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watters_chapter.pdf
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Annals of Global Health, VOL. 82, NO. 3, 2016
M a y eJ u n e 2 0 1 6 : 5 3 2 – 5 7 4
New and Emerging Priorities for Global Health
Funding: Indian Council for Medical Research.
Abstract #: 2.071_NEP
One community at a time
R.J. Bischoff 1, P.R. Springer1, N.C. Taylor1; 1University of NebraskaLincoln, Lincoln, NE, USA
Program/Project Purpose: Mental health conditions continue to
be one of the leading causes of disability worldwide. This is largely
because adequate mental health care is not readily accessible in many
parts of the world, including in many parts of the U.S. These disparities in access to care are the result of a complex interplay between
availability of mental health care providers, affordability of care,
and additional factors that influence the perception and acceptability
of mental health care (e.g., stigma, culture, policy). Solutions that
work must address this complexity. The purpose of this program
was to develop a community partnership model to reduce mental
healthcare disparities that address the complexity of challenges faced
by underserved communities, locally and globally.
Structure/Method/Design: Funded through a grant from the
USDA, we have developed a model for reducing mental health
care disparities around the world one community at a time. We
used rural towns (<2500; designated as Mental Health Care Professional Shortage Areas) in the U.S. as laboratories for the mental
health care disparities problem worldwide. Our innovative model
emphasizes working within the local cultural context to a) build
community capacity to make a difference by mobilizing existing
resources, b) collaborate with local medical providers, and c) determine sustainable ways to increase access and acceptability to mental
health care (including telemental health).
Outcome & Evaluation: Through the collection of qualitative and
quantitative data from patients, medical providers, and staff at enduser sites, we evaluated the feasibility of the model. Five years after
its implementation, we interviewed members of the communities in
which the model was used to determine principles that facilitated
sustainability. Key findings of both the feasibility and sustainability
study will be presented.
Going Forward: The application of this model has implications for
addressing global mental health disparities. We have increased the
scale of the project globally as we are implementing the model in Brazil
and are in discussions with other global partners in Portugal and
Australia; demonstrating how local solutions can have global impact.
Funding: USDA Challenge Grant (2009).
Abstract #: 2.072_NEP
Hepatitis C Treatment Outcomes in Kigali, Rwanda
S. Taylor1, R. Simango1, Y. Ogbolu1, R. Riel1, D.J. Riedel2,
E. Musabeyezu3; 1Office of Global Health, University of Maryland
School of Nursing, Baltimore, MD, USA, 2Institute of Human Virology
and Division of Infectious Diseases, University of Maryland School of
Medicine, Baltimore, Maryland, USA, 3Department of Internal
Medicine, King Faisal Hospital, Kigali, Rwanda
Background: Existing research on hepatitis C virus (HCV) treatment outcomes in sub-Saharan Africa is very limited. This study
was undertaken to determine the HCV sustained virologic response
(SVR) 24 weeks after treatment completion and the frequency and
severity of adverse events in patients undergoing HCV therapy in
Kigali, Rwanda.
Methods: The study was a retrospective review study of all patients >
18 years old treated for HCV with ribavirin and interferon combination therapy at King Faisal Hospital in Kigali, Rwanda from January 1,
2007 to December 31, 2014. Patient’s paper and electronic charts were
reviewed for data collection. Approval for the study was obtained from
the University of Maryland Institutional Review Board and King
Faisal Hospital K-Ethics and Research Committee.
Findings: The study included 69 patients; 52% were male, and
the median age at the start of treatment was 48 years (range 2569). The majority of patients had HCV Genotype 4 (61%) and
<2% of patients had genotypes 1, 2, 3, or 5 (33% unknown genotype). Sustained virologic response 24 weeks following completion
of treatment was 32%. 57% relapsed after six months, and 12% of
patients had unknown outcomes. The most frequent side effects
included headache (56%), fatigue (51%), and non-abdominal
pain (49%). The most common adverse laboratory values were
neutropenia (94%), thrombocytopenia (39%), and anemia (30%).
Three patients (4%) died following treatment (causes of death
unknown).
Interpretation: Sustained virological response of patients in this
study was lower than in other studies conducted in sub-Saharan Africa.
Cytopenias were the most frequent side effects and were consistent
with other studies. More comprehensive studies on HCV care and
treatment outcomes with the new direct acting antivirals will need to
be completed as these drugs become available in Rwanda.
Funding: None.
