In her book, Searching for Normal in the Wake of the Liberian War, Sharon Abramowitz examines the societal impacts of trauma as a result of war. She describes how the Liberian people who are not suffering from mental disability view others around them as “not normal,” or “totally traumatized” (65). Due to the lack of mental health education, Liberians believe trauma is a step on the “continuum of mental illness”, which begins with a person being normal, and results in insanity and ultimately death. While one may be quick to jump to the conclusion that the Liberian opinion of mental health is an uneducated one, I do believe that they accurately describe at least one social aspect of mental disability. To some extent, Liberians understand the debilitating effect an untreated mental disability can have on one’s livelihood. However, the understanding of mental health is quite limited, as many Liberians also believe that “people experiencing severe trauma or psychosis must have seen or done something to have incurred this terrible fate,” and the mental disability must be “God’s punishment” (79). A mental disability not directly caused by war or some other horrific event does not appear to fit within the Liberian description of trauma.

Farmer et al.’s Reimaging Global Health offers a more broad definition of mental health conditions, claiming that they are not all “neatly packed as disease[s],” like PTSD is in the developing world (222). Many people across the world suffer from PTSD; it is a very crippling disorder. However, not all mental health conditions are PTSD, and trauma does not necessarily develop into PTSD. Providing care to a plethora of mental health conditions is essential. The example of Valentine from the Abramowitz’s book depicts someone who is not directly traumatized from fighting in the Liberian War, but rather from living day to day during a time of conflict. I would argue that “traumatization” has much more to do with his social situation than direct violence However in places such as Liberia, that form of a mental health condition is not well understood. The problems and inequality that people face everyday can have just as great of an effect on mental health as one catastrophic event. I found the study published by The Lancet to be incredibly interesting, as it explained that “mental disorders increase the risk of both communicable diseases … and noncommunicable diseases” and that alternatively these diseases increased the risk of developing a mental disorder (215). Healthcare funding in developing nations should focus on both mental health and disease in order to most effectively care for patients.

Perhaps the most glaring obstacle to providing widespread care for mental health disorders is self-reporting, as social stigmas prevent many from seeking help. This lack of self-reporting is echoed in Mark Anderson and Achilleas Galatsidas’ article for The Gaurdian entitled “Mental Healthcare 50 Times More Accessible in Wealthy Countries”. Many people who suffer from mental illness do not come forward, due to shame. “They feel if they disclose that they have a mental disorder they will be discriminated against” and their societal value will decrease (Anderson). While almost one in ten people have a mental health disorder, the world’s poorest countries have a dearth of mental health workers. The need for mental health care is only rising with the “increasing prevalence of conflicts and natural disasters,” which increases stress on developing communities (Anderson). Mental health needs to be given a higher level of priority, on par to that of diseases such as HIV/AIDS, malaria, and TB in developing countries.

It is challenging to emphasize care of mental health issues when there is no distinct treatment. The gap in our medical knowledge of how to best care for patients suffering from mental health disabilities is expansive. Our best chance of bridging this gap is integrating our clinical understanding with ethnographic studies of populations in developing nations to understand who is suffering and why. Providing mental health care is an incredibly complicated task; one that developed nations have yet to understand. I would argue the only way to currently provide care to developing nations is by training local traditional healers and medical professionals. While we may never be able to quell violence and its associated trauma, with greater scientific and cultural understanding we may be able to provide care for enduring mental health problems and better grasp the growing mental health crisis.

Discussion Questions:

  • In Searching for Normal in the Wake of the Liberian War, Abramowitz highlights the result of mental disorders and trauma postwar. Attention is only paid after a traumatic event has occurred, not before. Would it have been beneficial to this population to provide mental health care and education before violence ensued? Should mental health care be provided as a preventative measure in developing countries? If so, how can that be achieved?
  • What is the best way to determine if mental health care provided to developing nations is “adequate” or helpful? With communicable and noncommunicable diseases there is either treatment or disease. However, with mental health disorders there is no direct cure. How do NGO’s, the WHO, or developing nations themselves deem a public mental health effort as successful?

Outside Source:

Anderson, Mark and Achilleas Galatsidas. 2015. Mental Healthcare 50 Times More Accessible in Wealthy Countries. The Guardian, 20 July 2015. http://www.theguardian.com/global-development/datablog/2015/jul/20/mental-healthcare-world-health-organisation.

