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Why maternal mental health should be a priority

Post originally appeared here.

As 2015 quickly approaches, the global health community has been made increasingly aware of our progress toward Millennium Development Goals (MDGs). Some remarkable progress has indeed been made. For example, the proportion of underweight children under the age of five in developing countries has declined from 28% to 17%between 1990 and 2011. Significant progress has also been made in reducing mortality among children under the age of five. In 1990, 12 million children under five died, compared with 6.9 million children in 2011. In 2011, 2.5 million people were newly infected with HIV, representing a 24% decrease from the 3.1 million people newly infected in 2001. However, one millennium development goal has shown particularly slow progress: MDG 5, namely, improving maternal health. Few countries are on track to achieve the first part of MDG 5’s goals, reducing maternal morality by 75%. Sub-Saharan Africa is in the most dire position, with a regional maternal mortality rate of 640 maternal deaths out of 100,000 live births, and a decline rate of merely 0.1%. In the summer of 2012, the University of Cambridge hosted a conference on the topic of “New Approaches to Maternal Mortality,” recognizing the crucial need to address the question of what is going on with global maternal mortality rates and to begin to address potential solutions.

While numerous factors are still converging to produce this grim picture, one key element is often missing from the discussion: improving maternal mental health. Working toward solutions to mental health problems that plague new mothers in a wide variety of settings, including in developing countries, could go a long way in improving both maternal and child health. Integrating mental health programs with maternal health programs is not only as important in saving mothers’ lives as screening for malaria and treating HIV in pregnant women but it could also prove essential in achieving two distinct but interrelated Millennium Development Goals: improving maternal health and reducing the number of deaths in children under the age of 5.

A recent article in PLOS Medicine delineates some reasons why maternal mental health is not a high priority on maternal health agendas. For one thing, a number of myths prevail that make maternal mental health seem irrelevant or unimportant in comparison to other threats facing maternal health. One especially troubling myth is the notion that maternal mental health problems are rare in developing countries, where maternal deaths represent a more significant problem than in the developed world. The authors note that this perception is misguided and cite evidence that rates of perinatal depression in low- and middle-income countries are actually higher than in high-income countries, ranging from 18% to 25%. Another misperception involves the idea that maternal depression is only tangential to maternal health. There is a conception that obstetric complications and infectious diseases represent much more immediate threats to maternal health than mental health issues. Yet this notion turns out not to be entirely true. Maternal depression certainly contributes in a very direct and striking manner to poor outcomes in infants. Maternal depression has been associated with pre-term birth, low birthweight, undernutrition, and higher rates of diarrheal disease. Suicide is actually a leading contributor to maternal mortality worldwide, and suicidal thoughts and tendencies occur in up to 20% of mothers in low- and middle-income mothers, in comparison with 5 to 14% of mothers in high-income countries.

Part of the problem with treating maternal depression is that it can be difficult to detect, especially in resource-poor countries. Core symptoms of depression such as fatigue and poor sleep are also effects of motherhood and often go unnoticed in new mothers. Screening for depression should be an integral component of antenatal visits and health care professionals who do not specialize in mental health should be trained to recognize symptoms of depression in pregnant women and new mothers. Over the last decade, interventions by non-mental health specialists have produced promising results, and efforts are being expanded to low- and middle-income countries with encouraging outcomes. ThePerinatal Mental Health Project (PHMP), based at the Mowbray Maternity Hospital in South Africa, included screening by midwives of all women in antenatal care for mental health problems and referrals for counseling and psychiatric care if necessary. The intervention resulted in high coverage (90%) and uptake (95%) of PMHP screening, and staff responsible for the screening expressed relief, rather than a feeling of burden, about the integration of maternal and mental health systems in order to address a previously unmet need.

International donors and stakeholders should be made aware of the dire effects of maternal depression on maternal and child health and should be encouraged to provide funds and aid specifically for maternal mental health. In particular, the evidence for the effects of mental health on physical health should be emphasized in communication with international donors. In addition, donors should be made aware that integrating mental health services into existing treatment platforms could prove an important opportunity to leverage resources efficiently, a major current preoccupation of the global health community.

If the Millennium Development Goals are to be achieved, the international health community needs to stop viewing them in isolation from each other and recognize that many of them are intertwined and require integrated interventions. At the same time, holistic views of both health systems and individual health are vital. Strengthening across health systems, which includes strengthening local mental health services, will bring us closer to achieving the MDGs. In a similar manner, viewing individual health holistically, as the combined effect of the health of various systems, including not only the body but also the mind, will help ensure that we pay due attention to a wider variety of factors contributing to poor health worldwide.

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How can we improve global infectious disease surveillance and prevent the next outbreak?

Originally published here

ABSTRACT Section: ChooseTop of pageABSTRACT <<The state of infectious d…Problems with global infe…Possible solutions to glo…References Next section

 

Despite a significant amount of progress in the past decade, global infectious disease surveillance still often falters, as in the case of the emerging novel coronavirus that has killed at least 17 people in Saudi Arabia. This article argues that we must continuously re-evaluate global infectious disease surveillance systems. It takes stock of problems in various countries’ infectious disease surveillance systems and offers recommendations for how to improve surveillance and ensure more rapid reporting. Chief among the recommendations are strategies for reducing fragmentation in global surveillance systems and methods for making these systems less disease-specific. Suggestions are also offered for ways to improve infectious disease surveillance strategies in resource-limited settings.

