Archive for the 'development' Category

Refugees, 2013: Changing faces, changing places, changing policies

This week’s Economist has a fine summary of how refugees have grown in number and diversity, and the international community’s response to these changes. Among things to note is the continuing trend observed a few years ago in a JAMA commentary (and critiqued by a skeptic or two… oops) of urban resettlement, which UNHCR now says it prefers to people resettling in refugee camps. UNHCR is also more explicit about its policy encouraging local political integration and even economic development as solutions in long-term refugee crises. These efforts are mirrored by changes in policies of countries who receive the most refugees (overwhelmingly in the developing world).

David Apollo Kazungu, Uganda’s Commissioner for Refugees, says it no longer makes sense to treat refugees as a humanitarian issue. “Those who stay for years throw up developmental problems for us, such as how to find enough land, water and jobs for everyone,” he argues. Uganda has already tried to improve the lot for the nearly 200,000 refugees it hosts by placing them in settlements rather than camps, and by giving them land to farm.

Within this discussion is the acknowledgement that forced migration and voluntary (or economic) migration are not entirely separate phenomena. Read the entire article here.

More evidence that measuring local concepts of distress matters

The latest issue of Psychological Assessment includes an article by University of Pennsylvania postdoctoral research fellow (and soon to be Manhattan College Assistant Professor) Nuwan Jayawickreme that provides support for the use of locally developed distress measures in post-disaster settings that are beyond the cultural boundaries of Western psychology’s usually realm. Are Culturally Specific Measures of Trauma-Related Anxiety and Depression Needed? The Case of Sri Lanka provides empirical evidence suggesting that once locally-developed measures of posttraumatic distress are administered, administering measures of PTSD and depression (as defined by DSM-IV) does not provide any more useful information vis-a-vis an individual’s impairment of day-to-day functioning.

Developing psychological distress measures in non-Western disaster zones has been on the agenda of many in the disaster mental health field for over a decade now. The essential problem is that conceptualizations of mental health problems and the way that different people from different cultures express their distress vary widely. So, when mental health professionals need to assess individuals to see if they need treatment, they need a measure (questionnaire, survey, or some other standard measurement tool) that is sensitive to that population. How  are such tools to be developed? Jayawickreme explains:

Identifying such idioms first need to use ethnographic methods to understand how the social world interacts with the individual’s physical and psychological processes. Such ethnographic studies usually involve an in-depth examination of a specific culture’s conceptualization of a particular experience. Once the concepts and the idioms used by the community in question have been identified, questionnaires or inventories can be developed to assess these concepts, which are then validated using iterative statistical and field testing methods

And that’s what he did. And then he administered this measure, called the Penn/RESIST/Peradeniya War Problems Questionnaire (PRP-WPQ), the PTSD Symptom Scale (or PSS, a standard PTSD scale developed by trauma treatment luminary — and Jayawickreme advisor — Edna Foa) and the Beck Depression Inventory (the BDI, a standard measure of depression) to 197 Tamil Sri Lankans living in the war torn northern and eastern parts of the island. And then he looked at the incremental ability of the PTSD Symptom Scale and the Beck Depression Inventory to predict a measure of functional impairment.

Jayawickreme’s regression analysis showed what some of us have been talking about (and even publishing empirical results on) for a while now: Using measures of psychological distress with local populations that incorporate terms that they can understand is better at getting at the functional impairment due to this distress than using DSM-IV based measures.

The current findings provide support for the notion that sensitive measurement of  psychopathology in non-Western, war affected populations may require the development of instruments that incorporate local idioms of distress. As noted earlier, there are limited resources available for providers of psychosocial aid in non-Western, war-affected countries. Given the considerable needs of such populations, it may seem inappropriate to engage in what appears to be a costly and complicated process to develop measures incorporating local idioms of distress. The current results do indicate that the PSS and the BDI predict functional impairment to a substantial degree. However, the current results also suggest that measures incorporating idioms of distress may improve our ability over and above the established measures to identify those who are functionally impaired because of mental illness and who therefore need assistance.

