Race Correction and Inequalities in Medicine

The history of medicine is fraught with unnecessary racialization. In “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body,” Comaroff writes about how the black body became “associated with degradation, disease, and contagion” and how colonial medicine “link[ed] racial intercourse with the origin of sickness.” These overtly racist ideas have decreased in influence over time. However, even today, the remainders of these ideas still manifest themselves in racial inequalities in treatment and access to medical resources, and in the general racialization of medicine, both in the U.S. and around the world.

Smedley and Smedley write about the consistent racial and ethnic disparities in health care in their paper, “Race as Biology is Fiction, Racism as a Social Problem is Real.” They report a series of shocking statistics, which include that Africans Americans and Hispanics in the U.S. tend to receive lower quality health care across many different disease areas, African Americans are more likely than whites to “receive less desirable services, such as amputation,” and that these disparities are “found across a wide range of clinical settings including public and private hospitals, teaching and nonteaching hospitals.…” Similarly, Livingston details a scenario where a patient O (a black man) is expected to endure an incredible amount of pain during a bone-marrow biopsy without making any sounds of pain. When Mr. J (a white man) undergoes a similar bone marrow aspiration, Dr. A holds his hand and the Motswana nurse comforts him. Livingston writes that “his whiteness apparently creates different expectations around his stoicism.” Smedley and Smedley write that racialized science (and any science that looks for differences between racial groups) can only maintain and reinforce existing inequalities. Although many racial disparities in health are also the product of socioeconomic differences, Smedley and Smedley argue that when we accept this concept, there is the implicit idea that these socioeconomic differences are acceptable.

In her recent book, Breathing Race into the Machine, Lundy Braun writes about racial comparisons in lung capacity and about the race correction of spirometers. Since the 19th century, it has been a well-established concept in scientific literature and in the medical community that African Americans (and most other racial groups other than people classified as whites) have a lower lung capacity than whites. Therefore, when doctors measure patients’ lung capacity even today, their spirometer values are “race corrected.” This means that the spirometer values considered “normal” for black patients are reduced, and black patients are not offered treatment or any sort of medical interventions for lower lung capacities than white patients with the same numbers. There are a few issues with this practice.

First, using race to correct for lower lung capacity ignores socioeconomic or environmental reasons for this decreased lung capacity. Often race issues are tied to socioeconomic differences and socioeconomic factors in lung capacity can also be connected to environmental explanations. Neighborhoods with lower socioeconomic status and high rates of minorities have also been shown to have higher rates of environmental pollution. Secondly, there is the issue of whether race should even be considered when taking this kind of medical measurement. When Braun interviewed physicians, they did not have a standardized way of determining race. Some physicians determined their patients’ race by looking at them and others asked patients to self-identify. Modern genomics show that there is more genetic variation within a race than there is between races, so using race as a biological concept seems even more flawed.

In the scene from Improvising Medicine, the doctors expect different things from the black man than from the white man and accordingly treat the two patients in different manners. However, juxtaposing Braun’s work on spirometers and race correction with Smedley and Smedley’s statistics on racial inequalities seems to create a sort of tension. Medical professionals are acknowledging how a certain minority group has worse health than others, but at the same time, they continue to be given worse care in the hospital. Race is one of the major factors in health care inequalities, and it would seem like acknowledging it would help fix this problem. Often, the first step to resolving an issue is addressing the issue and determining the roots of the problem. Nonetheless, the race correction of spirometers seems racist and unproductive in its current use.

It would be incredibly problematic if this type of race correction occurred globally and included other measures of health. Race correction could become a way of explaining structural violence and inequality produced by racial and socioeconomic factors, as well as becoming a method through which further inequalities were perpetuated through the decreased distribution of therapy or other medical interventions to these groups.

 

Discussion Questions:

  1. How do we move forward from simply acknowledging and naming racial inequalities in health to working to eliminate these inequalities (especially if simply making physicians aware of these inequalities doesn’t change anything)?
  2. If race is more of a social concept than a biological one, how productive is it to acknowledge race in terms of medical inequalities?
  3. How can race correction (and other similar viewpoints in the general public or in the medical community) be eliminated?
  4. Thinking about how “normal” is thought of differently (in relation to PTSD symptoms in Liberia, or classifying “normal” around the world), can race correction be justified if it shifts measurements towards the average value of the under-privileged community?

 

Sources:

Comaroff, Jean. 1997. “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body.” In Knowledge, Power and Practice, S. Lindenbaum, and M. Lock. University of California press, 305-29.

J. Livingston. 2012. Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic. Durham, N.C.: Duke University Press.

Shaban, H. 2014. “How Racism Creeps Into Medicine.” The Atlantic. [http://www.theatlantic.com/health/archive/2014/08/how-racism-creeps-into-medicine/378618/, accessed Sept 29, 2015].

Smedley A. and Smedley, B. 2005. Race as Biology is Fiction, Racism as a Social Problem is Real: Anthropological and Historical Perspectives on the Social Construction of Race. American Psychologist 60(1): 16-26.