The state of infectious disease surveillance and reporting Section: ChooseTop of pageABSTRACTThe state of infectious d… <<Problems with global infe…Possible solutions to glo…References Previous sectionNext section

In light of recent panic over the detection of a novel influenza A virus (H7N9), an editorial in The New England Journal of Medicine warned that “we cannot rest our guard” [1]. The authors commended Chinese scientists for rapid identification and reporting of the new virus [1]. At the same time, by February 15, 2013, a novel coronavirus, occurring eerily exactly a decade after severe acute respiratory syndrome (SARS), had killed 6 of the 12 people infected to that point [2]. Yet 6 months after the first report of this novel coronavirus, not nearly enough is known about the illness. Scientists feel certain that there are more cases, some perhaps so mild that the infected individuals are not seeking care. Human-to-human transmission of the newly characterized coronavirus probably occurs, but little is known about the mechanism or efficiency of infection [3]. Part of the problem is that affected countries have not offered the appropriate amount of information for full epidemiological analyses to be conducted. Saudi Arabia has reported 9 novel coronavirus infections to the World Health Organization (WHO), but information is still missing about patient age, sex, residence, and circumstances surrounding infection [3]. Although SARS was ultimately largely contained, China’s initial reluctance to report the outbreak is another well-known example of resistance to reporting disease outbreak information [4]. China also did not report a 2003 case of H5N1 until 2006 [5].

‘Infectious disease surveillance’, an important component of any public health system, refers to a variety of strategies, including monitoring a disease over time and reporting of clinical cases or disease clusters. Some surveillance systems depend on clinical observation, some on laboratory tests, others on computer-based searches of public health records or individual patients, and still others on mathematical modeling and prediction [6]. A decade after the SARS epidemic, it seems apt to take stock of how much better prepared we are now to deal with emerging pathogens. The evidence is mixed. On the one hand, we have come very far. Infectious disease surveillance has improved, and scientific advances make it easier to sequence the genome of an emergent pathogen much more rapidly. The SARS experience also induced the introduction in 2005 of new international rules to report novel diseases [6]. Electronic and communication networks have expanded, and the WHO has even begun to provide information on emerging outbreaks in real time on their website. The WHO has also developed a wider network, the Global Outbreak Alert and Response Network (GOARN), aggregating information from a wider variety of sources, and has revised the International Health Regulations to include more infectious diseases [7]. At the same time, our experience with the novel coronavirus shows that there is still a ways to go in improving our global response to emerging infectious disease threats. Many countries still lack the infrastructure to detect and report a disease early on. After the first case of novel coronavirus in Saudi Arabia, it took 3 months for information about the illness to emerge in the global arena [3].

Problems with global infectious disease surveillance Section: ChooseTop of pageABSTRACTThe state of infectious d…Problems with global infe… <<Possible solutions to glo…References Previous sectionNext section

What are some of the problems with the current operation of local and international infectious disease surveillance systems? One obvious problem is the reluctance of local governments to report diseases for fear of negative repercussions on tourism and trade and general feelings of embarrassment. On a more structural level, systems of disease reporting and surveillance are extremely fragmented, since surveillance systems tend to be reactive and disease-specific [5]. For example, in the USA, surveillance systems are decentralized, operating under local, state-controlled reporting regulations, with information then forwarded to the Centers for Disease Control and Prevention (CDC). Even in countries with centralized reporting procedures, there may not always be a straightforward link between centralized control and effectiveness of surveillance [5]. Reporting relationships between local entities and the capitals of these countries may often be lacking. For example, this was certainly the case in China during the SARS outbreak: although China has strong centralized political control, communication between localities and the capital were observed to be very weak during the SARS epidemic [5]. This lack of communication is not always the case, but it does show that centralized control does not always mean more effective surveillance.

Competition for public health resources can sometimes render funds for infectious disease control inadequate [5]. We also have a surprising dearth of knowledge when it comes to epidemiological mapping of infectious disease threats. It is difficult to gauge the seriousness of emerging disease threats if we do not have a full understanding of their geographical spread [8]. Surveillance systems that are too disease-specific can also miss the early warning signs of emergent infectious disease threats [9]. They are also often passive, picking up on new diseases in a haphazard manner, and developed according to the local organization of public health systems, making international recognition much more difficult [5].

Possible solutions to global infectious disease surveillance challenges Section: ChooseTop of pageABSTRACTThe state of infectious d…Problems with global infe…Possible solutions to glo… <<References Previous sectionNext section

What can be done to improve surveillance systems and aid in the prevention of emerging epidemic threats? Evidence suggests that outbreaks in developing countries are being reported more swiftly, especially informally by individual citizens. As a result, some experts suggest that focusing on ways to improve infectious disease reporting via cell phones, whether through SMS or smart phones, could be an incredibly useful venture [10]. The development of more systems similar to HealthMap that aggregate and organize informal web-based modes of infectious disease reporting, such as online news sources and discussion sites, could also be incredibly useful [11]. These systems must be made more user-friendly to individuals living in developing countries in particular, where a significant infectious disease burden exists. Strategies may include developing interfaces in additional languages and implementing mobile phone alerts [11].