Abstract #: 2.073_NEP
Challenges and strategies for implementing mental health
measurement for research in low-resource settings
R.L. Tennyson, C. Kemp, D. Rao; University of Washington, Seattle,
USA
Background: The gap between need and access to mental health
care is widest in low-resource settings. Health systems in these
settings devote few resources to the expansion of mental health
care, and mental health is missing from the agenda of most global
health donors. This is partially explained by the paucity of data
regarding the nature and extent of the burden of mental illness in
these settings. The accurate and comparable measurement of this
burden will be essential to advocating for, developing, and implementing appropriate policies and services for mental health in
low-resource settings. This study surveys the unique challenges associated with measurement of mental health in these settings globally,
and proposes a framework for use by future implementers.
Methods: We reviewed the literature on mental health measurement in low-resource settings, focusing on studies that have attempted to adapt valid, reliable assessment tools from high-resource
settings and implement them in low-resource settings. We also
collected case studies from researchers in the field who have direct
experience in this area.
Annals of Global Health, VOL. 82, NO. 3, 2016
M a y eJ u n e 2 0 1 6 : 5 3 2 – 5 7 4
Findings: We first outline an approach that uses qualitative data to
adjust existing, validated assessments so that they directly reflect the
psychosocial constructs of the new target population, and so that
they are more easily implemented in that context. We then describe
the incorporation of cognitive interviews to ensure understanding
and agreement in items between researchers and participants. Lastly,
we outline an efficient method for improving the reliability of measures
through the careful training and supervision of research teams.
Interpretation: Inaccurate estimation of the prevalence of mental
illness, as well as misunderstandings regarding its etiologies and
expressions, are associated with unnecessary costs to the health
system and to people living with mental illness. Researchers interested in accurately measuring the mental health burden in a lowresource setting must carefully modify validated assessment tools.
By adhering to at least one of the strategies outlined in this study,
researchers will improve the reliability and validity of their assessments, leading to improved understanding of the burden of mental
health in the settings where action is most needed.
Funding: None.
Abstract #: 2.074_NEP
Estimation of unmet need for inguinal hernia repair among
infants in low- and middle-income countries
R. Tessler1, S. Gupta1, W. Stehr2, E.A. Ameh3, B. Nwomeh4,
A. Kushner5,6,7, D. Rothstein8; 1UCSF East Bay Department of
Surgery, Oakland CA, USA, 2UCSF Benioff Children’s Hospital
Oakland, Oakland, CA, USA, 3National Hospital, Abuja, Nigeria,
4
Nationwide Children’s Hospital, Columbus, OH, USA, 5Society of
International Humanitarian Surgeons/Surgeons OverSeas, New York,
NY, USA, 6Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, 7Columbia University, Department of Surgery, New
York, NY, USA, 8Women & Children’s Hospital of Buffalo, Department
of Surgery, Buffalo, NY, USA
Background: Inguinal hernias in infants are common and usually
mandate semi-urgent repair in high-income countries. With an estimated two to five billion people worldwide lacking access to prompt
and safe surgical care, many of these hernias go un-treated, particularly in low- and middle-income country (LMIC) settings. There is
a paucity of data regarding the global burden of this problem. The
goal of this study is to estimate the incidence of inguinal hernias in
infants in LMICs, extrapolate rates of incarceration, and estimate
the impact of providing universal hernia repair.
Methods: Estimates of annual live births in LMICs (135 million),
incidence of infant inguinal hernia (3-5%), incarceration frequency
(10-30%), and percentage of the population lacking access to
surgical care (28%-70%) were used to calculate the annual volume
of inguinal hernias in infants in LMICs without access to adequate
surgical care. Disability adjusted life years (DALYs) averted were
calculated using the estimate of 5.7 per repair in LMIC settings.
Findings: Of the 135 million annual live births in LMICs, an estimated 4.05 to 6.75 million will present with an inguinal hernia in
the first year of life. Of these, 1.13 to 4.73 million may go untreated
due to lack of access to surgical care. Between 405,000 and 2.03
million hernias will incarcerate, leading to associated complications,
New and Emerging Priorities for Global Health
563
including death. An estimated 6.46 to 26.9 million DALYs could
be averted by timely repair.
Interpretation: A large unmet need for inguinal hernias exists for
infants in LMIC settings. With increasing success in efforts to reduce
mortality in children under the age of 5, the incidence of inguinal
hernia will likely increase. Efforts to improve data collection and
increase resources may help reduce preventable deaths and disabilities.
Funding: None.