Corporate Power and Access to Healthcare

Pyrimethamine, more commonly known as Daraprim, is a drug that is frequently prescribed for the treatment of protozoal infections and malaria around the world. It is also very often prescribed for HIV positive patients in combination with other drugs. Until recently, not many knew of this drug even though it features on the World Health Organization’s List of Essential Medicines. However, that changed overnight as a new pharmaceutical company acquired Daraprim and raised its price to a whopping $750 for a pill. This development also brought attention to the rising prices of other prescription drugs, uncovering a trend which is seeing the interests of patients being pitted against the profits made by pharmaceutical and insurance companies. We know from our readings of Smedley and Smedley and Kris Holloway’s account of her experiences in Mali, that race (beyond its relation to socio-economic status) and gender are major determinants of access to healthcare around the world, but socio-economic status which is influenced by both of the aforementioned factors still remains the primary determinant. If you live in a country like the UK, where the state bears most of the healthcare costs, the inflation of pharmaceutical prices may not affect you much; however, for most of the developing world, where 70% of the world’s population resides, the price of medicines can be a barrier to being able to avail treatment for a disease.

 

90% of the people living in developing countries have to buy their own medicine. Diseases like malaria and HIV for which Daraprim is prescribed are more prevalent in developing countries. But how is an ordinary citizen from sub-Saharan Africa, where the average annual income is less than $750, supposed to afford sustained treatment for a long term disease like HIV if a single pill costs $750? This problem is not limited to HIV and malaria either. A recent study found that treatment for pneumonia in Tanzania costs an ordinary worker a whole month’s wages.

 

Some countries like India are able to subsidize some medication but most developing countries don’t have the capacity to do that. The majority of medication in most of these nations has to be imported from overseas as only 7% of world’s pharmaceuticals are produced in the developing world. Multinational pharma corporations have entrenched themselves on the global health landscape. Given that their global presence has prevented the development of domestic pharmaceutical industries, their manipulation of prices is a major concern as a lot of people depend on them for their medicines and this gives these corporations immense power. Power that they can wield in a socially responsible manner or use to milk people for their money.

 

Multinational corporations extol the virtues of corporate responsibility. Nevertheless, their track records show that they tend to exploit people and resources (their motivation for going multinational), pollute the environment and disappear once they’ve gotten what they wanted. As we learnt from our readings about the tobacco industry, profit driven corporations stop at nothing to raise their profit margins, even if that means selling addictive and harmful products like cigarettes to children or promoting a culture of smoking. If tobacco companies which sell a health hazard are able to have their way, one can’t help but wonder what pharmaceutical companies on whom the world depends on can get away with.

 

At the end of the day, the pharmaceutical sector is a business. Like many other corporations, they may not be conscientious and may even be willing to deny the poverty stricken and the impoverished their pills and let them suffer to be able to rake in more profits. This makes me wonder, are these corporations any different from the colonizers of old who used political power to exploit others economically? After all, the East India Company, the so called original corporate raiders, started out as a trade mission and evolved into a power hungry, exploitative machinery. Capitalist tendencies of pharmaceutical companies as illustrated in the instance of Turing Pharmaceuticals and Daraprim are a warning sign. In fact, journalistic organizations like WikiLeaks have being tolling the alarm bells for a while. WikiLeaks’ latest exposé, that of the Healthcare Annex to the secret draft “Transparency” Chapter of the Trans-Pacific Partnership Agreement (TPP), outlines the construction and enforcement of a transnational legal system that will allow multinational pharmaceutical corporations to exploit the world’s basic human need for healthcare by strengthening their oligopoly. While the sources may be questionable, the concern being aired is quite real… For long, public health scholars have highlighted the need for more healthcare professionals like doctors and nurses in order to improve access to healthcare globally; however, if multinational pharma companies maintain their current trajectory, we may see the need for affordable medication added to that list.

WikiLeaks-TPP-Healthcare-Cartoon

 

Discussion questions –

How can states induce pharmaceutical companies to recognize their social responsibility and provide more equitable access to drugs? How might international organizations such as the World Health Organization play a role in this?

Over-priced medicines are certainly a big problem. However, underpriced medicines can be as well. In India for instance where the government subsidizes antibiotics, a combination of over prescription and self medication have led to alarming levels of antibiotic resistance. How can we allow people the access to medication and prevent them from misusing it? How can any pertinent regulations be enforced?

 

Holloway, Kris. Monique and the Mango Rains: Two Years with a Midwife in Mali. Long Grove, Ill: Waveland Press, 2006.

Boseley, Sarah. “Dying for Profit.” The Guardian, September 8, 2003, sec. Environment. http://www.theguardian.com/environment/2003/sep/08/wto.fairtrade7.

Brandt, Allan. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America. 1 Reprint edition. Basic Books, 2009.

Brink, Susan. “Why India Is A Hotbed Of Antibiotic Resistance And Sweden Is Not.” NPR.org. http://www.npr.org/sections/goatsandsoda/2015/09/17/441146398/why-india-is-a-hotbed-of-antibiotic-resistance-and-sweden-is-not.

Comaroff, Jean. 1997. “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body.” In Knowledge, Power and Practice, S. Lindenbaum, and M. Lock. University of California press, 305-29.

Cox, Joseph. “Surprise! Big Pharma Don’t Want Developing Countries Having Access to Cheap Medicine | VICE | United Kingdom.” VICE. http://www.vice.com/en_uk/read/american-lobbyists-are-fighting-to-halt-the-availability-of-affordable-medicine-to-the-3rd-world.

Dalrymple, William. “The East India Company: The Original Corporate Raiders.” The Guardian, March 4, 2015, sec. World news. http://www.theguardian.com/world/2015/mar/04/east-india-company-original-corporate-raiders.

Dorling, Philip. “Medicines to Cost More and Healthcare Will Suffer, according to Wikileaks Documents.” The Sydney Morning Herald. http://www.smh.com.au/national/medicines-to-cost-more-and-healthcare-will-suffer-according-to-wikileaks-documents-20150610-ghkxp0.html.