Class Readings:

Abramowitz, Sharon. 2014. Searching for Normal in the Wake of the Liberian War. Philadelphia: University of Pennsylvania Press. (Ch. 3)

Farmer et. al. Reimagining Global Health. p 213-225

24 thoughts on “Trauma and Violence”

  1. I think the only way to truly determine whether mental health care is “adequate” would be through longitudinal studies that assess mental health of a wide range of patients both before these practices are implemented and years afterwards, which seems costly (if not somewhat impractical).

    I’m also curious about how to reduce the stigma associated with mental health, because I think this would make a huge difference in more developed countries like the U.S. I think the stigma is generally decreasing as more people are educated about the biological correlates of mental disorders and through increased discourse about mental disorders through social media, etc., but how can we make this information/attitude more widespread?

    1. – I think that education and knowledge is the most valued resource people can attain. Acquiring a better understanding of a situation before it transpires can only benefit the individual. However, I think that in this situation it could be different. The reason I say this is because if you do become traumatized or are diagnosed with depression, people may not realize it because this new lifestyle is “normal” for them. In Searching for Normal in the Wake of the Liberian War, the three women would wake up in the middle of the night crying, praying, and yelling, yet they would wake up as if nothing happened. Therefore, they would need someone to advise them to seek help—in this case education would be useful for the other person. Also, like you mentioned, people could be shameful in realizing they have a disorder and rebel against seeking help. I think that mental health care should be provided in developing countries especially because they have higher risks of anxiety and depression due to the traumatic events that happen in their lives. They also have daily stresses providing “basic needs” such as food and shelter. This would most likely result in a costly investment that may take years to achieve without the help of developed countries that have wealthy philanthropists.
      – I think the best way to demonstrate if mental health care is a successful investment is by looking at statistics. You could see if providing mental health care center in the US has been beneficial, if so, then implement mental health care centers in developing countries, and document their progress. I think that it is hard to measure a mental health effort. You could document how much happier a person is feeling or if they are experiencing less nightmares. But even that can be precarious. I don’t think that a mental disorder can ever fully be cured because it is hard to “unsee” something so horrific. It can be alleviated to the best of a doctor’s ability, but I’m not sure to what extent.

    2. I definitely agree that by reducing stigma towards mental disabilities it becomes possible to provide better and more extensive care. However, I definitely struggle with how this can be achieved. As you mentioned, even in developed countries like the US, stigma towards mental disability is very high. So how can we expect to lower stigma in developing countries- where concepts like the devil and being “possessed” are the easiest way to understand what is happening to those who are suffering? Especially when it comes to mental health, I find it difficult to come up with a solution or an approach to care since we really know very little about the biology of mental disorders. Do you think this inherent obstacle exists until we have a better understanding of mental health?

      1. Hi Sarah,
        I’m not exactly sure if we are in the same section or not, but in our section we talked about the stigmas related to mental health. Mental illnesses are seen as a punishment and often shameful. In Monique and the Mango Rains, birth control has a stigma as well– you are seen as a prostitute. However, tobacco is seen as “attractive” in developing countries. Now, in the US smoking is usually seen as unattractive due to the the correlation between smokers and cancer. Do you think that the US is to blame for this misleading advertisement? Do you think that this will just be a trend in developing countries? Is there a way we can help?

        1. Hi Sam,

          I think your connection between mental health and the tobacco companies is really interesting! I think that the US tobacco companies are responsible for the misleading advertisement to developing countries, but the US government is responsible for helping tobacco companies spread into developing countries in the first place. I think that overtime this trend will become obvious in developing countries, simply because the data is too obvious to ignore. I think by sharing the data we have on the risk of smoking is the best way to help, but at this point it is up to the governments to cease smoking in their respective countries, but the US should definitely be lending assistance. In terms of mental health, I don’t know if the same trend will follow, mental health is a more personal health issue than smoking and every person is impacted by trauma differently. I believe that worldwide education efforts about mental health are needed. Additionally, I think by establishing mental health programs and providing psychiatrists, therapy, and antidepressants to developing countries, we can begin to educate people around the world about mental health and try to remove the stigma associated with mental illness.