Coordinating global reporting systems to better aggregate and share data is essential, as is training individual citizens to recognize and report outbreaks [5]. Just as community health workers and clinicians have been trained to detect outbreaks, so should individual citizens be educated about the signs of emerging infections and the protocol for reporting. For example, community educators could teach village communities in developing countries about the warning signs of emerging infections or about symptoms of common infectious threats in the region. Village citizens would also be taught about how to report infectious disease threats to the appropriate authorities, always being encouraged to over-report rather than under-report. In more developed countries, where people have easy access to the internet and technologies such as iPads and iPhones, government agencies could even develop applications that function as checklists for infectious disease threats and facilitate the process of reporting. For example, the US CDC recently developed an iPad app called “Solve the Outbreak” that, although a game, allows people to function as infectious disease epidemiologists; it is also intended to teach people about the warning signs of emerging infectious disease threats and inform them about the steps to take to report these threats. Additionally, explaining to policymakers why disease surveillance should be a priority is vital [5]. Seizing upon the right timing is important in this process, for instance in the wake of an epidemic disease threat such as novel coronavirus, when the problem of infectious disease outbreaks is already on the minds of high-level decision-makers. Clarifying that proper surveillance efforts are cost-effective is also essential in convincing policymakers of the importance of strengthening these systems.

Directing disease surveillance efforts to the right locations is also crucial. At the moment, most disease surveillance efforts focus on more developed nations, but threats of emerging infectious diseases may be most significant in places such as Africa, Latin America, and Southeast Asia because of population growth and increased antibiotic use [12]. Encouraging more countries to adopt the same infectious disease surveillance systems, such as the ProMED-mail system, to complement their own strategies, and making subscriptions to such services easy and affordable, could help reduce fragmentation of global infectious disease surveillance techniques [13]. International veterinary agencies that monitor global animal safety and disease need to be better connected to agencies such as the WHO that focus on human disease in order to help control infectious diseases with animal reservoirs [14]. At the moment, the operations of these types of agencies are wholly separate from each other, demonstrating another key source of fragmentation in global infectious disease surveillance systems.

Quality infectious disease surveillance is lacking especially in developing countries, where the infectious disease threat is often greatest. One way to close the gap in infectious disease surveillance is to better disperse technological advancements such as rapid diagnostic tools [15]. There is evidence demonstrating that rapid, affordable, inexpensive diagnostic tools can greatly contribute to quicker and more effective infectious disease surveillance [6]. Diagnostic tests that differentiate between different strains and organisms and point-of-care diagnostic tests are also needed [16]. Steps should be taken to help more local clinics in developing countries connect to the internet and thereby have the opportunity to take part in an important form of emerging infectious disease reporting. Web-based forms to report diseases via cell phone should also be provided in developing countries, since cell phones are widely available even in low-income villages [5]. International aid and public health agencies need to create realistic funding plans to help improve healthcare infrastructure in developing countries, including distributing resources needed to develop and distribute rapid diagnostic tools and training local health workers to use them [6].

Much research on the effectiveness of certain kinds of surveillance still needs to be done. More reports about the timeliness of responses to infectious disease outbreaks should be implemented. The best way to measure timeliness is to calculate the median delay between the date of disease occurrence (as identified by disease onset date, diagnosis date, or laboratory result date) and the date the public health system was notified for particular infectious disease threats. Evaluations of surveillance systems should more regularly take timeliness of response into account as a key measure of further needed progress [17]. Similarly, comparative cost-effectiveness analyses need to be conducted on various surveillance systems to have a better understanding of which forms of surveillance and reporting are most financially efficient. Clear measures of effectiveness and cost-effectiveness of various, existing infectious disease surveillance methodologies are desperately needed [6]. One 2010 PLoS One study of the Integrated Disease Surveillance and Response (IDSR) system in Burkina Faso provides a good model of how to measure this [18]. The authors of this study collected epidemiological data on the number of meningococcal meningitis cases in Burkina Faso before and after the implementation of the IDSR. They found a significant decline in cases, and although they noted this decline could be the result of other factors, they hypothesized that the decreases were primarily the result of the novel surveillance system, largely because the authors did not find statistically significant evidence for the existence of other factors to explain the decrease, such as an increase in vaccine imports. They then estimated costs per case, costs per death, and costs per sequelae prevented and concluded that the implementation of the surveillance system was cost-effective. More studies such as this one could be conducted in other regions with other infectious diseases to measure cost-effectiveness.

Although infectious disease surveillance has been vastly improved in the decade since SARS, there is still plenty of room for further progress. Even as China is to be commended for the rapid response to H7N9, we cannot rest easy. We must still continuously re-evaluate global systems of infectious disease surveillance and continue to improve them.

Declaration of interest: No special funding has been received for this article. The author declares no conflicts of interest.

