LETTER FROM THE EDITORS
April 2015 Dear Readers, The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global focus. Our goal is to bridge the gap between scholarship and practice, connect students and faculty, and bring together voices from across a spectrum of disciplines and sectors. We are continuing to engage the Yale community through thought-provoking scholarship and writing on all issues relevant to global health. This issue explores topics focused on the theme â&#x20AC;&#x153;Health Systems,â&#x20AC;? with article topics ranging from cases of burns in Peru to healthcare reform in Sweden. Health systems are the mechanisms through which delivery of efficacious response to health challenges must operate. In an interconnected world, the ways in which health systems interact with the governmental and non-governmental actors that shape them, and with populations, are worthy of our critical examination. All of the articles from this issue and our previous issues are available on our website for your perusal. Looking ahead to our future publications, we welcome your submissions.
Editors-in-Chief, The Yale Global Health Review
The Yale Global Health Review is the premiere undergraduate-run publication at Yale University covering topics in health. We feature original research, thoughtful commentary, and balanced reporting with a global health focus.
Submit pitches and manuscripts to firstname.lastname@example.org. All articles published represent the opinions of the authors and do not reflect the official policy of YGHR or the institution(s) with which the author is affiliated, unless this is otherwise indicated. yaleglobalhealthreview.com or twitter.com/YaleGHR Issue sponsored by the Yale Undergraduate Organizations Committee and the Yale Global Health Studies Program Published by Joseph Merrit & Company
4 LEADERSHIP EDITORS-IN-CHIEF
MANAGING EDITOR/PUBLISHER ASSOCIATE EDITORS
ONLINE EDITORS WEBMASTER
Amy Chang Katherine Fang Alison Mosier-Mills Shea Jennings Alicia Ding Sophia Kecskes Kevin Nguyen Ephrem Rae Peter Suwondo
The Things Money Cannot Buy: The Distinction between Cost and Cost-Effectiveness
Diagnosing Lyme Disease
INDIA: Examining the Efficacy of the RSBY Program in Providing Healthcare for the Rural Poor
SWITZERLAND: Regarding Health System Reform
GAZA: Enduring Disorder: PTSD in Gazan Children
PERU: Burns in Peru: A Neglected Global Health Crisis
Questioning Fundamental Assumptions
OCD and Me
Alexander Cruz Alykhan Nurani Amber Tang Jennifer Godfrey Moktar Jama Caroline Tangoren Katherine Xiu Akhil Upneja Lelina Chang Alykhan Nurani
WRITING Sophia Kecskes, Sreeja Kodali, Rachel Perler, Hannah Samson, Richard Skolnik (Lecturer in Health Policy and Management, Yale â&#x20AC;&#x2DC;72), Amber Tang, Emily Thacher, Akhil Upneja
cover design by Sarah Eckinger
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PRODUCTION PRODUCTION AND DESIGN
layout design by Katherine Fang and Shea Jennings
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The Things Money Cannot Buy: The Distinction between Cost and Cost-Effectiveness recent studies have also found similar results, indicating an improvement in health with more public health expenditure. This could be attributed to the fact that, historically, public health spending has tended to benefit the upper and middle class, but has since begun to target increasing accessibility to the lower class. Additionally, aggregate health benefits are most visible with reforms targeted to the poor. 3 Regardless, variations in the correlation between expenditure and health may be an indication that health outcome is influenced by external factors such as skill level of physicians and specific health interventions rather than merely monetary expenditure. 7 A large part of the discrepancy
Pippa Ranger/UK DfID
Health care is now considered a “luxury” good, in part due to its high income elasticity. For every 10% increase in income, there exists a 15% increase in demand for health care.1 However, despite increases in spending, policymakers have failed to improve the quality and accessibility of health care. The United States spends more resources on health than any other country, yet its health outcome, measured in factors of morbidity and mortality, continues to lag behind in comparison to many other industrialized countries.2 The same holds true for developing and low-income countries where poorly targeted health expenditure results in few tangible gains in health outcome. In the 1990s, several studies found no statistically significant correlation between public health expenditure and actual health status when using infant and child mortality as a measure of health.3 For example, in India no association was found between public spending and health, but rather, health was correlated with per capita income, female literacy and the percentage of the population below the poverty line. 4 One cross-country study published in 1999, found that increases in public spending in the health sector accounted for less than a seventh of the 1%
differences in child mortality. However, once again, income and female education were strongly associated with improvements in health. 5 In urban areas of low income countries, the most significant factor of child mortality was access to electricity, while in rural areas, the most significant factor was vaccination within the first year of birth. 6 However, several other cr o s s -co un t r y studie s found that increased public spending did in fact decrease child and infant mortality rates. One such study, published in 2002 by the International Monetary Fund, showed a significant, albeit weak, correlation between increased health spending and reduced infant and child m o r t a li t y r a t e s . Othe r m ore
A community health worker in India vaccinates a child. Only 44% of children ages 1 to 2 are fully vaccinated in India.