    3. Interestingly, I think the issue of stigma is different in developed and developing countries. In developed countries, I believe the issues is that many people do not understand mental health as a disease, and see it rather as a choice. I think that many people believe a person can choose to be happy, can plan ahead to avoid being anxious, or can actively decide to eat or not eat, when in fact having a mental illness means you don’t have that control. In developed countries, and especially in the US, we rely on scientific evidence for proof. So much of the brain and mental health is not understood, and until then I think stigma against mental illness will remain high. In developing countries the issue of stigma is different. As we discussed about Abramowitz’s article centered on life after the civil war, everyone had experience trauma in some way, and to step forward and say that you are suffering from a mental illness takes away from the fact that everyone is affected by the trauma and trying to deal with it on their own. Additionally, with little to no psychiatrists in developing countries, what is the point of acknowledging disease if there is no treatment. I think that in order to make the information of mental health more widespread we have to establish the possibility of care in developing countries. If you educate people about mental health, but then don’t provide care, does that really help?

    4. Hi Methma,

      I tried to post a response under your post but for some reason it went under Samantha’s. It starts out “Interestingly, I think…”

  2. Sarah,

    In your conclusion, you note that “Providing mental health care is an incredibly complicated task; one that developed nations have yet to understand.” While for the most part I agree with this statement, I believe that it could be expanded to encompass both developing and developed nations. Even in the U.S., I do not believe that we have adequately addressed the issues surrounding mental health. There is still a great deal of stigma, under-treatment, and over-treatment of mental illnesses in our society, and due to this great complexity we continue to grapple with issues regarding diagnosis and access to treatment. Furthermore, I am not so sure it is a matter of comprehension of the issue at hand, but rather a lack of an ability to actually do anything to remedy it. Many developing nations scarcely have the resources to address infectious disease, but are now facing the dual-burden imposed by increasing rates of chronic non-infectious disease as well (as we saw illustrated in Improvising Medicine).

    I do however think your post addresses a critical issue: that mental health is often relegated to the least important position in the (socially-constructed) hierarchy of health issues when determining where to allocate resources. You mention that “The need for mental health care is only rising with the “increasing prevalence of conflicts and natural disasters,” which increases stress on developing communities (Anderson). Mental health needs to be given a higher level of priority, on par to that of diseases such as HIV/AIDS, malaria, and TB in developing countries.” I very much agree with you on this point, and would further argue that many developing nations not only face the dual-burden of disease, but the triple-burden of having to grapple with a devastating combination of infectious disease, chronic non-communicable disease, and mental illness. And—as you thoughtfully point out—having an infectious or non-communicable disease can increase your risk of developing a mental illness, only further increasing the burden on these countries.

    1. Hi Sabrina,
      I definitely agree that both developed and developing nations do not fully understand mental health. What I was trying to convey was that if developed countries do not know how to best treat mental illness, and we are the ones forming NGO’s to try to educate developing countries, how does this help since we still do not know what to do here at home. Additionally, I think it is unfair to try to educate developing countries about mental health, without providing mental health resources, such as psychiatrist, options for therapy, some form of medication, as well. I think that both need to be done!

      The triple burden of disease you described is a really good point, albeit quite depressing. After taking this class, it has left me really frustrated that people do not have the motivation to help people in developing countries who are dying from preventable diseases. If the relationship between infectious disease, chronic disease, and mental health is so cyclical, it seems possible that by address one aspect of health, the others would be indirectly addressed as well. To me this makes it seem a little easier and a little more hopeful.

  3. Hi Sarah,

    Thank you for your post. Your point about mental health care before trauma ensues is a very interesting one that I have never thought about before. The difficulty with providing this care would be knowing where traumatic events will occur next, but I guess this could be avoided by offering mental health care and awareness in all places. The more I think about it the more I think that this is a great idea. It is one thing to go through a traumatic experience and then later be told that you are suffering from a mental illness, and a totally different experience to be educated on mental illnesses and then develop one. I believe this second situation would be the most beneficial for the one suffering because not only would they be able to recognize that their suffering was not normal, but they would also know that it was ok for them to ask for help. I can see this sort of preventative mental health care being beneficial in countries where there is not imminent danger of traumatic events. In our own country I believe that this kind of care would be extremely effective in getting rid of stigma around mental health and encouraging people to ask for help.

