Mobilizing resilience in conflict affected areas and humanitarian emergencies Joop de Jong MD, PhD Em. Professor of Cultural Psychiatry and Global Mental Health VU University Adjunct Prof of Psychiatry Boston University AISSR, University of Amsterdam [email protected]

Pathways to Resilience III: beyond nature vs nurture Halifax 2015

Talk is based on experience combining interventions and research among adults and children in a variety of cultures               

Afghanistan Algeria Angola Bangladesh Bosnia Burundi Bhutan Cambodia China Eritrea Ethiopia Gaza Guinea Bissau Haiti India

              

Indonesia Kosova Mozambique Namibia Nepal Netherlands Philippines Rwanda Senegal Sri Lanka Sudan Surinam South Africa Swaziland Uganda

The appalling state of affairs in global mental health %

Burden

Mental health budget

Treatment Fys/Men

Budget residential

Aftercare

LIC

7,9

0,5

48

6

73

7

21,4

5,1

65

24

54

45

LMIC HMIC

HIC

* Often worse for child and adolescent mental health • Development Assistance for Health 1990-2007 from 5.6 to 21.8 billion dollar, but not to mental health (IHME, 2010)

Why public mental health? defined as the discipline, the practice and the systematic social actions that protect, promote and restore mental health of a population

Other factors influencing treatment gap (next slides)

Impact political violence (PV), war and disaster (D) (next slide)

Lack of professionals Reservoir of human capacity (next slide)

Effect Psychotherapy* Universal variables 30% Contextual variables 40% *Asay, T.R, & Lambert, M.J. (1999). The empirical case for the common factors in therapy: Quantitative findings. Washington: American Psychological Association.

Technique 15% Placebo 15%

Human resources for mental health

PV

D D

D PV

PV D

PV

PV

D

High vs Low and Middle income countries: Political Violence – involvement 1 : 10 Cyclones/hurricanes: 3 : 1 but casualties 8 :10 Refugees: 1 billion  1 :12 to west 1:5 to other LMIC, 75% as IDP in own country

Treatment gap in peace time versus war and disaster Situation in times of peace

•

• Burden of Mental Disease in LMIC (11%) > contribution tb, HIV/ AIDS and malaria

9/11

Post-disaster:

Post-disaster:

treatment gap larger

treatment gap larger

Service delivery factors

Beneficiary factors

• Few resources (infrastructure, human, policies)

• Expression psychopathology (depression, anxiety, ptsd, idioms of distress)

• Even less professionals: exodus (Al, Ir, Afg), or genocide (C, Rwan)

• Different explanatory models eg

• Delivery models not prepared for mass stress, due to social or colonial history (eg Soviet)

• Suffering experienced in spiritual, religious, family, community terms

• Psychologists little training in (trauma-focused)therapy (e.g. China, Algeria)

• Survivors belong to different ethnic group than providers

• Survivors in rural areas, intellectuals in cities • State sector weak: private practice at the expense of the public sector and the rural areas

Six major challenges Challenge 1 Prevention model • Translate risk, protective and resilience factors into multi-sectoral, multi-modal and multi-level preventive interventions involving the economy, governance, military, human rights, agriculture, health, and education • Apply them in an integrative way in emergency, rehabilitative and reconstructive interventions, moulded to historic, political-economic and sociocultural context

Rose’s classical curve applied to conflict, mh

SOCIETY-AT-LARGE or (INTER)NATIONAL

COMMUNITY

FAMILY & INDIVIDUAL

UNIVERSAL PREVENTION

Economy, governance and early warning Free media and press Resolve underlying root causes of violence (Inter)national laws Defining and condemning human rights violations Expanding security institutions Military’s role of last resort Reinforcing peace initiatives and conflict resolution Arms and landmine control Prevent the reemergence of violence Humanitarian operations War tribunals and the persecution of perpetrators Peace-keeping forces Human rights advocacy

Rural development and food production Community empowerment Decreasing dependency and learned helplessness Public health and education Peace education and conflict resolution in schools and the community Public (psycho-) education, community sensitization and awareness raising Security measures

Include women and children in the distribution of economic growth Family reunion/family tracing Family/network building Improvement of physical aspects Resilience groups for children

SELECTIVE PREVENTION

Humanitarian relief operations: shelter, food, water and sanitation (Co-occurring) Natural disasters: quality standards Voluntary repatriation Reparation and compensation

Conflict prevention & resolution Crisis intervention Vocational skills training

Recruitment of child soldiers Reparation and compensation for afflicted families Public health and disease control Mental health and psychosocial support (MHPSS) Crisis intervention

INDIACTED PREVENTION

Peace-keeping and peace-enforcing troops. Peace agreements

Reconciliation and mediation skills between groups

Involve the family in rehabilitation and reconstruction

Six major challenges Challenge 2 • In addition to ecological and transgenerational resilience which other disciplines are helpful? 