Abstract #: 2.075_NEP
Impact of access to cesarean section and safe anesthesia on
maternal mortality ratio in low-income countries: A new
reality in the post 2015 era
S. Thomas1, J. Meadows2, K.M. McQueen3; 1University of Tennessee
Health Science Center, Memphis, TN, USA, 2Touro College of Osteopathic Medicine, New York, NY, USA, 3Vanderbilt University, Nashville, TN, USA
Background: Despite global efforts to reduce the maternal
mortality ratio (MMR) through the WHO Millennium Development Goal 5 (MDG#5), MMR remains unacceptably high in
Low-income countries (LICs). Maternal death and disability from
hemorrhage, infection, eclampsia, and obstructed labor, may be
averted by timely cesarean section (CS) and safe anesthesia. Most
LICs have CS rates less than that recommended by the World
Health Organization (WHO). Without access to CS, it is unlikely
that MMR in LICs will be further reduced. Our purpose was to
measure the MMR gap between the current MMR in LICs and
the MMR if LICs were to raise their CS rates to the WHO recommended levels (10-15%).
Methods: This model makes the assumption that increasing the
CS rates to the recommended rates of 10-15% will similarly decrease
the MMR in these LICs. World Health Organization health statistics were used to generate estimated MMRs for countries with CS
rates between 10-15% (N¼14). A weighted MMR average was
determined for these countries. This MMR was subtracted from
the MMR of each LIC to determine the MMR gap. The percent
decrease in MMR due to increasing CS rate was calculated and
averaged across the LICs.
Findings: We found an average 62.75%, 95%CI [56.38, 69.11%]
reduction in MMR when LICs increase their CS rates to WHO
recommended levels (10-15%).
Interpretation: Maternal mortality is unacceptably high in LICs.
Increasing CS rates to WHO recommended rates will decrease
the maternal mortality in these countries, significantly decreasing
the mortality ratio toward the projected MDG#5.
Funding: None.
Abstract #: 2.076_NEP
Impact of HIV on postpartum hemorrhage in South Africa
A. Thrasher1, M. Sebitloane2, N. Robinson1; 1University of Illinois at
Chicago, Chicago, IL, USA, 2University of KwaZulu-Natal, Durban,
KZN, South Africa
4
Rethinking Psychiatry
are constrained by history and culture as much as by biology. Indeed, in
the c'Oncepts of anthropology, biology, hLstory, and culture are deeply interwoven.
In the chapters that follow I will apply this framework of cultural criticism to psychiatric research and practice. The attempt to apply psychiatric
Chapter 1
categories, so profoundly influen(:ed by W e..stern cultural premises, to nonWestern societies .is dramatically illustrated in cross-cultural research, the
suhjL>cl of the first thri,~ chapters.
What Is a Psychiatric
Diagnosis?
Disease is not a fact, but a relationship and the relationship is the product of
classificatory process . .
Bryan S. Turner,
The Body and Society
What other taxonomies might revolutionize our view-for taxonomies are
theories of order?
Stephen jay Gould,
Animals and us
Individuals are types of themselves and enslavement to conventional names and
their associations is only too apt to blind the student to the facts before him.
The purely symptomatic forms of our classifications are based on the expressive
appearances that insanity assumes according to the temper and pattern of the
sub;ect whom it affects. In short, individual subjects operate like so many
lenses, each of which refracts in a different angular direction one and the same
ray of light.
William James, cited in Eugene Taylor:
William James on Exceptional Mental States,
The 1896 Lowell Lectures
I am sitting in a small interview room at the Hunan Medical College in
central China. It is August 1980 and the temperature is over 100
}>Cdegrt!€5. I am sweating profusely and so is the patient I am interviewing,
pallid, 28-year-old teacher at a local primary school in Changsha
•’ ‘ «•hn•oA name is Lin Xiling. 1 Mrs. Lin, who has suffered from chronic headfor the pa.o;t six years, is telling me about her other symptoms: dizzitiredness, easy fatigue, weakness, and a ringing sound in her ears.
:She has been under the treatment of doctors in the internal medicine clinic
5
Rethinking Psychiatry
What Is a Psychiatric Diagnosis?
of the Second Affiliated Hospital of the Hunan Medical College for more
than half a year with increa.”>ing symptoms. They have referred her to the
psychiatric clinic, though against her objections, with the. dia~osis of
neurasthenia. 2 Gently, sensing a deep disquiet behind the tight hps and
she has put these suicidal ideas to the side and has made no plans to kill
herself.