    1. I think preventative mental health care would be an amazing aspect in any health system, developed or developing country. Unfortunately, I think it is also unlikely due to cost. In the US, insurance companies don’t like to pay more than they have to. Mental health care is extremely expensive and there is not concrete end point to therapy and care. With the extremely negative reactions to Obamacare about ensuring everyone, I think it is even less likely mental health care for all will be implemented, even though it is probably a really good idea.

      In developing countries I think the issue with preventative health care is different. In this case, while people may be suffering from mental illness, that isn’t what is killing them for the most part. I think to have a productive and effective mental health program, it has to be in conjuncture with infectious and chronic disease care. In Sabrina’s comment, she talks about how theres a triple burden of disease, and I think the process is cyclical. Hopefully, by addressing infectious diseases, mental health can also be addressed and treated.

  4. Hi Sara, I liked how in your question you pointed out the fact that more often than not data is collected only after a traumatic event has taken place. In the news’ headlines we are often flooded with images of results found after something has taken place, we are not flooded with data regarding social determinants of mental health as often i.e. with Haiti and the earthquake we saw the images of ruins but how many times during that year did we see pictures of the country’s infrastructure or policies that led to its economic standing? I think your question definitely made me become more aware of how easy it is to forget the obvious social media patterns that exist today. And therefore, because social determinants of health are not always at the forefront of CNN per say, it is harder for people to voice out their concerns in a legislative manner to conduct change or voice outrage. All this leading to an answer to your question in which I believe that treating mental health and educating about mental health would inherently be educating a population of the structural violence that has been embedded in their lives and thus making them more aware of what had to take place for them to be at risk for having a mental illness.

    1. Hi Florisel,

      I definitely agree that by educating a population of the structural violence they have experienced, we could start to address mental health. However, I wonder if symbolic violence would be a factor and if people would take personal blame. Additionally, I think it is difficult for people from a developed country to going into a developing country and point out all the problems and social injustices, without helping to remedy the issue. Addresses structural violence, and trying to make a change, seems incredible complicated. We have talked about the factors that influence structural violence a lot, but is it possible for NGO’s to address this or does it require the local government to step in and enact major societal reform? Is it hypocritical to condemn structural violence in other countries when it is alive and well in our own?

  5. Recently in class we have been talking about how to get people involved in global health initiatives. In a Guardian article by Andrew Chambers, Chambers mentions how it is difficult to generate empathy, and therefore donations, for mental health because there is no emotional snapshot that will depict suffering from a mental disability that people can relate to. If we all agree that mental health is important, how do we get people involved in providing or donating to mental health care? Additionally, a lot of people mentioned implementing preventative health care, and I agree that this might be the most successful way to combat mental illness. However, is this a practical approach? Since there is no way to predict where trauma will occur before it actually happens, how do we know which countries to help? Is it possible to provide or train local health providers to provide preventative mental health care in every developing country, and for that matter developed country as well?

    (http://www.theguardian.com/commentisfree/2010/may/10/mental-illness-developing-world)

  6. Hey Sarah, thanks for your post! I first just wanted to point out that the continuum you mentioned Liberians using (and others considering uneducated), going from life to death with mental illness in the middle, is actually very similar to the one subscribed to by DALYs and those who use them. As you point out, quickness to judge reveals an inability to recognize the peculiarities of one’s own cultural constructions as well.

    More importantly, though, I wanted to add on to the really interesting point you make about the diversity of mental illnesses in contrast to the way most international attention is related to PTSD. It struck me as similar to the situation we studied where chronic diseases in the global south are erased or made invisible, while infectious diseases are highlighted. Here, it seems too that there is an emphasis on PTSD and mental illness related to trauma, while glossing over the other, more mundane yet just as pervasive mental illnesses that have less clear causes (poverty as opposed to war) and are less associated with these countries (individual vs. collective suffering). I think a lot could be said about this, and what it says about the way we construct suffering…

    Finally, I wanted to respond to your point that social stigma is the biggest obstacle to treatment, which I’m not convinced is necessarily the case. Rather, I worry that we point to this cultural reason as a way to get out of recognizing a real lack of care available. Access to appropriate care remains, I think, the biggest barrier – in terms of lack of practitioners, lack of transportation, lack of hospitals, lack of medications and therapists, and so much more. It also creates a situation where we assume the ignorance of “them” and assert our own authority, placing blame on “culture” as opposed to on the structural violence actually causing the mental illness in the first place. While I recognize the importance of decreasing stigma, I just wanted to bring up the hard fact that even if we get rid of all stigma, if there is no care available that won’t ease much or any of the burden of mental illness. Meanwhile, if care is provided, people might begin to take advantage of it regardless – as with ARVs, for example. Anyway, just some thoughts. Thanks!