References Section: ChooseTop of pageABSTRACTThe state of infectious d…Problems with global infe…Possible solutions to glo…References << Previous section
  1. Uyeki TMCox NJ. Global concerns regarding novel influenza A (H7N9) virus infections. N Engl J Med 2013; 368:1862–4.
  2. Kahn G. A novel coronavirus capable of lethal human infections: an emerging picture. Virol J 2013;10:66.
  3. Enserink M. New coronavirus reveals some of its secrets. Science 2013;340:17–8.
  4. Hipgrave D. Communicable disease control in China: from Mao to now. J Global Health 2011;1:224–38.
  5. Morse SS. Global infectious disease surveillance and health intelligence. Health Affairs 2007;26:1069–77.
  6. Hitchcock PChamberlain AVan Wagoner MInglesby TVO’Toole T. Challenges to global surveillance and response to infectious disease outbreaks of international importance. Biosecur Bioterror 2007;5:206–27.
  7. Enserink M. War stories. Science 2013;339:1264–8.
  8. Hay SIGeorge DBMoyes CLBrownstein JS. Big data opportunities for global infectious disease surveillance. PLoS Med 2013;10:e1001413.
  9. Mawudeku ARuben MLemay R. Global public health surveillance: the role of nontraditional surveillance tools. In: Lemon SMHamburg MASparling PFChoffnes ERMack A, editors. Institute of Medicine Forum on Microbial Threats. Global infectious disease surveillance and detection: assessing the challenges—finding solutions, workshop summary. Washington: National Academies Press; 2007.
  10. Chan EHBrewer TFMadoff LCPollack MPSonricker ALKeller M, et al. Global capacity for emerging infectious disease detection. Proc Natl Acad Sci U S A 2010; 107:21701–6.
  11. Brownstein JSFreifeld CCReis BYMandl KD. Surveillance sans frontières: internet-based emerging infectious disease intelligence and the HealthMap project. PLoS Med 2008; 5:e151.
  12. Jones KEPatel NGLevy MAStoreygard ABalk DGittleman JL, et al. Global trends in emerging infectious diseases. Nature 2008;451:990–3.
  13. Madoff LCWoodall JP. The internet and global monitoring of emerging diseases: lessons from the first 10 years of ProMED-mail. Arch Med Res 2005;36:724–30.
  14. Butler D. Disease surveillance needs a revolution. Nature 2006;440:6–7.
  15. Lipkin WI. The changing face of pathogen discovery and surveillance. Nature Reviews 2013;11:133–41.
  16. Heyman HLBrilliant L. Surveillance in eradication and elimination of infectious diseases: a progression through the years. Vaccine 2011;29S:D141–4.
  17. Jajosky RAGroseclose SL. Evaluation of reporting timeliness of public health surveillance systems for infectious diseases. BMC Public Health 2004;4:29.
  18. Somda ZCPerry HNMessonnier NRDjingarey MHKi SOMeltzer MI. Modeling the cost-effectiveness of the Integrated Disease Surveillance and Response (IDSR) system: meningitis in Burkina Faso. PLoS One 2010;5: e13044.

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Is fear a useful measure in preventing outbreaks?

Post originally published here

In Los Angeles in 1924, after a series of mysterious deaths, Yersinia pestis, or bubonic plague, was swiftly identified as the culprit. Immediate quarantine of exposed people in selected areas helped to make the outbreak less than a devastating epidemic. But some public officials and newspaper reporters, in a desperate attempt to explain the origins of the illness, began equating the disease with people of Mexican descent. Panic quickly struck the city. Hotels and restaurants fired thousands of Latino workers. Health officials destroyed houses in low-income neighborhoods deemed “public health menaces” without offering compensation to the displaced. Fear of the disease rapidly attached itself to deep-seated fears of low-income individuals and foreigners and produced an unacceptable set of practices in the name of preventing an epidemic.

But is fear always detrimental in the face of potential epidemics? In other words, is fear ever, in fact, a useful preventative tool? Excessive, widespread panic may, of course, be counterproductive in the fight against emerging microbial threats. But small doses of fear, instilled carefully and systematically by epidemiologists and public health officials, may be vital in certain situations.

Complacency and lack of fear might have a role to play in the recent dramatic drops in vaccination rates in the U.S. and other developed countries. In states in which philosophical exemptions to vaccines are permitted, the rate of this voluntary opting out was 2.6% in 2009, up from 1% in 1991. A certain misplaced form of fear might in fact be driving this phenomenon in some cases: parents have latched onto the false belief that vaccines cause autism and overestimated risks associated with vaccination. But recent declines in vaccination rates may also be due to a lack of appropriate fear. Sixty years ago, the consequences of life without most modern vaccines were eminently visible: polio paralyzed 16,000 Americans every year; rubella caused birth defects in 20,000 babies; measles infected 4 million children and killed 3,000 annually. Today’s parents view infant mortality as a phenomenon of the past or a devastating problem relegated to developing countries. Parents in the second decade of the 21st century have probably never witnessed an infant suffering from pertussis or diphtheria. Newly trained pediatricians may not know what a Koplik spot is, let alone have seen one The threat of child mortality is not looming in developed countries, and many parents do not realize that, in the

absence of vaccines and proper herd immunity, these illnesses, as well as infant death, could once again become immediate threats. In the case of declining rates of infant vaccination, might not a small dose of fear help?  If parents were more frightened about the consequences of notvaccinating their children, whooping cough epidemics such as the one in Washington State this past year might be prevented.