Kelly, Stephanie. “Testing Drugs on the Developing World.” The Atlantic, February 27, 2013. http://www.theatlantic.com/health/archive/2013/02/testing-drugs-on-the-developing-world/273329/.

McGee, Suzanne. “Daraprim ‘Profiteering’ Controversy Lifts Lid on Soaring Cost of Prescription Drugs.” The Guardian, September 27, 2015, sec. US news. http://www.theguardian.com/us-news/us-money-blog/2015/sep/27/daraprim-profiteering-cost-prescription-drugs-martin-shkreli.

“Medicinal Drugs in the Third World.” Text. Cultural Survival. http://www.culturalsurvival.org/publications/cultural-survival-quarterly/brazil/medicinal-drugs-third-world.

Pollack, Andrew. “Drug Goes From $13.50 a Tablet to $750, Overnight.” The New York Times, September 20, 2015. http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html.

Smedley A. and Smedley, B. 2005. Race as Biology is Fiction, Racism as a Social Problem is Real: Anthropological and Historical Perspectives on the Social Construction of Race. American Psychologist 60(1): 16-26.

Turnbull, Nancy. “Turnbull: On Inequality In Medical Spending And The Cost Hearings.” Commonhealth, June 26, 2011. http://commonhealth.wbur.org/2011/06/inequality-medical-spending.

Trauma and Violence: From Liberia to Katrina

The debate surrounding the importance of mental health is complicated by personal experience and the aggregate prevalence of mental disorders. In America, we focus on treating mental health on a case-by-case basis through psychiatric services that utilize therapy and prescription medication. Individuals who have the resources and information can seek out treatment from health care providers to unpack traumatic experiences or other sources of emotional stress.

But what happens to our conception of trauma and the treatment of mental illness when conflict arises, and a thousand people in Monrovia are killed in less than a month? What, if anything, can be done to assess and “diagnose” the experience of trauma on a population level?

Abramowitz examines the experience of Liberians after the nation’s second civil war, and explains the struggle for people to regain, reconstruct, and reconfigure their identities in the aftermath of extreme violence. She defines trauma as “a rupture of the self,” and describes the need for people to cope with their experiences in order to build new lives in the midst of pervasive cultural and social uncertainty (Abramowitz). The collective memory of thousands of people who were witness to the most horrid acts of violence committed against their family members and communities now had to negotiate social values and terms of peace whilst dealing with immense emotional suffering.

To understand the mental health needs of this “traumatized nation” using the western model of a per person, by request basis would be a mistake. Health care services provided by NGOs and government agencies must be proactive in recognizing symptoms of mental illness and recommending treatments.

Yet, these solutions are complicated by the link of trauma and violence to poverty and socioeconomic disparity. It is often asserted that mental illness requires resources that low-income nations cannot afford, and usually conflict torn places do not have secure institutions to deliver services anyway. Additionally, social stigmas associated with mental disorder discourage people to question or report their emotional states, and diminish the opportunities of the mentally ill in employment, education, and marriage (Farmer 217). Not only that, but co-morbidities between mental illness and communicable disease mean that the burden of all disease is compounded on those worst off in the world.

Socioeconomic disparity can also serve as a lens to understand the parallels between the experience of trauma in post conflict countries and the trauma from natural disasters. Violence and disaster both produce conditions that affect people on a mass scale, especially poor people, and lead to the deprivation of torn communities. The stress from disaster and violence are both characterized by uncertainty and existential crisis – not knowing where your family is, not knowing if they are okay, not knowing what will happen to you tomorrow.

For example, in the aftermath of a devastating earthquake in Nepal in April of 2015, the rate of suicide increased by 41% over a period of three months since the event, according to police data (“Suicide Rate Surges Post Quake: Report”). It has been studied that in places where disasters occur, the initial shock and trauma usually subsides within a year. This has the implication that the suicide rate will normalize in Nepal soon after the earthquake. However, the case of hurricane Katrina conveys that different chronic problems persist long past the initial disaster event. A recent survey reports that ten years later 47.7% of participants were living with PTSD in New Orleans (Kelley). Though many studies done in the past of survivors of previous hurricanes “showed quicker and more complete recovery from mental disorders,” the high rate of PTSD in Katrina victims stands out as a failure of services to return to New Orleans (Kelley). Additionally, the survey validates the need for consistent mental health treatment beyond the first years that follow a disastrous event.

The relationship between violence and disaster reveals the complexity and extensive domain of trauma experienced by large populations. Paul Farmer points to one solution that can address this trauma by singling out successful, low cost programs in Ecuador and Colombia that train primary care workers in the recognition and treatment of mental disorders (Farmer 219). He quotes Arthur Kleinman about the standard practices of mental health that can be utilized across cultures, “serious psychiatric disorders such as schizophrenia and depression are recognizable around the world, even if they differ in their course and convey different meanings depending on the local context” (Farmer 224). This offers some hope for the abilities of communities to incorporate mental health testing into their current routines in a way that is practical and substantive. If the world is going to continue to see large-scale violence and natural disasters, and we know that it will, then mental illness is not just a nation-state issue; it is global issue and should be included in the determination of the UN’s Millennial Development Goals.

 

Discussion Questions:

  1. Are western practices of therapy and psychiatry appropriate blueprints from which to model mental health services in low-income, post-conflict nations?
  1. As world temperatures rise and the effects of climate change continue to impact populations, the rates of violence are expected to increase. In the case of Syria, it is claimed that drought led to the insurrection and political instability that has produced millions of IDPs and refugees. And in the case of Nigeria, it has been argued that drought created the conditions of instability that were exploited by Boko Haram (Shockman). Do you think climate change will have a role in the violence and rates of trauma-related illnesses of the future?

