Archive for the 'globalization' 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.

More from McGill’s Summer Program: The Affliction Film Series

McGill University’s Summer Program in Social and Cultural Psychiatry is not just about the differences between Swedes and Irish. As part of the summer program’s keynote course, Cultural Psychiatry, McGill luminary Laurence Kirmayer includes a number of film clips in the syllabus to give students a chance to observe some of the phenomena that gets diagnosed by psychiatrists using Western psychiatric categories, but may perhaps make more sense by examining the patient’s cultural and historical context.

One of the most striking films shown (so far) comes from Robert Lemelson’s psychiatric anthropology series, Afflictions: Culture and Mental Illness in Indonesia. In “Shadows and Illuminations,” a man presents with visual and auditory hallucinations of Balinese spirits, disorganized behavior and inappropriate dress. His family and neighbors regard him as odd, so it’s not the case that he is just odd to our foreign eyes. Our psychiatric practice tells us to look for schizophrenia. He reports the symptoms began with the death of his daughter, and we think perhaps it is a posttraumatic stress reaction of some sort. He is examined by two traditional healers and a psychiatrist, all of which have their own treatments, but none of which seem to help. Accommodations are made for the man’s behavior in his own home, and he seems to get a little better. Improvement had nothing to do with our diagnosis, or lack thereof.

Each story in the series situates behavior and concepts of illness within the families and societies in which they occur. Not satisfied with biological explanations of these patients’ problems, Lemelson’s films remind us that psychiatric practices have non-psychiatric implications, specifically around family relations, historical meaning-making, and even implications related to the freedom of the individuals with mental health problems.

The Catholic bishops’ exorcism workshop: Distinguishing demonic possession from mental illness

Next week, Catholic bishops from around the US will meet in Baltimore for their general assembly. As happens before many large conferences, this weekend attendees can take a workshop in order to improve their professional skills: the Conference on the Liturgical and Pastoral Practice of Exorcism. Bishop Thomas Paprocki of Springfield, Illinois has organized the workshop in response to a rising number of requests for exorcisms nationally. The Catholic News Service reports that 56 bishops and 66 priests have signed up.

The Catholic News Service report explains that not everyone in the Catholic clergy can do exorcisms:

Under canon law — Canon 1172 specifically — only those priests who get permission from their bishops can perform an exorcism after proper training.

The Catechism of the Catholic Church explains that an exorcism occurs when the church, in the person of an exorcist, asks “publicly and authoritatively” in Christ’s name “that a person or object be protected against the power of the evil one and withdrawn from his dominion.”

Exorcism is rooted in the acts of Jesus Christ:

Scripture contains several examples of Jesus casting out evil spirits from people.

“We don’t think that’s poetic metaphor,” Bishop Paprocki said.

Not surprisingly, there is a fair amount of tongue-in-cheek coverage of the conference in the US press. However, for mental health professionals like myself, the Catholic Church’s response to this increased demand is nothing to laugh at. Reports of spirit possession are commonplace in many parts of the world, and certainly not limited to Catholics — my own experience with people “tormented by demons” comes from work with Muslim refugees from Darfur, Sudan. Although many of us have psychiatric interpretations of these phenomena when we encounter them, we are in minority; there are many more people who are convinced of their supernatural etiology. In other words, for most of humanity, the reasons for odd thoughts and behavior are spiritual, not scientific. The US is one of only a handful of countries in which spiritual explanatory models do not hold sway. In a global perspective, it is the exorcism conference’s media attention and tongue-in-cheek coverage that is notable, and not the topic of exorcism itself.