When is it appropriate to sound the alarm bell and when should public health officials keep the public calm? Obviously, hysteria is never a useful response to any looming epidemic or public health threat. But in the case of emerging and not immediately apparent threats, such as the possibility of a pertussis outbreak or the growing rate of antibiotic resistance, it might be necessary to jolt people out of their complacency. Antimicrobial resistance is a complex problem, but there are a number of ways that we can reduce the damage. In many countries, there is no national regulation on antibiotics, healthy animals are given antibiotics for growth or to prevent disease, antibiotics can be purchased over the counter, and doctors prescribe antibiotics too readily. In this case, sounding the alarm bell loudly and repeatedly is absolutely necessary. On the other hand, in a case such as the 2003 outbreak of SARS, the amount of fear may have been out of proportion with the threat at hand, may have produced destructive mass hysteria, and may have resulted in a perhaps offensive avoidance of Asians and Asian countries.

Especially in cases of unknown, emerging microbial threats, health officials must help the public walk the line between healthy fear and detrimental widespread hysteria. Heightened fear of threats that are looming but not immediately in sight may sometimes be justified as a stimulus to preventative action. At the same time, fear of disease must be appropriately contained, in proportion with the crisis at hand, and must never become a proxy for irrational fears, such as xenophobia, that are all too easily stimulated in the face of complex health emergencies.

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Why Mental Illness-Focused Gun Control May Be More Harmful Than Helpful

This article was originally published here.

Dr. Sara Gorman examines the risks involved with mental illness-focused gun control.

In the aftermath of the mass shooting earlier this year in Newtown, Connecticut, debates have been raging in the U.S. about what steps to take to prevent such tragedies in the future. In particular, policy officials and the public alike have been pondering whether more stringent controls on potential gun buyers and gun owners with mental illness should be implemented and what these controls might look like. Shortly after the Newtown shootings, Senator elect Marco Rubio called for guns to be “kept out of the hands of the mentally ill.” In a more extreme statement, the National Rifle Association (NRA) suggested an “active national database of the mentally ill.” A recent study by researchers at the John Hopkins Bloomberg School of Public Health found striking similarities in the opinions of gun-owners and non-gun-owners when it came to restricting the ability of people with mental illness to own guns. 85% of all respondents to the survey supported requiring states to report people to national background-check systems who are prohibited from owning guns because of a history of being involuntarily committed or being declared mentally incompetent by a court. Most respondents, whether gun-owners or non-gun-owners, were resistant to allowing people with mental illness to own guns. Clearly, the provision of tight restrictions on potential gun owners with mental illness is an unusual arena in which gun-owners and non-gun-owners can agree.

There is no question that guns pose a potentially serious problem for people with mental illness. Some forms of mental illness can be associated with heightened potential for violence, but, more importantly, the risk for successful suicide among depressed persons with guns is much higher than the risk for those without guns. Nevertheless, are gun control efforts that require the names of people with mental illness to be kept in a national database such a good idea?

The truth is, we have to be much more careful about gun control efforts that have the potential to target people with mental illness. There are two main reasons to approach these kinds of laws with a healthy dose of caution: one reason is that gun control efforts focusing on mental illness have the potential to exacerbate public stigma about the potential violence associated with mental disorders; the second reason is that gun laws that in particular involve collecting the names of people with mental illness in national databases have the potential to deter people from seeking the care they may desperately need.

Ample evidence has suggested that stigma and discrimination against people with mental illness is often correlated with perceptions that people with mental illness are inherently violent. People who believe that mental illness is associated with violence are more likely to condone forced legal action and coerced treatment of people with mental illness and may feel that victimizing and bullying people with mental illness is in some way justified. The idea that mental illness and violence are closely related is quite common. A 2006 national survey found that 60% of Americans believed that people with schizophrenia were likely to act violently toward another individual. Even so, research has repeatedly established that psychiatric disorders do not make people more likely to act in a violent manner. Gun laws targeting people with mental illness are likely to worsen the perception that mental illness and violence go hand in hand, and, as a result, stigma and discrimination are likely to be exacerbated.

Gun laws targeting people with mental illness may in some instances save lives. Successful suicides, or even suicide attempts, might be avoided, for instance. On the other hand, in addition to perpetuating a stigmatizing belief that people with mental illness are dangerous, gun laws that focus on people with mental illness might involve measures that deter people from seeking psychiatric care. If people are afraid that the government and other parties will have access to their confidential mental health information, they may be much more reluctant to seek help in the first place. In the end, this kind of deterrence could cause more harm than good, not to mention that increased stigma and discrimination also often lead to a decrease in help-seeking behaviors.