Recent focus on child soldiers and what the research says

The International Criminal Court (ICC) has made its first ruling, convicting Congolese rebel leader Thomas Lubanga of using children younger than 15 as soldiers. For basic media coverage, see here, here, and here. The conviction if Lubanga is the ICC’s first in its decade of existence, and for those of you interested, the BBC has a decent discussion of the costs, estimated at $900 million, here.

Lubanga could have been accused of any number of war crimes, but the ICC chose to focus on child soldiering (due to the quality of evidence, say prosecutors). The recent Invisible Children anti-Joseph Kony video recently trending on Twitter (no need for a link, I’m sure) chooses to also focus on child soldiering. Clearly this is compelling stuff for the media as well as legal teams, nightmare material for those who love kids and those who fear teenagers. From the sympathetic side we often hear simplistic pronouncements like this one from today’s New York Times:

Social workers say that even if children have enlisted willingly, looking for food, status or protection, they are often still permanently damaged by war-time violence and drugs.

There is, however, a research literature on child soldiers that presents a more nuanced picture. Although certainly former child soldiers suffer higher rates of physical and mental health problems than similar kids, the research suggests that there is more hope for them than is commonly portrayed. The work of Jeannie Annan and Chris Blattman show that there is wide variability in what child soldiering actually entails, and, that former child soldiers — far from being permanently damaged — are more active in peaceful post-conflict political processes than their peers. Theresa Betancourt‘s work shows that symptoms of emotional distress decrease over time among many, and I believe she has plans underway for treatment trials for those with continuing problems. Brandon Kohrt’s work presents (among other things) complex stories of reintegration through film, as well as research articles.

All this is not to say that child soldiering is in some way really not so bad. Making this a cause is indeed appropriate. But there is more to the issue than just crazed violent teenagers and their adult bad guy overlords. Child soldiers become former child soldiers, adults who live lives and can contribute to their societies.

Windshield ethnographers, Human Terrain Teams, and counterinsurgency: Improving the military’s cultural competence

I just finished reading Nathan Hodge’s Armed Humanitarians: Rise of the Nation Builders, about the evolution of the United States’ military’s mission in Iraq and Afghanistan in the last decade. There’s plenty to learn from Hodge, a staff writer at the Wall Street Journal, and the value of the book will be judged, I expect, for its documentation of (1) the massive philosophical changes that occurred within the military in response to instability in the wake of “regime change” in Baghdad and Kabul and (2) the massive outsourcing of military-relevant tasks to security firms, services corporations, and… anthropologists? Anthropologists and related social scientists were all involved in a new tactic, the use of Human Terrain Systems.

In a chapter titled “Windshield Ethnographers,” Hodge introduces us to the Human Terrain System which was based on the idea that “brigade commanders needed social scientists to provide advice” so that they didn’t have to rely on a “library loaded with ethnographic data” when making their rounds establishing alliances with local sheiks and mullahs. Five-person Human Terrain Teams would be embedded with brigades or regiments in order to provide intelligence — or, as social scientists call it, information (there’s some discussion of this in the awkward situations this distinction produced) — on local customs, relations between local leadership, and the little things that can really mess up inter-cultural communication (like an American soldier talking directly to an Afghan woman of the house).

What convinced the military that they should forge alliances with pointy-headed academics? Well, Hodge describes the source as an article by a policy fellow at the Office of Naval Research, Montgomery McFate, published in Military Affairs in 2005. Anthropology and Counterinsurgency: The Strange Story of their Curious Relationship argued that the military should bring in anthropologists and other social scientists in order to serve their new nation building objectives.

Once called “the handmaiden of colonialism,” anthropology has had a long, fruitful relationship with various elements of national power, which ended suddenly following the Vietnam War. The strange story of anthropology’s birth as a warfighting discipline, and its sudden plunge into the abyss of postmodernism, is intertwined with the U.S. failure in Vietnam. The curious and conspicuous lack of anthropology in the national-security arena since the Vietnam War has had grave consequences for countering the insurgency in Iraq, particularly because political policy and military operations based on partial and incomplete cultural knowledge are often worse than none at all.