    1. Hi Sarah and Allison!

      Sarah, thanks for the interesting post – I agree with your points regarding the difficulty of self-reporting in a world where texts such as the DSM would have us believe that there is truly a clearly defined set of boxes into which our feelings and responses to life experiences could be “neatly packed”. I would also have to agree with Allison, that social stigma is not necessarily the largest obstacle that sufferers of mental illness and psychological pain face.

      I appreciate the point you make, Allison, that sweeping ideas about social stigma and perhaps a belief in a sort of lack of courage to self-report or seek help creates a blaming narrative of mental healthcare problems in developing nations that completely sweeps infrastructural issues under the rug. It’s equally important, in my view, to strive to make available the proper clinicians, clinics, support facilities, medications, and relationships (on doctor-patient, patient-patient, community, and national levels) to provide compassionate and reflexive care for each individual in a suffering population WHILE we strive to mold current assumptions and social/personal anxieties about seeking help and thereby “outing” one’s difficulties with mental illness. I believe if the former is properly executed, it will be because the latter has begun, and it will continue to develop a culture of mental health consideration characterized by the latter.

      1. Hi Emma,

        What you suggested at the end of your post seems to be a trend in the other comments I have read. Obviously stigma is barrier to care in some ways. However, the biggest barrier to care is simply that there is no care. I believe that providing mental health care will be more challenging than other health efforts have been. That is because there is no easy way to cure mental illness, and you can’t just give someone medication to treat the problem. Actually, approaches to providing mental health care seem to emulate approaches to restructuring total health care systems in a country. It not only requires infrastructure, physicians, and supplies, but also a change in social ideals and underlying perceptions of health and long term treatment. Do you think there is a way for an NGO to provide such care, or must the local government take the initiative to change the system?

        1. Hi Sarah,

          Thank you so much for this post and your follow-up comments! I completely agree that mental-illness is a particularly difficult health challenge to tackle simply because there is no prescribed treatment. This leads me into one of the questions you asked in the original post about prevention for mental health illness. I definitely think that ideally, mental health prevention efforts should be made in developing countries, however I am unsure of how practical this would be. Personally, I don’t think developed countries such as the US have made very many successful mental health prevention efforts, and these countries have much more resources than countries such as Liberia. Although somewhat cynical, I think it would be part to convince a lot of developing governments that they should be spending a large portion of their health budgets on mental health prevention. With any prevention effort, it is hard to get funding because successful prevention prevents things from happening, so then there aren’t “lives saved” statistics, and there are only “projected lives saved” numbers. Mental health is even more challenging in particular because so little is understood about it. While mental health does lead to disability and death, it’s not considered a deadly disease such as an infectious disease is. That might pose another challenge on getting funding for this type of prevention effort.

          Thanks again for your posts! They are super thought-provoking!

          -Rebecca

  7. Hi Allison,
    While I think to an extent stigma might be a barrier to care, I think it is in a different way than in developed countries. In developing countries, many people are struggling in many different ways. When it comes to health, almost no one has the access to care they deserve. Stigma here means that by coming forward you are acknowledging that your situation is worse than someone else’s situation. Additionally, I think people are hesitant to acknowledge a mental illness when there is no care available. I definitely agree that no access to care is a bigger barrier than stigma. I also think it is unfair to try to educate people about mental health care, but not provide access to psychiatrists, therapists, etc. I agree with your connection ARV distribution, and if mental health care was available I think people would seek it. I think the best way to combat stigma is to provide mental health care and show people that it really can help.