Systems approach: Socio-ecological models

Public health: preventing disease..promoting health through organized efforts and informed choices of society, organizations, communities and individuals

Health systems: activities w purpose to promote,restore, or maintain health

Syndemics: a set of health problems interacting synergistically

in a socio-political context

Ecological and transgenerational resilience

Eg Health systems • We think we operate in a rational world • But this is what health systems look like

Complex systems in humanitarian emergencies Humanitarian agencies Ministry of Health Disaster managers/ experts

Finance Ministry

Provincial/District hospital Primary Care clinics Private GPs Community MH Clinics

Helpers /tourists

Justice & Laws

Professional associations

Health, Social, Criminal Non-discrimination Health insurances

(I)NGOs

Ministry Social Affairs

Drug companies

Military

Ministry Education

(I)NGOs Mental Hospitals

Human rights organizations

Private psychiatrists

Blue helmets Peace keepers

Universities

Ministry of Science

Public Health Department

Diplomats

Rural developers

UN: Coordination Food Health Women Economy Reconstruction Refugees

Six major challenges Challenge 3 Go beyond ‘Alma Ata’ (1978) Pool and share resources 

Alma Ata, the capital of Kazakhstan, site of the 1978 WHO/UNICEF conference ‘Health for All by the Year 2000’

Without duplicating ongoing efforts

Economy Rural development Income generation

And practicing basic ph principles (horizontality etc)

Occupational skills Micro-credit schemes Stability livelihoods

Resilience Peace TRCs (Truth Reconciliation Commissions) Transitional Justice Mitigating emotions of impunity, anger, revenge

Non-violent upbringing

Social capital Empowerment Community dynamics Social support Information & Communication Community competence Wellness & stigma

Medical (N)C Diseases (HIV, TB, Diabetes, Mental disorder)

Social Rape victims, GBV, Former combatants, Child soldiers Disaster prevention DDR (Disarmament, Demobilization, Reintegration)

Six major challenges Challenge 4

• And we operate in a traumascape

Traumascape: the systemic dynamics of local and international representations and actions around extreme stress

Cascade of events often determines the focus of assistance • media, pop and movie stars • voter-dependent & geopolitical considerations • the role of UN/government • influx (I)NGOs • local stakeholders • funders • professionals

De Jong 2007 Traumascape

terrorism human rights child rights governance gender based violence domestic violence combat veterans child soldiers

Expertise & funds will go to a specific region or a specific type of disaster, often to the detriment of other catastrophes

• Professional/ethical/ epidemiological considerations are often overruled by the traumascape

Six major challenges Challenge 5 Nature-nurture • Culture 100/100: disentangling the biopsychosociocultural • Culture double edged: family, stigma, exclusion

• What is the emic perception of resilience? • How assess, emic and etic R, CCD and psychopathology? • Future: cultural neuroscience/anthropology: no illusion of one brain

Six major challenges Challenge 6: Mathematics • Few policy planners use models to calculate the capacity of their health system on a national, regional or district level • Mathematics would enable us to distribute limited resources in proportion to demographics, socio-economics, national or social insurance, community services, hospital beds, duration of hospitalization, incidence, suicide rates, or stigma

Challenge 6: Mathematics (cont) Consider the mental health system as a hub among sectors:  economic sector (for income generation among the poor)  social sector (as a safety net)  educational sector (for children and youth)  legal sector and women’s organizations (for human rights violations and family violence)  consumers (e.g., self-help groups)  insurance and other companies Address the most difficult problem of contemporary science: “how to deal with complex systems as wholes” Levins 1974

Conclusion 1 • A treatment-based model (in emergencies) does not solve the treatment gap, both in HIC and LMIC • Resilience as a socio-ecological characteristic helps us to nest our cognitive-emotional models in a wider context as proposed by a public health, a systems and a syndemic approach • Tap into other resources eg communities, healers, CAM, lay people

Conclusion 2 • Resources for reconstruction are wasted on initiatives having much in common (rural development, peace building, psychosocial issues, micro-financing, HIV or other public health priorities or care for the ill and disabled)  more synergy in prevention • We need in-depth ethnographic research on R and on CCD and measure them in parallel with ‘western’ constructs • Translate the take-away lessons of this conference into professional competencies back home

• Thank you for your attention