“Explanatory models” are sets of reasons for why things happen the way they do. Mental health practitioners are often interested in their patients’ explanatory models of their psychological problems in order to treat them more effectively. Reading through media coverage you get the sense that although rooted in a predominantly supernatural explanatory model, the perspective of the US bishops organizing the conference is actually somewhat of a hybrid, combining a concern for spiritual hygiene with a concern for psychological well-being. Although the US may be globally out-of-step in terms the majority’s emphasis on scientific explanations, hybrid spiritual-scientific explanatory models are the norm in our globalized world. In other words, in the US most people tend to emphasize scientific parts of explanations for odd behavior whereas in most other parts of the world most people emphasize spiritual parts, but in reality many people hold both types of explanations for such behavior simultaneously. The New York Times report devotes a fair number of column inches to the difference between “real” possession by the Devil and other possession-like states, and this seems to be the point of the conference:

“Not everyone who thinks they need an exorcism actually does need one,” said Bishop Thomas J. Paprocki of Springfield, Ill., who organized the conference. “It’s only used in those cases where the Devil is involved in an extraordinary sort of way in terms of actually being in possession of the person.

So just what are the symptoms of demonic possession?

Some of the classic signs of possession by a demon, Bishop Paprocki said, include speaking in a language the person has never learned; extraordinary shows of strength; a sudden aversion to spiritual things like holy water or the name of God; and severe sleeplessness, lack of appetite and cutting, scratching and biting the skin.

A person who claims to be possessed must be evaluated by doctors to rule out a mental or physical illness, according to Vatican guidelines issued in 1999, which superseded the previous guidelines, issued in 1614.

(That’s 385 years between guidelines, for those of you who were wondering. The next set of guidelines is presumably due in 2384.)

I think it’s safe to say that most Catholics in the US do not believe that training priests in the proper procedure for exorcisms is a priority in 2010. Some posit that other factors are in play behind the pre-meeting exorcism institute. Notre Dame Professor of Catholic history R. Scott Appleby says that the conference is best explained as a way to bring back those among the flock who have strayed because the church is no longer seen as distinct from other, more secular institutions.

“What they’re trying to do in restoring exorcisms,” said Dr. Appleby, a longtime observer of the bishops, “is to strengthen and enhance what seems to be lost in the church, which is the sense that the church is not like any other institution. It is supernatural, and the key players in that are the hierarchy and the priests who can be given the faculties of exorcism.

“It’s a strategy for saying: ‘We are not the Federal Reserve, and we are not the World Council of Churches. We deal with angels and demons.’ ”

Book review of Crazy Like Us on

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 .

Vikram Patel at NYU, and a genuine global mental health agenda

Last Friday, March 6, the good folks at NYU’s program in Global Public Health hosted a lecture and discussion with global mental health luminary Vikram Patel. Dr. Patel is one of the forces (perhaps the driving force) behind the field of global mental health, and one of the architects of the Lancet’s series on the subject in 2007. This relatively new field combines public health, cross-cultural psychology, and human rights, and seeks to expand concern for mental health disability from it’s purview as a Northern luxury into a worldwide movement. For more general information on the topic, visit

Dr. Patel’s talk at NYU was largely a call to action, as opposed to an empirical evaluation of the field’s successes and failures to this point. This is not to his discredit; Dr. Patel knows of what he speaks. From his groud-breaking work on Shona idioms of distress in his native Zimbabwe to his more recent clinical trials of community health workers’ delivery of mental health services in his family’s homeland India, Dr. Patel is well-steeped in several of the field’s parent disciplines. But Friday’s purpose was to spread the word. Lauding the success of the HIV/AIDS public health movement, Dr. Patel called on public health workers — or at least the public health trainees present — to take up similar strategies to convince public officials and other healthcare workers that mental health must be a priority in the developing South as well as developed North.

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.

This brought a question from the crowd (well, actually a question from me): If 90% of the mental health research is done in the developed North — the place where academics have the technology, funding, and financial interests to do research — and more research needs to be done in the less developed South, how should this be accomplished without running roughshod over local explanatory models of mental distress and local service models that may do some good? Dr. Patel acknowledged that this was a major concern, and provided the following solution: work with and teach local practitioners to do the research.