Essentially, McFate was arguing that in order to succeed militarily against a counterinsurgency, the military had to improve its cultural competence. (There really are too many cynical comments to make at this point — I will refrain… but feel free to contribute in the comments section below.)

Hodge writes well, and he refrains from the holier-than-thou commentary that has become typical in critiques of the US’s blunders in Iraq and Afghanistan. His history is well-sourced, and much of the book is built on his own, first-hand, reporting. Put this on the required reading list for humanitarian aid workers, and maybe for soldiers too.

NIMH, LMICs, & CHIRMH: Funding for global mental health research

Back in March of this year I wrote about Vikram Patel’s call for more international mental health research:

As for research, Dr. Patel noted that 90% of mental health research is done in the developed North (and within that, most in the US), and insisted that that must change. Research must guide practice in order to avoid the mistake of simply applying US or European models elsewhere. Along these lines, he pointed to recent funding interest in global mental health, even by the US’s NIMH (specifically, a recent blog post by director Thomas Insel titled “Disorders without Borders” — good grief!), a research body not known to fund many international projects.

Since then the National Institutes for Mental Health (NIMH) has come up with more than just ominous blog titles. As I was trolling program announcements (“PAs” — the mechanism by which the National Institutes of Health says to researchers what they are really interested in paying for) earlier today I stumbled across several intended to fund research outside of the global North (that’s North America and Europe), or in the language used in these PAs, “LMICs” — “low- to middle-income countries.” Most of these were offered in a variety of funding amounts, from $50,000 to $250,000 (US dollars) per year over 2-5 years.

Here a a few. There’s the basic public health PAR-10-278: Global Research Initiative Program, Basic/Biomedical Sciences, intended to

promote productive development of foreign investigators from low- and middle-income countries (LMICs), trained in the U.S. or in their home countries through an eligible NIH funded research or research training grant/award.

For neurologists there’s PAR-11-031: Brain Disorders in the Developing World: Research Across the Lifespan, which

encourages exploratory/developmental planning grant applications proposing the development of innovative, collaborative research and research training projects, between high income country (HIC) and low- to middle-income country (LMIC) scientists, on brain and other nervous system function and disorders throughout life, relevant to LMICs.

There’s even an ethics PA: PAR-10-174: International Research Ethics Education and Curriculum Development Award,

applications from institutions/organizations that propose to develop masters level curricula and provide educational opportunities for developing country academics, researchers and health professionals in ethics related to performing research involving human subjects in international resource poor settings.

(Not a bad idea for folks in the North involved in international research either, I might add.)

By far the biggest news among these titles is the new RFA-MH-11-070: Collaborative Hubs for International Research on Mental Health (U19). “U series” grants (look at the “U19” in parentheses at the end of the title) are meant to pay for academic infrastructure — scholarly institutes and centers that produce a lot of research and are thought to be indicators of universities’ general research prowess. Here’s the full “purpose” section:

The National Institute of Mental Health invites applications to establish Collaborative Hubs for International Research on Mental Health (CHIRMH).  This program aims to establish three regional hubs to increase the research base for mental health interventions in World Bank designated low- and middle-income countries (LMICs) through integration of findings from translational, clinical, epidemiological and/or policy research.  Each regional hub is to conduct research and provide capacity-building opportunities in one of six geographical regions (i.e., East Asia and the Pacific; Europe and Central Asia; Latin America and the Caribbean; Middle East and North Africa; South Asia; Sub-Saharan Africa).  The purpose of the CHIRMH program is to expand research activities in LMICs with the goal of providing the necessary knowledge, tools, and sustainable research-based strategies for use by government agencies, non-governmental organizations, and health care institutions to reduce the mental health treatment gap.  The mental health treatment gap refers to the proportion of persons who need, but do not receive care.  As a group, awardees will constitute a collaborative network of regional hubs for mental health research in LMICs with capabilities for answering research questions (within and across regions) aimed at improving mental health outcomes for men, women, and children.