  8. Hey Sarah!
    I thoroughly enjoyed your post! I though your brought up some really good points about the complex nature of mental illness and its deep and crippling effects. You also asked some very interesting discussion questions. While I don’t really believe there is a direct answer they definitely got me thinking a lot about the issues in a more complex way.
    Preventative measures I think are incredibly important in almost all diseases and I don’t think mental illness is any different. Having a system in place that can recognize mental health problems early on and treat them before they are that serious could be incredible helpful. I believe if people are aware of the symptoms of mental health and are able to recognize them in not just themselves which is very difficult but also in their loved ones it is definitely possible to see cases coming to light before they reach a level in which they are more difficult to cure.

    I also agree with Allison’s point about social stigma and the lack of appropriate care. Though I wouldn’t dismiss the contributions of stigma as a barrier to care I definitely think that to get rid of stigma would do very little if there is not resources in place. I believe there need to a double-sided approach in which both these issues are addressed simultaneously thus improving results.

    1. Hi Yilena,

      I agree with everything you said! I think that having systems in place for preventative mental healthcare would be amazing and a great way to educate people about symptoms while also providing treatment. At the same time this would be a way to have double-sided approach like you mentioned, addressing stigma and providing treatment. However, I worry that addressing mental healthcare is not a priority for NGOs and for developing countries. The burdens of infectious and chronic diseases are so high, and these are the diseases causing death. Ideally, programs could be developed that encompass treating the whole patient, not just the visible symptoms. Creating such sustainable “all-inclusive” programs will take an international commitment to address health. However, I am not sure that countries and companies are ready (or will ever be ready) to put aside economic gain in favor of health.

  9. Hi Sarah,

    Thanks for your entry! Very informative and summed up both texts very well. I’ll try and address the second question:
    “What is the best way to determine if mental health care provided to developing nations is “adequate” or helpful? With communicable and noncommunicable diseases there is either treatment or disease. However, with mental health disorders there is no direct cure. How do NGO’s, the WHO, or developing nations themselves deem a public mental health effort as successful?”
    I would say the best way to determine whether or not mental health care is adequate would be if there exists far fewer cases of trauma, or whichever mental disability is being treated, than there existed at the start of the trial. Though you say there is no direct cure to certain mental illnesses, there are, of course, effective ways in which to manage these illnesses that have been proven to lessen the risk of incurring many of the illness’s symptoms.
    Thus, with regard to NGOs and the WHO deeming a mental health effort as successful or not, it should use the same metric by which my first statement provided–are there significantly fewer cases, or complications associated with the cases, of said mental illness than there were before. If there are, I would imagine the whole endeavor to be a beaming success!

    1. Hi Chad,

      Thanks for your post. I like your straightforward idea about measuring success by having a fewer number of new cases of trauma than existed at the start of the trial. However, I wonder if success could actually be indicated by a greater number of cases. If an NGO were to go into a community and begin to provide mental health care, I imagine people would be pretty hesitant to trust the foreigners talking about disease they don’t see as the major health problem. Additionally, it is possible people may not recognize themselves as suffering from a mental illness. I would think, that overtime, if the program was successful, the NGO’s care efforts would attract more people by word of mouth. If someone goes to the clinic and has a positive experience, they may advocate for their family and friends to also go to the clinic. People would come out of the woodwork! However is it possible to determine between a successful health effort that attracts more people versus an unsuccessful effort that does not treat enough people or provide effective care so the number of people suffering from mental illness increases?

  10. Hi Sarah,
    Thanks for your post! I think you made some really interesting points about how countries or NGOs would be able to deem a mental illness intervention as being successful, which is something I haven’t considered before. Mental illness is not as clear cut as other illnesses like HIV and TB so allocating the appropriate resources in low-resource settings is a hard obstacle to overcome. I think preventative measures regarding mental illness is important, but as was said in some of the previous comments it’s a much harder sell, especially because it’s hard to evaluate it’s success. But I guess to answer your question, I think countries would have to carefully monitor the status of the mental health of those who come into care. Which as you stated there is no “cure” so unlike with HIV or TB there isn’t a direct way to test mental health. I’m not sure what is the most appropriate for health professionals to deem a person “cured” especially in low-resource settings which are unlikely to offer traditional western approaches to treating mental illness like therapy and counseling.

Leave a Reply

Your email address will not be published. Required fields are marked *