Outside Sources:

Kelley, Kendra. “10 Years After Hurricane Katrina, Mental Trauma Remains.” Mississippi News Now. WorldNow and WDAM, 31 Aug. 2015. Web. http://www.wdam.com/story/29837949/10-years-after-hurricane-katrina-mental-trauma-remains

Shockman, Elizabeth. “Is Global Warming Contributing to the Current Refugee Crisis?” Pri.org. Public Radio International, 28 Sept. 2015. Web. <http://www.pri.org/stories/2015-09-27/global-warming-contributing-current-refugee-crisis>.

“Suicide Rate Surges Post Quake: Report.” The Kathmandu Post, 9 Sept. 2015. Web. <http://kathmandupost.ekantipur.com/news/2015-09-15/suicide-rate-surges-post-quake-report.html>.

Trauma and Violence

In the chapter of Abramowitz’s text, Searching for normal in the wake of the Liberian war, Abramowitz describes the post-war Liberian society and the collective trauma engulfing its members after years of civil war violence. The statistics that begin the author’s exploration are sharp: 50% of the country’s population reported “significant levels of PTSD symptoms,” 40% reported symptoms of depression. However, as the author mentions herself, these statistics allow one to understand the symptomatology of mental illness in the population, but to really understand the trauma one must look at the stories of the people.

Stories of the Liberian civil war feature atrocities ranging from human sacrifice to child soldiers being provided with cocaine and guns in preparation for battle. The war ended with an estimated 200,000 dead and 1.5 million displaced, and a society in complete disarray. As Abramowitz mentions, “violence had transgressed the most basic social values” during this war. I did not fully comprehend what this meant until I read an article in Newsweek featuring an interview with an ex-combatant named Mary who was 16 when the war ended in 2003. After the bar, she opened a bar which she manages with another 10-year-old girl, catering to “homeless crack-smoking teenagers” and older men. The article reports that Mary frequently engages in violence, beating and kicking her “manager” in the stomach if she breaks glasses, and getting into fights with adults.

Such a story can only be imaginable within the context of a place that lacks any sense of social order and sense of normalcy. It seems to me that the point Abramowitz is conveying is that the collective trauma of the Liberians stems from not only the violence of the war, but additionally from the collapse of social order under the pressures of civil war. The author retells the stories of those who have lost their roles in society – Valentine, who has lost his role as a loving son and student; Kumba’s neighbor, who has lost his role as the sub-chief of his village. In sociological theories pertaining to violence, when people can claim well-defined identities and roles in a given context, the situation is problem-free. Problems start to arise when a society cannot afford for its members to have well-defined situated identities and roles, because the societal structure is a mess. This lack of definition is echoed in the text – there were “voids of social and cultural space” allowing for violence to breed. This, in turn, would lead to more trauma, and more disorder and violence. Valentine describes feeling stuck without “forward momentum,” as his society continues to spiral down into more trauma and violence.

Present-day conflicts have the possibility of following the same trend as Liberia. What will post-war Syria look like? Already the war has been taking place for 4 years, with over 300,000 killed (June 2015 SOHR estimate) and over 4 million refugees (July 2015 UNHCR estimate). Already horrific stories have spread of children beheaded and women forcibly impregnated by members of the Islamic State. When Syria emerges from this civil war, will it have a functioning societal structure in place to prevent the downward spiral of post-war trauma and violence?

As Abramowitz mentions, Liberians who had fled during the war were the ones who seemed happier and healthier in the post-war society. The solution I have to prevent societal collapse in Syria is improvement in the global effort to accommodate its refugees. If people can be allowed to live and work in functioning environments with strong moral codes, if and when they return to their home country these people can transition back into recreating a sense of normalcy for themselves as they rebuild their country.

Discussion Question 1: Is it idealistic and demanding to think that European countries should just “open up their borders” and allow in as many refugees as they can without collapse of their infrastructure and economy?

Discussion Question 2: How can one even judge how many refugees countries can take in without total collapse? Many countries have stated that they can only take in and handle a few thousand. This to me appears to be out of Islamophobia and laziness.

Additional sources:

Left, S. (2003, August 4). War in Liberia. Retrieved from The Guardian: http://www.theguardian.com/world/2003/aug/04/westafrica.qanda

MacDougall, C. (2013, July 31). When Liberian Child Soldiers Grow Up. Retrieved from Newsweek: http://www.newsweek.com/2013/07/31/when-liberian-child-soldiers-grow-237780.html

Writer, S. (2014, November 14). ISIS Accused of Crimes Against Humanity. Retrieved from Al Arabiya News: http://english.alarabiya.net/en/News/middle-east/2014/11/14/ISIS-commits-crimes-against-humanity-in-Syria.html

 

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

Trauma and Violence

Post-traumatic stress is something that can take on many forms and arise from many different circumstances. It is also known at post-traumatic stress disorder (PTSD) but sometimes the word disorder is removed to decrease the stigma surrounding it. In an article in Vanity Fair called How PTSD Became a Problem Far Beyond the Battlefield, the author, Sebastian Junger, explains that “Because PTSD is so adaptive, many have begun leaving the word “disorder” out of the term to avoid stigmatizing a basically healthy reaction.” PTSD was originally associated with combat soldiers, but has since been recognized as something that can affect anyone who faces any trauma. As Junger explains in his article, sometimes those who experience the most severe forms of PTSD are victims of rape, and those who witnessed but were not directly involved in combat, such as himself, as journalist who travelled to Afghanistan. Sharon Abramowitz explains, in her article, Searching for Normal In the Wake of the Liberian War, people are forced into a condition they are not accustomed to, where the suffering detaches them even before they have made a trial run. Abramowitz states, almost fifty percent of the population living in Liberia at the time of the Liberian war reported severe symptoms of PTSD.