This simple-sounding solution is actually a tall order. The money and research technology (and here I’m talking about specialized research training as well as computer software) is in the North. The academic motivation for high-quality research is also largely Northern — “publish or perish.” It’s hard to see how NIMH-funded research would not evince a preference for US-led projects. So at the moment, beyond projects that hire locals to collect data, it’s hard to find projects that really substantively involve local ideas and researchers and people schooled and based in the research-resourced North (like the students at NYU last Friday). But there are a few — although very few — projects that fit the bill.

The first is Patel’s own work. Although he holds several professorships throughout the Europe and North America, he is based in Goa, India, and his research is there, and includes local staff. However, until more Vikram Patels arise (which won’t be too long, I think), his remains a special case of a culture-spanning researcher, trained in Northern/Western models and adapting, applying and distributing them throughout the developing world.

The best example of a US-led project is a USAID-funded program out of the Center for Victims of Torture (CVT) in Minneapolis, the International Program Evaluation Collaborative, or IRPEC. The brainchild of Jon Hubbard, the Research director at CVT, IRPEC aims to transfer the technology of empirical research to NGO’s working in mental health and human rights around the world in order better collect and analyze data to improve their services (and, of course, to get grants from Northern foundations which require such information). At this point I should probably disclose that I was an evaluator for IRPEC this past summer (see entries on Cambodia and Peru for related material), and that I was pretty impressed.

During this evaluation Jon told me a story of meeting a researcher who evaluates such programs who asked him, “Okay, but where’s your data?” Jon replied, “It’s not my data. It’s their data.” Until we can take up Hubbard’s example, those of us in the North who work in global mental health will always be in danger of “getting it wrong” — both ethically as well as empirically — in our quest to answer Vikram Patel’s call.

Flying monks, talking turtles, brain tumors: A cautionary tale in cross-cultural medicine from Laos

A few weeks ago, a young woman named Chloe Thomas contacted me in response to the placebo series. She has a fascinating real-life cautionary tale in global health: what the clash between Lao traditional medicine and globalized Western medicine means for a man with a potentially operable brain tumor. No easy answers, stories like these are important in illustrating the sticky points and pitfalls of cross-cultural health care.

Last year when traveling through Southeast Asia I was deeply inspired by the beauty of the people of Laos yet frustrated by their lack of access to basic health services. Small and landlocked, Laos routinely places among the lowest in many health and development indicators. I returned, college idealism in hand, dedicated to help in anyway I could. I found a volunteer opportunity with a NGO in the capital, Vientiane. The NGO’s work attempted to preserve Lao traditional medicine for both its cultural heritage and importance as the sole access to healthcare of any kind for most rural and impoverished populations.

I know many of you reading this may share my initial skepticism, traditional medicine as hokum, an almost ignorant naiveté. But approximately 60- 80% of the global population is dependent on medicinal plants to fulfill primary healthcare needs, and in Africa and Asia, this figure may be upward of 80%. This widespread use is most often attributed to confidence in efficacy, accessibility, and affordability. (For those needing further persuasion, information and/or definitions see the WHO’s Traditional Medicine Strategy.) Furthermore, the use of medicinal plants employed by these various cultures is often the first step in the discovery of bioactive compounds that lead to novel drugs[1] — think artemisinin.

As a medical school aspirant I was eager to explore the evidence-based efficacy of traditional medicinal plants and their potential health benefits, as well as understand different cultural perspectives in medicine. Armed with only a BA and having no experience in either the aid world or ethnomedicine, I was aware I needed to reach out to those more capable of undertaking research and inducing change. Promoting the safety and standardization of plants currently being used was, and should be, a priority. I hungrily began reading, researching, and contacting those in the field.

The first few months proved a crash course in aid politics, grant writing and how to tactfully navigate through the Lao bureaucracy. It was also during this time my Director (whom I will henceforth call Mr. Smith) slowly revealed himself as a self-proclaimed master in Lao traditional medicine (though seemingly without formal, or even informal training). I was not too concerned with this, as over 70% of Laotians routinely use traditional medicine. However, when he continued to talk about his ability in the same sentence with flying monks and talking turtles, and then spoke of his life goal of being able cure the sick by simply walking past them, it became clear that this religious conviction and personal ambition would pose a great challenge to any objective approach I made.