6
mask-like squint, I a.o;k Mrs. Lin if she feels depres.o;;ed. ‘”Ye,..o;;, I am unhappy,” she replies. “My life has been difficult,” she quickly adds as a justification. At this point ‘Mrs. Lin looks away. Her thin lips tremble. The
brave mask dissolves into tears. For several minutes she continues sobbing;
the deep inhalations reverberate as a low wail.
After regaining her composure (literally reforming her “face”), Mrs ..Lin
explains that she is the daughter of intellectuals who died during the Cultural Revolution while being abused by the Red Guards, 3 She and her four
brothers and sisters were dispersed to different rural areas. Mrs. Lin, then
a teenager, was treated harshly by both the cadres and peasants in the
impoverished commune in the far north to which she wa.•; sent. She could
not adapt to the very cold weather and the inadequate diet. After a year
she felt that she was starving;, and indeed had decreased in weight from
1 It) to 90 pounds, She felt terribly lonely; in five miserable years her only
friend was a fellow middle school student with a similar background from
her native city, who shared her complaints. Finally, in the mid-seventies
she returned to Changsha. She then learned that one of her sisters had
committed suicide while being “struggled” by the Red Guards, and a
brother had become paralyzed in a tractor accident. Three times Mrs. Lin
took the highly competitive entrance examinations for university education, and each time, to her great shame, she failed to achieve a mark high
enough to gain admission. 4 Two years before our interview, she married
an electrician in her work unit. The marriage was arranged by the unit
leaders, Mrs. Lin did not know her husband well before their marriage,
and afterward she discovered that both he and his mother had difficult,
demanding, irascible personalities. Their marriage has been characterized
by frequent arguments: which end at: tim€’~’> with her husband beati~g her,
and her mother-in-law. with whom they live, attacking her for bemg an
ungrateful daughter-in-law and incompetent wife. Both husband and
mother-in-law hold her responsible for the stillbirth of a nearly full-term
male fetus one year before.
Over the past two years, Mrs. Lin’s physical symptoms have worsened
and she has frequently sought help from physicians of both biomedicine
and traditional Chinese medicine. When questioned by me, she admits to
more symptoms-,-difficulty with sleep, appetite, and energy, as well as
joylessness, anxiety, and feelings that it would be better to be dead,
has an intense feeling of guilt about the stillbirth and also about not being
able to be practically helpful to her paraplegic brother, During the
six months she has developed feelings of hopelessness and helplessne;s,
well as self-abnegating thoughts. Mrs. Lin regards her life as a failure.
has fleeting feelings that it would be better for all if she took her life,
7
From Mrs. Lin’s perspective, her chief problem is her “neurasthenia.”
She remarks that if only she could be cured of this “physical” problem and
the constant headache, dizziness, and fatigue it creates, she would feel
more hopeful and would be better able to adapt to her family situation,
, Fo: a ~orth Amencan psychiatrist, Mrs. Lin meets the official diagnos~Ic cn~ena for a major depressive disorder. The Chinese psychiatrists who
mtervwwed her with me did not agree with this diaguosis, They did not
deny ~hat she was dep~essed, but they regarded the depression as a manif~statwn of neurasthema, and Mrs. Lin shared this viewpoint. Neurasthema:-a syndrome of exh~ustion, weakness, and diffuse bodily complaints
beheved to be caused by madequate physical energy in the central nervous
system- is an official diagnosis in China; but it is not a diagnosis in the
American Psychiatric Association’s latest nosology.
For the anthropologist, the problem seems more that of demoralization
as a s~rio~s l~fe distress due to obvious social sources than depression as a
~syclu~tnc disease. From the anthropological vantage point, demoralizati~n m1ght. also be conceived as part of the illness experience associated
;:~.:he d1se~~· neurast~enia or depression. U~llness_rlf~£$J.Q _ th~ .P~~
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~t m~erp~eta~wn differs systematically for those professionals
who~ onentatwn ts dtfferent. And other social factors-such as clinical
speCialty, institutional setting, and, most notably in Mrs. Lin’s case the
distinctive culhual backgrounds of the psychiatrists-powerfully influ’ence
the mt~rpretahon. Th~ interpretation is also, of course, constrained by
Lm s actual expenence. Psychiatric diagnosis as interpretation must
“‘<,,meet son~e res~stance in l~ved experience, whose roots are deeply personal
and physwlogiCal. .The dtagnosis does not cre ...
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