Unfortunately, there is very little treatment for this and any other form of mental disorder due to many different barriers to care. Based on research for a paper I wrote discussing PTSD in American soldiers returning from war, the two biggest barriers were stigma and lack of access to care. In Farmer et al.’s book, Reimagining Global Health, one way to decrease the lack of access to care is to combine mental health care with primary health care. Many countries have found this to be more efficient and reach more people, either by having psychiatrists located in the same location as primary care physicians or having primary care providers trained in psychological health maintenance and care.

As I found in my research, the VA (Veteran’s Association) had tried to implement something similar based on survey results from soldiers saying this would be helpful. Unfortunately what this does not help is the stigma associated with any mental health diagnosis, as Farmer et al. describes as something that can greatly affect someone’s life, causing them to not be able to gain employment, and affecting the way family and friend’s view them.

Abramowitz explains that the entire mental and physical demeanor changes in people affected by PTSD, to the point that their own friends and family do not even recognize them. Because of this, often the friends and family try to get the person help before they themselves will reach out. Both in Liberia and the United States alike, many people who wish to seek treatment cannot afford the treatment they need. Farmer explains that neuropsychiatric morbidity is underdiagnosed and antidepressants are underutilized in rich and poor countries alike. In Reimagining Global Health, the DSM-V manual of mental disorders is discussed as something that can be a barrier to care because of the different forms across different cultures. The DSM-V describes PTSD and the symptoms associated with it, and is something for health care providers to use as a baseline to help diagnose different mental disorders and illnesses. Farmer et al. explains that the DSM-V is written based on American and European cultures, which may limit its use across culturally diverse populations.IMG_2374

 

Discussion Questions:

  • Do you agree that stigma is one of the biggest barriers to mental health care, especially the treatment of PTSD? What do you think might be other effective ways of dealing with stigma as a barrier to care? If you can think of any other major barriers to receiving mental health care, what are they and what might be some possible solutions?
  • Based on Farmer et al., the DSM-V can limit utility across cultures, which might reduce the diagnosing and care of mental health disorders around the world. What might be some of the cultural barriers caused by the DSM-V and what are some possible ways to address these problems? What might be some ideas for a more universal approach to mental health diagnosis and treatment?

Additional Sources:

Junger, Sebastian. “How PTSD Became a Problem Far Beyond the Battlefield.” Vanity Fair June 2015: n. pag. Web. <http://www.vanityfair.com/news/2015/05/ptsd-war-home-sebastian-junger>.

Doolin, D. T. (2009). Healing Hidden Wounds: The Mental Health Crisis of America’s Veterans. DTIC Document.

McNally, R. J. (2012). Are We Winning the War Against Posttraumatic Stress Disorder? Science, 336 (6083), 872–874. http://doi.org/10.1126/science.1222069

Racism and Trauma

In Searching for Normal in the Wake of the Liberian War, Abramowitz emphasizes the presence of trauma as it exists in the larger context of war conflict.  Her exploration of trauma is unique because, by focusing on war conflict, she talks of a disturbance that is inherently discrete in its timeframe–in the case of the Liberian Civil war, approximately a decade.  But, what happens when that phenomenon of rupture is spread over a longer breadth of time, perhaps centuries?  Is trauma as Abramowitz defined it applicable to long internalized conflicts, such as racial conflict?

Abramowitz defines trauma as “what happens when pervasive violence and vulnerability lead to profound experiences of rupture.”  This indicates that trauma can be triggered by physical and nonphysical impetus and by first hand or indirect manners.  Monica Williams in the NPR article argues that it is this vicarious nature of trauma that allows us to understand racial conflict as a harbinger of trauma.  Speaking as an expert in mental health disparities, Williams says, “We hear in the news about African-Americans being shot in a church, and this brings up all sorts of other things and experiences.  Maybe that specific thing has never happened to us. But…we know people in our community, and their stories have been passed down. So we have this whole cultural knowledge…[that] sort of primes us for this type of traumatization.”  From William’s work, we can extrapolate that the recent media focus on black brutality must be having significant, collective effects on the mental health of the African American populace.  Moreover, second-hand traumatization, such as the overwhelming presence of police officers in the predominately black community of Ferguson after the Michael Brown shooting, can only exacerbate vulnerabilities felt by African Americans.

Nevertheless, second-hand trauma is not a recent experience for African Americans.  Despite contemporary media attention to the phenomenon of black inequality, social disparity has long been the narrative of Africans in America ever since the establishment of the slavery enterprise in the late 17th century.  Over centuries, social hierarchy based on race has been so ingrained in the U.S. that it has become the exemplar of social reality (see Smedley and Smedley).  Therefore, not only is society trained to exhibit certain behaviors to African Americans, but also African Americans naturally internalize and reflect such socially-engineered prejudices. Carl Bell, the former CEO of the Community Mental Health Council in Chicago, suggests that as a result of this institutionalized racism, African Americans must endure speckles of microaggression during their day to day lives.  Overtime, these microaggressions build and build and essentially pull away the individual from his place in society.  As the social fabric ruptures, racism as a whole has an individual & very personal traumatic effect on the African American.