It is true that the U.S. mental health system is in need of reform and that strategies to detect people in danger of hurting themselves or others earlier are desperately needed. Even so, it is difficult even for mental health professionals to predict the future violence potential of their patients. Furthermore, it is not only misguided but also potentially harmful to focus gun control efforts on people with psychiatric disorders. What’s more, these kinds of efforts will probably make very little difference in the homicide rate in the U.S. It would be more worth our while to focus gun control efforts not on mental illness per se but perhaps more importantly on alcohol abuse. The association between alcohol abuse and gun violence is convincing. As a result, in Pennsylvania, for example, people who have been convicted of more than three drunk driving offenses may not purchase a gun. Keeping guns out of bars and other drinking establishments is also probably a wise move. Doing background checks for domestic violence is also a useful measure in reducing gun violence in the home. As the U.S. reconsiders gun control legislation, it is important to recognize that some measures might do more harm than good. Paying closer attention to scientific evidence and remaining focused on the most effective strategies for targeting those most likely to commit violent acts must be the strategy going forward.

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Should women who have undergone FGM be granted asylum in the U.S. on medical grounds?

This article was originally published here.

Since 1994, when a Nigerian woman and her two daughters were granted asylum in the U.S. based on fear of female genital mutilation (FGM) in their native country, the legal community has been avidly debating the question of whether FGM should be considered grounds for asylum. A 1996 case, in re Kasinga, established a precedent for granting asylum to women based on a well-found fear of persecution in the form of FGM.

Today, the question is still, however, controversial. There is no standard definition of “persecution,” a fear of which is required for asylum seekers to gain asylum, and even though “membership in a particular social group” may help an individual gain asylum, this definition has not been officially extended to include women subject to gender-based injustices. In addition, the Kasinga case doesn’t apply to women who have already undergone FGM, who are almost never granted asylum on the logic that they have no real grounds to fear further persecution. In other words, since the persecution has already occurred, there is no requirement to protect these women under the Refugee Act of 1980 .

Although the law does not generally allow it, many legal scholars remain advocates of granting asylum to women who have already undergone FGM. Yet whether granting asylum for women who have already undergone FGM on clinical grounds is legitimate remains an open question. It is our belief that clinicians have a significant role to play in asserting that women who have undergone FGM have significant grounds to be granted asylum in the U.S. and other Western countries.

There is abundant evidence that female genital mutilation results in both short-term and long-term obstetric and gynecologic damage. A World Health Organization (WHO) prospective study of 6 African countries found that women with FGM were more likely to have postpartum hemorrhaging, extended maternal hospital stays, stillbirth or early neonatal death, and give birth to infants with low birthweight than women without FGM. Several studies have established that risk of transmission of HIV is increased for women with FGM. The practice of FGM may indeed be contributing to the perpetually increasing HIV epidemic in sub-Saharan Africa. In the case of infibulation, in which the vaginal orifice is narrowed by cutting and appositioning the labia minora and/or labia majora, complications include dysmenorrhea, stagnation of blood in the uterus or vagina, chronic pelvic infection, repeated urinary tract infections, chronic vaginitis, and dysuria.

These medical complications have frequently been cited as reasons to grant asylum to young women who fear the possibility of future FGM if returned to their native countries. But what about women who have already undergone FGM? There are two essential reasons to insure that these women are not returned to the countries in which FGM took place and in which the practice is still sanctioned. First, the surgical procedure deinfibulation, which is performed in the United States and other Western countries, can reverse some of the anatomical damage done by female circumcision and reduce risks for medical and obstetrical complications. It is unlikely that women will be able to access this procedure in their native countries. Moreover, those who do undergo reparative deinfibulation are at risk of facing ostracism, stigmatization, discrimination and even re-infibulation in their home countries. Given that clinicians have an ethical duty to recommend the reparative procedure for their patients who are victims of FGM, it would seem clear that there is an affirmative duty to insure that these patients not be returned to an environment that would disrupt the benefits of surgical repair.

Second, it is essential to examine the psychological consequences of FGM in order to understand the risks of forced repatriation. Although it  has always been assumed that FGM causes increased rates of mental disorders, especially trauma responses, measuring the adverse psychological effects of FGM is difficult, particularly because of the pride some women feel in having taken part in an ancient cultural tradition. Some reactions to FGM among women might include feelings of pride, beauty, cleanliness, and faithfulness and respect to tradition. Despite these positive associations, several recent studies have determined that women with FGM may be more prone to psychiatric disorders than women without FGM. In one study, circumcised women in Senegal showed significantly higher rates of PTSD, psychiatric illnesses, and memory problems than uncircumcised women. In a more recent study of 4800 pregnant women, 38% of whom had undergone FGM, 80% of those circumcised continued to have flashbacks to the FGM event, 58% had some form of affective disorder, 38% had anxiety disorders, and 30% had PTSD. Evidence has begun to accumulate that FGM does indeed have a significant impact on women’s mental health. A hallmark of PTSD is pathological “re-experiencing” of the original trauma and avoidance of cues related to the original traumatic event. Clearly, returning a woman who has undergone FGM to the scene of her traumatic event engenders substantial risk of worsening trauma-related psychiatric illness. This is especially unacceptable given the likelihood that treatment for the psychological and psychiatric consequences of FGM is not readily available in cultures that encourage the practice in the first place.