The treatment gap for mental disorders across the world is large and leads to chronic disability and increased mortality for those affected.  Research is needed to identify effective treatment and prevention strategies to close this gap. Mental health research that ultimately enables effective services to preempt, prevent, and treat mental disorders requires both infrastructure and partnerships.  Tackling the urgent challenges of the treatment gap demands effective collaborations among researchers, mental health service users, mental health service providers, and government agencies that will implement and sustain services.  Therefore, a goal of this FOA is to support research partnerships and activities in LMIC settings that will stimulate research to address the prevention and treatment of mental disorders and ultimately increase the evidence base for mental health interventions.

Notably, the PA states that “This program is not intended to support research that can be conducted primarily in and/or by United States or other high income country institutions.” This has the potential to be the start of something big, a US-funded development effort for global mental health. The NIMH is committing $2 million to this effort in 2011, and applicants are eligible for awards up to $500,000 per year for up to 5 years. (Letters of intent are due December 21 and applications due January 21, 2011, for those of you thinking about applying.)

Randomistas, development economics, and the poetry of evaluation

Last week’s New Yorker featured an engaging portrait by Ian Parker of MIT development economist Esther Duflo, perhaps the leading light among that field’s “randomistas.” These (mostly) young economists have made their mark on their profession by applying randomized control trials (borrowed from medicine) to development strategies. This really shouldn’t surprise anyone — randomized control trials have been used for other types social programs (e.g., delinquency prevention) for years now, and given that economics is about human behavior it’s surprising that economists haven’t embraced this earlier.

Also familiar to behavioral scientists are the objections to assigning participants at random to experimental and control groups.

“You shouldn’t be experimenting on people.” O.K., so you have no idea whether [your programs] work–that’s not experimental?

The former is met far to infrequently with the latter. Someone comes up with an idea for some intervention, they announce their intentions and put that idea into practice, and all of a sudden it is accepted as the right thing to do… and to test whether it works better than doing nothing (which really means “better than engaging the variety of things people do that you don’t know about”) thus becomes the wrong thing to do. That’s some sloppy ethics, at best.

The one objection to randomized control trials mentioned in the article that might hold water is that an intervention shown to be empirically supported in one context might not be empirically supported in another due to variation in ecological and temporal phenomena. Of course, the logical solution is more experimentation, not less. In their psychosocial programs in the Democratic Republic of Congo, the Center for Victims of Torture has instituted what Research Director Jon Hubbard calls “rolling control groups” to address the problem of changing context. The situation in conflict zones is often very fluid, and so if a program is shown to be better than doing nothing during one intervention period (6 weeks for CVT’s program) that doesn’t mean that it will be better during the next. So Hubbard came up with the rolling control: at the beginning of each intervention period, the program accepts and screens 125% of their capacity, then randomly assigns 25% to a wait list control; after the intervention period they give post-tests for each group, viola! They have a small-scale randomized control trial that shows their funders that they are monitoring the effectiveness of their programs for each cohort.

The article on Duflo ends with a couple paragraphs on the art of the evaluator’s profession that I found particularly striking — but admittedly, maybe only a data nerd like myself would love:

“It can’t only be the data,” Duflo said, showing a rare willingness to generalize. “Even to understand what data means, and what data I need, I need to form an intuition about things. And that process is as ad hoc and impressionistic as anybody’s

It can’t only be the data, but there must be data. “There is a lot of noise in the world,” Duflo said. “And there is a lot of idiosyncrasy. But there are also regularities and phenomena. And what the data is going to be able to do–if there’s enough of it–is uncover, in the mess and noise of the world, some lines of music that may actually have harmony. It’s there, somewhere.”

Book review of Crazy Like Us on STATS.org

STATS is an organization that examines the reliability and validity of quantitative findings in social science and medicine for laypeople, specifically journalists. Today they feature a book review of Ethan Watters’ Crazy Like Us: The Globalization of the American Psyche, by none other than yours truly. Here’s a teaser:

those of us who work in the small corner of mental health research that examines the differences in diagnoses and symptoms between cultures are somewhat surprised by Crazy Like Us; our field, generally, remains well hidden in the crease between psychology and anthropology. That our first popular treatment should be a highly critical survey of this field of mental health is doubly shocking.

Keep reading, here .


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