The difficulty with attributing the racism experience to traumatization (as proposed in the NY Times article and the NPR article) ) is that the event of “violence and vulnerability” is not always immediate or readily apparent.  For instance, in chapter 3 of her book, Abramowitz cites Suah, the Liberian director of an international NGO.  Suah claims that the Liberians present in the country during the war were physically marked by trauma.  On the other hand, those who were removed from the incident, such as refugees and Liberians living outside the country during the war, looked significantly “younger, healthier, happier, and fatter.”  This essentially begs the question: where is the empirical proof that racial conflict can cause trauma, especially when experienced second-hand?  Moreover, how can racism, which is often exhibited in contemporary society as underlying rather than overt, be linked to mental health of African Americans with certainty?  The fact is that connecting racism to trauma is difficult especially with the dearth of research.  Perhaps the even bigger worry is whether we need to understand the trauma in its larger context to treat the trauma.

Outside Sources

Corley, Cheryl. “Coping While Black: A Season Of Traumatic News Takes A Psychological Toll.” NPR. NPR, 02 July 2015. Web. <http://www.npr.org/sections/codeswitch/2015/07/02/419462959/coping-while-black-a-season-of-traumatic-news-takes-a-psychological-toll>.

Hu, Elise. “The Psychological Effects of Seeing Police Everywhere In Ferguson.” NPR. NPR, 25 Nov. 2014. Web. <http://www.npr.org/sections/thetwo-way/2014/11/25/366611989/the-psychic-effects-of-seeing-police-everywhere-in-ferguson>.

Wortham, Interview Jenna. “Racism’s Psychological Toll.” The New York Times. The New York Times, 23 June 2015. Web. <http://www.nytimes.com/2015/06/24/magazine/racisms-psychological-toll.html>.

Class Readings

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

Smedley A. and Smedley, B. 2005. Race as Biology is Fiction, Racism as a Social Problem is Real: Anthropological and Historical Perspectives on the Social Construction of Race. American Psychologist 60(1): 16-26.

Discussion Questions

1.  Does trauma exist within a well-defined “time frame of injury”?

2.  Should/can race-based trauma be recognized by the DSM(Diagnostic and Statistical Manual of Mental Disorders)?

3.  Perhaps for a second we conclude that race-based trauma should be recognized. According to Williams, race-based trauma should be treated pathologically with clinical interventions. Do you agree?  Or is this just analogous to the case of infectious disease in which intervention (i.e. vaccination) does not really change the course of the culprit at hand?

4. Considering the lack of sufficient research on trauma and racial conflict, in what ways can the evidence behind race-based trauma be strengthened?

Trauma and Violence

It goes without saying that trauma and violence  can cause a serious toll of psychological effects on the human mind. It is unfortunate that there are so many people living with mental illnesses in the world we live in today, although the price to help these people is relatively cheap. Day-in and day-out, there are millions of people suffering from post traumatic stress disorder (PTSD), yet there are not enough facilities and organizations to help these people deal with the troubles of their past.

Recently more than ever, the world has experienced and witnessed this problem first-hand. There are approximately twelve million Syrian refugees who have been traumatized from the Syrian War going on in their home country. According to Dr. Peter Henningsen, there are three major traumatic backgrounds for those who have recently fled the country of Syria: those who have been involved in the Syrian War, those who are refugees, and those who are arriving in a foreign country after witnessing what has been going on in their homeland. Not only have these Syrians witnessed the war, but the majority have also been victims of violence themselves (Gregoire). If they haven’t been feeling the effects of mental illness already, these Syrian refugees are going to start developing symptoms of serious mental health illnesses soon.

As Paul Farmer states in his book, Reimagining Global Health, mental illnesses are usually underdiagnosed, and the resources to deal with these issues are “disproportionately low to the amount of people suffering” (Farmer et al, 213). With all of these traumatized refugees entering countries that don’t have enough resources to deal with all of the Syrian’s problems, how will this affect the refugees who are seeking help? According to Sharon Abramowitz in her article, Searching for Normal in the Wake of the Liberian War, she claims that the typical path of a traumatized person who has witnessed a war goes as follows; they are normal, then they become traumatized, then they become totally insane, and then they die. This idea of a refugee’s path after war seems rather morbid and hopeless, because Abramowitz conducted her studies in Liberia, where the resources to help these people were virtually non-existent. However, the countries that the Syrian refugees have come to since their escape are more likely to have the ability to put the refugees on a hopeful path.

Another aspect of the article by Abramowitz that will prove to be important in the coming months and years for the Syrian refugees is her claim that there is a triangulation between trauma, drug addiction and psychosis. As noted in the Huffington Post article by Gregoire mentioned above, at least one half of the twelve million Syrian refugees are children. These children have witnessed an intolerable amount of violence in the short amount of time they have been alive, and some have probably witnessed the killings of their own parents and family members. It will be extremely important for the countries that have taken in these children to guide them to a life without drug abuse. Some of these refugees may find that using these drugs may give them a high that helps them escape their past for some time, like the story we read of Valentine from Liberia in the Abramowitz article.

As Dr. Priscilla Daas-Brailsford mentions in the Huffington Post article, the focus of these countries will be to help cure the physical injuries and infectious diseases of the refugees, leaving many of the mental illnesses overlooked. A statistic that shows just how serious and necessary mental health care is for these Syrian refugees comes from this article as well: “Dietrich Munz, president of the German chamber of psychotherapists, estimated that while 3,000 to 4,000 psychotherapy sessions are offered in German refugee camps each year, the demand may be twenty times higher.” With statistics like this, it is essential for doctors, politicians, therapists, and everyone in these welcoming countries to do everything they can to prevent these mental illnesses from damaging the minds of the poor refugees even further. As evident from the Syrian refugees’ situation, trauma and violence can cause serious psychological issues in those who have witnessed war. The idea of mental health illnesses is becoming more and more acknowledged, but there needs to be far more resources to help those suffering from these diseases.