Sending women with psychological disorders as a result of FGM back to their native countries is akin to denying them a basic human right: healthcare. In cultures in which FGM is considered a point of pride, women are not likely to be able to obtain mental healthcare for the psychological consequences of their circumcision experience. While it is absolutely essential that Western physicians not stigmatize those women, some of whom may value and take pride in their circumcision, it is equally important that the medical field take a more vocal stand on the reality of the psychological fallout from FGM. A heated legal debate about whether women who have already undergone FGM should be granted asylum continues. Clinicians should add their voices to this debate, armed with clinical evidence that FGM has serious consequences for physical and mental health.

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Why are we so afraid of vaccines?

Article originally published here

Despite the official retraction of the 1998 Lancet study that suggested a connection between vaccines and autism, as of 2010, 1 in 4 U.S. parents still believed that vaccines cause autism.

This belief is often cited as part of the cause of rising rates of “philosophical exemptions” from vaccines among parents in the U.S. Twenty states allow “philosophical exemptions” for those who object to vaccination on the basis of personal, moral, or other beliefs. In recent years, rates of philosophical exemptions have increased, rates of vaccination of young children have decreased, and resulting infectious disease outbreaks among children have been observed in places such as California and Washington. In California, the rate of parents seeking philosophical exemptions rose from 0.5% in 1996 to 1.5% in 2007. Between 2008 and 2010 in California, the number of kindergarteners attending schools in which 20 or more children were intentionally unvaccinated nearly doubled from 1937 in 2008 to 3675 in 2010. Vaccination rates have also decreased all over Europe, resulting in measles and rubella outbreaks in France, Spain, Italy, Germany, Switzerland, Romania, Belgium, Denmark, and Turkey.

The current outbreak of about 1000 cases of measles in Swansea, Wales is a jarring example of the serious effects of vaccine scares. A little over a decade ago, there were only a handful of cases of measles in England and Wales, and the disease was considered effectively eliminated. Yet after Andrew Wakefield’s discredited study in 1998, measles vaccination rates plummeted, with the lowest levels occurring in 2003-2004. There is evidence that the outbreak may in part be due to parents’ responses to media reporting. There is evidence that medical scare stories affect health behavior in general, and the reporting on MMR has been subjected to a kind of “false balance,” conveying the sense that there is a legitimate and sizeable conflict in the medical community about the dangers of MMR when in reality those touting this “danger” represent a fringe minority.

It is easy to become mired in philosophical and ethical debates about who in these situations has the right to make these decisions. Should parents have the liberty to put their children and other children at risk of contracting often fatal vaccine-preventable diseases? Yet a more immediate question should be: what kinds of communication from doctors and public health officials could realistically assuage parents’ concerns about the risks associated with vaccination? In order to disabuse parents of unfounded notions about risks associated with vaccines, it is vital to understand how most people form perceptions of risk in the first place. Armed with a better understanding of public perceptions of risks associated with vaccination, doctors and public health officials can begin to craft communications strategies that specifically target these beliefs. In other words, we should be applying risk perception theory to the development of communications strategies to encourage vaccination of children.

In 1987, Paul Slovic published a landmark article in Science about how the public conceives of and responds to various risk factors. Slovic emphasized that lay people consistently understand risk differently than experts do. Experts tend to evaluate risk using quantitative measures such as morbidity and mortality rates. Yet the public may not understand risk this way. Qualitative risk characteristics, such as involuntary risks, or risks that originate from unknown or unfamiliar sources, may greatly influence the average person’s valuation of risk.

Risk perception theory may go a long way in explaining why some parents still insist that vaccines cause disorders such as autism in the face of abundant evidence to the contrary. Research into risk perception indicates that vaccines are an excellent candidate for being perceived as high-risk. There are several features of vaccines that align them with features considered high-risk by most people: man-made risks are much more frightening than natural risks; risks seem more threatening if their benefits are not immediately obvious, and the benefits of vaccines against diseases such as measles and mumps are not immediately obvious since the illnesses associated with these viruses—but not the viruses themselves– have largely been eliminated by vaccines; and a risk imposed by another body (the government in this case) will feel riskier than a voluntary risk. Research has shown that risk perception forms a central component of health behavior. This means that if parents view vaccines as high risk, they will often behave in accordance with these beliefs and choose not to vaccinate their children.