Several weeks later, I checked my email to find an attachment from my Director of the medical record of a mid-twenty year-old, complete with a CT scan noting a mass in the right posterior fossa. The clinical impression relayed to me by Mr. Smith (obtained from the patient) was that this was a brain tumor, which without surgery would give the patient only months to live. Although Mr. Smith admitted that he was told the patient would have a good prognosis with an operation, he insisted that he another local traditional medicine practitioner, they could cure him using solely traditional medicine, and that he wanted me to document the progress.

Most likely the patient sought my boss’s care because they could not afford the operation. If this was the case, I was uncomfortable sitting by idly and watching this vulnerable person be used as a human subject to substantiate an experimental treatment. Human lives should be more precious than tools to validate one person’s conviction or to further their ambitions.

What’s worse still is that if the patient had opted for surgery (assuming he could find the means) and it was unsuccessful, Mr. Smith would no longer accept the patient, citing that the traditional medicine treatment would no longer be effective, almost as if it was out of personal vengeance. Choosing to respect one form of treatment should not mean having to reject the other.

Echoing the South African controversy surrounding traditional treatment for AIDS (involving the now deceased Health Minister Manto Tshabalala-Msimang), a myriad of emotions ran through me, bafflement, hostility, frustration. After a heavily emotional argument in which I pressed that we should at least advocate for funds for the operation if money was the sole determinant in the patient’s choice, my Director accused me of not believing in traditional medicine or his ability to cure.

I am not a doctor and still remain unsure about the accuracy of the diagnosis or the validity of the medical team’s consultation. But, I do realize what I was presented with was irresponsible and potentially fatal. While some plants have shown promise in cancer treatments, too many unknowns still remain for me to allow myself to participate in such a high stakes gamble.

No doubt there has been and will continue to be cases such as this. The ethical implications remain thorny, and literature scant (see here for one of the few articles I have found). With the growing use and recognition of the benefits of traditional medicine systems, there is also a growing need for safety, efficacy, quality and rational use. In fact, nationalization of Lao Traditional Medicine is a goal of the Government, and this would undoubtedly necessitate regulation, standardize treatments and hopefully create a governing body to whom malfeasance can be reported. Professionalization among traditional medicine practitioners would also enable a body of educated primary health care providers in the most rural and remote regions. Unfortunately, discerning the tangible from the intangible in these often religiously contextualized treatments will prove harder still.

It’s a sad reality not every person can afford the care they may desperately need. While I will respect this particular patient’s decision, I will only do so if presented with clear and accurate information on his choice, I will not be involved in a situation in which a patient is mislead by the desire of one person’s goal of attaining supernatural ability. My dilemma left me wondering–when do we admit the most realistic options for medical treatment? What’s the middle ground between Western medicine and traditional systems? Can the two ever co-exist in harmony while still respecting the benefits and fundamental beliefs in both systems? Or are there too many differences, areas of profound misunderstanding that make them perpetually destined for conflict. Perhaps my dilemma was just an example of this.

Apart from this instance, most of my experiences working with traditional medicine were positive, forcing me to revaluate my own perception and views of healthcare and medicine. It was challenging finding the delicate balance between science and religion, and acknowledging that my Western train of thought is just one among many world-views. Though I remain without clear resolve on many of the ethical issues that have arisen with the growing use of traditional medicine and alternative treatments, I hope that with more education will come more clarity. However, what I will take into my medical education is the importance of mutual understanding and respect when treating patients humanely and effectively across cultural chasms, for no matter where I work, there is no doubt that I will continue to work with patients whose healing beliefs greatly differ from my own.

Ms Thomas is originally from California, and a graduate from UC Berkeley (2008) in Molecular and Cell Biology. She is currently in the process of applying for medical school in the United States.


[1] R. Alves et al., “Biodiversity, traditional medicine and public health: where do they meet?” Journal of Ethnobiology and Ethnomedicine (2007), 3:14

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