Discussion Questions:

  • What do you think is necessary to ensure that the mental health of Syrian refugees do not become damaged any more than it already has? Does this matter fall in the hands of politicians? Doctors? Surrounding countries?
  • As we have seen in the news recently, many countries in Europe have closed their borders due to the large number of Syrian refugees who are looking for safe places to enter. Do you believe that these countries should close their borders?

http://www.huffingtonpost.com/entry/refugee-crisis-mental-health_55f9b694e4b00310edf55c73

 

Empowering Women with Economic Independence

Time and time again, we see that women are exploited on a massive scale with no regard for their health consequences. The American tobacco industry serves as a fitting example. Advertising specifically towards women because they were an untapped market at the time, the rates of female smokers began to rise and CEOs of the immoral corporations yielded all of the financial benefit. Women, of course, were left with crippling lung cancer some thirty years later. We also see exploitation when women are viewed misused as sexual objects, often resulting in the spread of life-threatening diseases and unplanned pregnancies.

In the overwhelming majority of societies, we see a recurring gender dynamic: Men are the presumed breadwinners while women are the second priority—expected to be docile and submissive. It is then no surprise that gender inequality is only exacerbated in developing countries. And when women are reliant on men to keep them afloat, there lies always the possibility of forfeiting their sexual and reproductive freedom. Societal norms of the “dominant male” pressure women out of asking to use condoms, and as a result many are left with no other option than to cope with venereal diseases and to give birth to children they didn’t anticipate. The best way to grant women ownership of their own bodies is through freeing them from financial dependence on a man. When a woman can financially support herself, she will not have to stay with a man who compromises her sexual and reproductive freedoms.

In Infections and Inequalities: The Modern Plagues, Paul Farmer tells the tragic story of Guylène, a Haitian woman who is continually left alone to care for her children after men consistently leave her after one or two years. Notably, at a later point in her life, Guylène conceives another child while fully cognizant that it is strongly against doctors’ recommendations. In such a situation, one is inclined to wonder: Was the birth of this child really on Guylène’s own accord or was it her partner’s rash decision to have unprotected sex and leave her to face the consequences? She spends her life trying to find economic support from men who only give her life-altering disease and children she can’t properly raise. Lack of financial freedom keeps her in search of a male supporter, and social norms allow him to dominate/pressure her sexually. If Guylène had the means to be financially independent, she would have been able to live without a man, but instead, she has no choice.

A study mentioned in Infections and Inequalities showed that women’s dependency on men for rent greatly decreased the likeliness of condom use because she lacks the authority to demand it. The most constructive method to combat this injustice is through providing women the means to become financially independent.

A strong determinant of a woman’s capability to support herself is the amount of education she has received. Education can more easily lead to a career, giving a woman more opportunity to leave a man if she is in an oppressive relationship. In Zambia, many girls would stop going to school once they got their period because the school lacked private bathrooms. As a result, they would resort to using a bush, which is demoralizing and emotionally scarring—especially for these young women. Amazingly, girls’ attendance shot back up after the school installed a toilet. All factors considered, something as little as providing a bathroom can inadvertently save a woman from early motherhood and/or deadly infectious disease!

Another approach is through teaching women about financial independence through hosting workshops and training. The co-founder of a financial services firm called Life & Money wrote an article on his workshops he gives to women in India, and has reported that he sees a lot of potential in the women who show up. A similar economic empowerment program was established in Guatemala, though the founders warned that programs like these can anger husbands to the point that they become even more abusive towards their wives than they were in the first place. With these concerns in mind, we must still push on in attempt to give all women the chance to be financially independent.

Whether it’s vocational or professional skills, all women in developing countries deserve an education in some sort of field that has the potential to lead her to a career. It is one of the only ways we can hope for a future in which women are not subject to the unpredictable and uncontrollable desires of a male partner and do not fall victim to venereal diseases and unplanned pregnancy.

 

 

Discussion Questions:

  1. To what extent does financial freedom really ameliorate the health status of women in developing countries? Are there other factors that stand in the way of a woman’s reproductive health more than financial dependency?
  2. What are your thoughts on the effectiveness public health projects such as the toilet installation at the school in Zambia? Will increased attendance in school protect women from relying on men in the future?
  3. Do the benefits of an economic empowerment workshop outweigh the risk of more intense abuse from a spouse? If not, how can we improve and/or alter the methods used to empower women to become self-dependent?