An interesting and not frequently addressed question about vaccine anxiety in the U.S. and Europe is how culture-bound these fears are. Can we find the same or similar fears of vaccines in low and middle-income countries? Cross-cultural comparisons might aid us in understanding the entire phenomenon better. Recent, tragic events have demonstrated resistance to foreign vaccine programs in Nigeria and Pakistan, spurred by the belief that vaccines were being used to sterilize Muslim children. In general, however, social resistance to vaccines and fear of vaccines causing illnesses such as autism is less common in low- and middle-income countries, in part because death from vaccine-preventable illnesses is more visible and desire for vaccines is therefore more immediate. There is, however, some evidence that confusion and fear of new vaccines, including doubts about their efficacy, does exist in some low- and middle-income countries. The examples of resistance to polio vaccination programs in Nigeria and Pakistan demonstrate a general belief, also held by many parents in the U.S., that vaccines contain harmful materials and that government officials are either not being appropriately forthcoming with this information or are deliberately covering it up. At the same time, anti-vaccine sentiments, although widespread, are often bound by culture and may even in some cases serve as a proxy for other culturally-based fears. These fears, heterogeneous as they are, are often constructed from local socially- and politically-informed concepts of risk rather than from close analysis of the actual risk data. This is an instance in which understanding how individuals conduct risk analysis might be more helpful than trying to present the actual evidence on the risks of vaccines over and over to a skeptical population. Yet even cross-cultural perspectives indicate that there is something fundamental about vaccines that can stir fear of diverse kinds in people. Although the content of these fears might differ, I would argue that the fundamental cause of fear is the same: vaccines, as man-made, unfamiliar substances injected into the body, are a classic candidate for high risk perception.

Understanding where the persistent fears of vaccination originate is the first step in effectively relinquishing them. Perhaps reminding people of other man-made inventions with crucial benefits would help assuage fears of the “unnatural” vaccine. Whether or not this particular strategy would help is an empirical question that merits urgent scientific enquiry. Isolating the precise elements that constitute irrational fears of vaccination is a vital component of designing effective public health campaigns to encourage parents to immunize their children against devastating illnesses.

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The importance of improving mental health research in developing countries

Originally published at The Pump Handle

In response to the realization that between 16% and 49% of people in the world have psychiatric and neurological disorders and that most of these individuals live in low- and middle-income countries, the World Health Organization (WHO) launched the Mental Health Gap Action Programme to provide services for priority mental health disorders in 2008. This focus on services is essential, but the WHO ran into a significant problem when confronting mental health disorders in the developing world: lack of research made it difficult to understand which mental health disorders should be prioritized and how best to reach individuals in need of care.

In 2011, The World Health Organization (WHO) embarked on a report entitled “No health without research.” The release of the report was recently postponed, but the problem identified by the report remains no less dire. In order to improve health systems in low- and middle-income countries, support for more research in epidemiology, healthcare policy, and healthcare delivery within these countries is essential.

Over the course of the past year and a half, PLoS Medicine has published a series of papers corresponding with this theme. In one paper, M. Taghi Yasamy and colleagues emphasize the importance of scaling up resources for mental health research in particular. This research, they explain, will help policymakers determine directions for improving policy and delivery of mental healthcare. Advancing this research will be challenging, though, because good governance for mental health research in developing countries is lacking.

Some of the most immediate problems with mental health research in developing countries are financial. Most developing countries lack institutions like the National Institute of Mental Health (NIMH) to help fund and structure research. Physicians and mental health professionals often have no incentive to conduct research because providing other health services is much more lucrative. In some cases, as in many countries in Latin America, researchers must fund their own research and experience no financial gain as a result of conducting research.

Yet financial reasons are not the only reasons for lack of mental health research in developing countries. Restructuring medical education could go a long way toward preparing physicians to participate in research. While research is valued as a key part of medical education and success in the United States, research is not a determining factor for getting into residency or achieving academic success in low-income countries. Many physicians-in-training thus encounter a lack of incentive to contribute to research initiatives. Making research a fundamental part of success in medical training could help make universities in low- and middle-income countries the research centers they are in high-income countries.

Even when clinicians and scientists in low- and middle-income countries are able to conduct mental health research, they often find it difficult to publish their findings in prestigious, widely circulating international medical journals. Researchers from developing countries often struggle to meet the requirements of indexed journals because of lack of access to information, lack of guidance in research design and statistical analysis, and difficulty communicating in foreign languages. Researchers in developing countries often work in research centers or universities that are not considered “prestigious” on an international scale and may not garner the attention of international journals. Editors may be more likely to give serious consideration to submissions from authors at big-name universities. Another serious problem with publication of research from developing countries in prestigious medical and scientific journals is the language barrier, with most top journals being English-language. Procuring better translation services for scientists in developing countries could be key in overcoming the dearth of publications from these areas of the world.

Policymakers and providers in developing countries may also struggle to learn about findings published in expensive journals for which their institutions cannot afford subscriptions. Open access policies represent one way to alleviate some of the problems mental health researchers in developing countries confront. Free access to a wider body of research published in highly-regarded journals could vastly improve mental health research in developing countries and help researchers attract the attention of these high-level journals.

Mental health interventions that truly help communities in low- and middle-income countries cannot succeed if data on epidemiology of mental disorders, current problems in the delivery of healthcare services, and evidence-based solutions are not available. A survey of mental health research priorities in low- and middle-income countries in 2009 found that stakeholders and researchers ranked three types of research as most important: epidemiological studies of burden and risk factors, health systems research, and social sciences research. Researchers and stakeholders agreed that attending to the growing problems of depression, anxiety, and substance abuse disorders, among other frequently occurring mental disorders, was dependent on procuring better resources for research.

Improving service gaps in mental healthcare is vital, especially in light of a growing epidemic of mental illness globally. But this work cannot be done without more research to identify the problems and evidence-based solutions that will help bring mental healthcare to all those in need.

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