Posts Tagged 'development'

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.

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 .

Richer refugees living in cities? A review of refugee trends presented in the Lancet

The Lancet’s special issue on Violent Conflict and Health (featured in the last three posts in this blog) includes required reading for refugee professionals examining trends in health-care needs among conflict-affected populations. The article, “Health-care needs of people affected by conflict: Future trend and changing frameworks,” is a collaborative effort between researchers at the UN High Commissioner for Refugees, the London School of Hygiene and Tropical Medicine, and the International Rescue Commission.

Recent trends include an increase in internally-displaced persons and a decrease in refugees — essentially due to an increase in intrastate conflicts. The concept of refugees fleeing across borders to escape wars between armies is old hat. Much more likely now is the armed conflict that happens within regions of countries, leading primarily to internal displacement. The best example of this is in a nation not often thought of in the refugee cannon. Currently, this country in home to the largest displaced population in the world… Give up? Colombia.

Two trends cited by the paper are worth thinking about a little bit: (1) the urbanization of refugees and (2) higher baseline development index of refugees’ countries of origin.

The urbanization of refugees refers to those people who flee their country and settle in cities rather than in refugee camps. You can think of Somalis in Nairobi (Kenya) and  Zimbabweans in Johannesburg (South Africa). Here’s a chart from the article showing the trend in the growth of urban refugees, 1996-2008. The aqua bar at the bottom is the number of refugees in camps, the next bar (is that khaki?) is the urban population, and the olive bar is the number in rural areas.

Where Refugees Live

Note the jump in the middle bar between 2005 and 2006 on to 2007. What major refugee crisis was coming to head these years? Well, the second largest refugee population in the world (1.9 million last I checked) was from Iraq, and many many many of those are in Damascus, Syria, and Amman, Jordan. So, the urbanization of refugees is certainly a trend in terms of numbers, but this chart doesn’t really tell us much beyond the fact that the Iraq War resulted in a large urban refugee population in neighboring countries. As Iraqis return home (as many have been doing for a year or so now) we shall see whether the urbanization trend is as strong as this article contends.

My guess is that urbanization of refugees is increasing, but that if you removed Iraqi refugees from these data, urbanization would be increasing at a lot slower rate than it appears here (perhaps at the rate urbanization is increasing in general). In any case increasing urbanization of refugees means that aid groups need to shift their strategies for needs assessment and service delivery; a group of refugees that is living dispersed throughout a city is much harder to find and help than a group living enclosed within the well-defined confines of a camp.

Contrast this with the trend examining the increasing baseline development index of refugee “sending countries” (i.e., the socioeconomic status of places where refugees flee has been increasing over time). Here the authors used the “human development index,” or HDI, presented in the chart below. The blue bar indicates refugees from “low human development” countries, the khaki from “medium and high development” countries.

HDI of Refugee Sending Countries

Here too we should think about how Iraq fits into this trend, as Iraq was a relatively well-developed country until recently. Note the general annual decrease of the blue bars from 1993 to 2008; here it looks like there was a trend before the emergence of the Iraqi refugee crisis, and so these data seem to present a more reliable trend than urbanization.

Note here that the HDI is a measure of countries, not people. This matters becasue it’s often the poorest who become refugees. For instance, Sudan has a moderate HDI (lots of oil, decent roads in the north), so the destitute farming refugees from Darfur or the rural cattle herders from the South would be evidence of this trend. It’s not the case that refugees are getting richer, only that the nations they flee from are richer. Indeed, there may be evidence in there somewhere for the hypothesis that an increasing income gap between richer and poorer is an important predictor in modern refugee-producing conflicts.

The globalization of American psychology

I know it’s bad form, but I’m going to quote myself, from yesterday’s entry:

For those of us who are trained in the US system and interested in global mental health, I can’t think of anything more important than developing a critique of our own failures. Let’s not globalize American medication or our rejection of empirically supported treatments.

And today, I open up my New York Times magazine, and voila: The Americanization of Mental Illness. (Am I controlling the New York Times through my blog?)

Ethan Watters presents a summary of his soon to be released book “Crazy Like Us: The Globalization of the American Psyche” and it’s worth a read. I won’t rewrite the whole piece here, but his essential argument is the good faith efforts of Euro-American mental health care practitioners is serving to change how people in other cultures view non-normative behaviors, and that’s not all good. He makes it clear that he is not belittling mental illness or the suffering that accompanies it, and that he respects Western medical science’s contribution to examining the mechanisms of mental illness. Here’s his follow-up:

Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Thoe stories, whether they rely on spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways… mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits, and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

This is good cultural psychology, and it’s great to see it’s getting fair play. Watters goes on to present research showing that the mental health literacy movement’s push to destigmatize schizophrenia by presenting it as a “brain disease” actually has the opposite effect, and how the medicalization of mental illness (as opposed to viewing it as a psychosocial problem) can result in the formation of a sufferer identity rather than as someone suffering from an affliction.

I encourage you to read the article, but I can’t resist a few quotes here. A Chinese psychiatrist is interviewed about an epidemic of Western-style anorexia in Hong Kong, and sums up the larger problem thusly:

As Western categories for diseases have gained dominance, micro-cultures that shape the illness experiences of individual patients are being discarded… The current is too strong.

Describing the anemic section of the DSM-IV given to non-Western mental illness categories:

Illnesses found only in other cultures are often treated like carnival sideshows. Koro, amok and the like can be found far back in the American diagnostic manual (DSM-IV, Pages 845-849) under the heading “culture-bound syndromes.” Given the attention they get, they might as well be labeled “Psychiatric Exotica: Two Bits a Gander.”

And here’s the kicker, on our exporting the culture that Judith Warner discussed yesterday:

The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence. These ideas remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as the many self-help philosophies and schools of therapy that have encouraged Americans to separate the health of the individual from the health of the group. These Western ideas of the mind are proving as seductive to the rest of the world as fast food and rap music, and we are spreading them with speed and vigor.


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