 

Sources:

Brandt, Allen. 2007. The Cigarette Century. New York: Basic Books (p. 448-492)

Bolis, Mara. 2015, September 11. “First, do no harm” in supporting women’s economic empowerment. http://politicsofpoverty.oxfamamerica.org/2015/09/first-do-no-harm-in-supporting-womens-economic-empowerment/

Iyengar, Partha. 2015, September 22. Women Empowerment and Financial Freedom. http://www.huffingtonpost.com/partha-iyengar/women-empowerment-and-fin_b_8162316.html

P. Farmer. 1999. Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press.

Mis, Magdalena. 2015, September 8. Zambia: How to Keep a Girl From Missing School, Marrying? Give Her a Toilet. http://allafrica.com/stories/201509081580.html

 

Reproductive Health Disparities: A Harsh Reality

Kris Holloway’s story, Monique and the Mango Rains, tells of her two years in Mali working as a Peace Corps volunteer. Holloway works closely with Monique Dembele, the sole village midwife and general healthcare provider in Nampossela, a small, remote, rural village. What stand out to me from her experience are the systemic, structural, social, and cultural circumstances that force the village women into perilous health positions, particularly pertaining to pregnancy and women’s health issues. The shocking fact is that the women in Nampossela have virtually no control over factors that directly and negatively impact their lives and health outcomes. This is very much like the inhabitants of Flammable, an urban shantytown in Buenos Aires, Argentina, whose children have strikingly high rates of lead poisoning, simply because of where and how they are forced to live. It seems that in the 21st century, this circumstance ought not to exist anywhere on our planet—so, how can it be that this is the reality for so many women and children?

 

Take, for example, the story of Korotun, a village woman who is beaten repeatedly by her husband (Holloway 2006: 53). Korotun believes that if she can get pregnant, her husband will not be so angry with her, so he will not beat her. She has no way to protect herself from the beating, and the harsh reality is that another pregnancy might not ameliorate her situation.

 

Or consider the example of Oumou, who has lost four children out of nine. She cannot bear to have more children for fear of them dying, so she wants a form of contraception. But her husband will not allow it. He would refuse to use a condom, and would not allow her to take oral contraception, forcing her to obtain and swallow any pills in secrecy.

 

Third, consider Bintou, a village woman who passes away after the birth of her seventh child. Holloway points out that the factors that caused Bintou’s death are manifold. It was the rainy season, so she could not give birth in the village’s dilapidated birthing house. Bintou might have been malnourished, or she might have suffered from malaria. Or maybe, Holloway hypothesizes, her uterus could not handle a seventh labor. The list goes on. Whatever the cause, these were all circumstances out of Bintou’s control. Had Bintou known how critically important sufficient rest was for the safety of her seventh pregnancy, perhaps she might have tried to rest. But how could she have known? Her uninformed husband would not let her rest from work because of the prevailing cultural norms and economic need for Bintou to help out at home and in the fields. Her husband did not even let her see Monique for a prenatal consultation, Holloway assumes. So Bintou did not have any much-needed advice about prenatal care.

 

All three of these women suffer from structural violence—the prevailing social, political, economic forces that directly impact personal, individual health (Farmer 2013: 9). They are victims of this violence with severely limited ways of protecting themselves. Korotun is not choosing to get pregnant because she wants another baby, but rather because she wants her husband to stop beating her. (In addition to being beaten by her husband, Korotun will now have an unwanted daughter.) Bintou of course did not want to die during labor. Despite Monique’s best efforts, these women had none of the knowledge or access to resources that could have prevented these adverse health outcomes because of the culture, society, and economy in which they live. Similarly, the residents of Flammable did not choose to live on top of garbage and toxic waste dumps—where children and pregnant women would be exposed to high concentrations of heavy metals. But they had no other choice.

 

But there is good news. Researchers all over the world are working to design innovations that can create lasting change. For example, an injectable contraceptive that lasts for 3 months has been introduced recently in Burkina Faso (McNeil, 2014). As Monique explains to Holloway, villagers love injections, because they “represent the pinnacle of Western medicine, and Western medicine is good” (Holloway, 7). Perhaps this will be a sustainable solution, which would allow women to use contraceptives with less of a risk that their husbands may find out.

 

My older sister had a baby this past summer, and her most difficult decisions during her pregnancy were whether or not she should choose organic, non-GMO foods, or which of many options was the best stroller to buy. She could take endless prenatal supplements, and had months of maternity leave to look forward to. The women of Nampossela could not fathom these options. While my sister’s experience certainly was not universal throughout the US, the disparity between our privileged existence in the developed world and the Malian women’s experience could not be more stark.

 

 

Discussion Questions:

I’m interested in the same question regarding Bintou’s death that Holloway poses on page 89: “If Monique had had access to more emergency medical care, could she have saved Bintou?” Monique successfully delivers so many babies with such simple tools—would investing in high-technology care be “worth” it? Would it be better to put resources towards other aspects of healthcare, such as malaria or HIV/AIDS prevention? Even if they were able to create a more hospital-like setting in Nampossela, would the villagers welcome the change, considering their cultural values that make their childbirth experience much different from the experience we are familiar with?

 

Who is responsible for these complex, multi-faceted problems? Who can help? Holloway, as a Peace Corps worker, certainly helped for the two years that she was stationed in Mali. And, there’s evidence that her and Monique’s work is making a difference: the number of women coming in for prenatal consultations has steadily increased over time (Holloway, 94). But will her work make a lasting impact? What kind of help would make a lasting impact? Will the village’s maternal health deteriorate again after Holloway’s two years there?

 

 

References:

 

Auyero, Javier and Debora Alejandra Swistun. 2009. Flammable: Environmental Suffering in an Argentine Shantytown. New York: Oxford University Press.

 

K. Holloway. 2006. Monique and the Mango Rains: Two Years with a Midwife in Mali. New York: Waveland Press.

 

McNeil, Donald. “New Contraceptive Shot Being Released in Africa.” 14 July, 2014. http://www.nytimes.com/2014/07/15/health/new-contraceptive-shot-being-released-in-africa.html?_r=0

 

P. Farmer, A. Kleinman, J. Kim and M. Basilico, eds. 2013. Reimagining Global Health: An Introduction. Berkeley: University of California Press.