between public health spending as a quantitative figure and actual health outcome can be accounted for by poor resource allocation. Ineffective public spending in the health sector draws attention to a need for policymakers and donors to prioritize in terms of cost effectiveness. For ex a mpl e, a ccordi n g to the 2012 Center for Global Development Brief, national public hospitals in India subsidize open-heart Children march for clean drinking water as part of the Indian government’s surgery, yet only 44% Total Sanitation Program. of children ages 1 to 2 poor, while increased spending funded as it targets wealthy and are fully vaccinated. L i k e w i s e , A v a s t i n , a in higher level reforms that middle class interest groups. treatment banned by the FDA in include specialized intensive In developing and low-income 2011 for its ineffectiveness and curative treatments tend to only countries, only $1 per capita is severe side effects, is subsidized benefit the rich. An investigation spent on public health, and only in Colombia, 8 while only 58% of of thirteen countries found that 25% of government spending is children are fully vaccinated. 50% of public health subsidies, allocated to primary health care R e c e n t r e p o r t s a l s o s u g g e s t b u t o n l y 2 9 % o f h o s p i t a l and public health services. 12 It is becoming increasingly that cost-effectiveness analysis subsidies, benefitted the bottom 10 clear that money, on its own, i s c r u c i a l i n d e t e r m i n i n g 40% of the population. In 2011, researchers tracked does not necessarily lead to components of health expenditure. For instance, some local public health agencies improved health for the general new treatments for patients with i n t h e U n i t e d S t a t e s o v e r public. Cost-effective analysis cancer or HIV/AIDS have cost- a t h i r t e e n y e a r p e r i o d a n d and reforms that target public effectiveness ratios of under found that a 10% increase in health must be coupled with $10 0 , 0 0 0 p e r e a ch i n cre a s e local public health spending i n c r e a s e d e x p e n d i t u r e i n in quality-adjusted life-year, r e s u l t e d i n a 6 . 9 % d e c r e a s e t h e h e a l t h s e c t o r t o e x p a n d suggesting these treatments to in infant mortality. The study accessibility of primary care, be cost-effective investments. c o n c l u d e d t h a t s p e n d i n g o n especially to the lower class. In On the other hand, some of the public health by local agencies other words, it’s not all about l e a s t e f f e c t i v e p r o g r a m s f o r led to significant improvements spending, it’s about spending HIV/AIDS reduction have less in health outcome, a result that wisely. than 0.1% as much potential was especially noticeable in www v a l u e a s s o m e o f t h e m o s t low-resource communities. 11 Although studies indicate effective programs that target improvements in disability- that increased expenditure in the public health sector adjusted life years. 9 Public health interventions y i e l d s s t r o n g b e n e f i t s t o for basic public goods, especially overall health outcome, public Amber Tang is a freshman in safe water and immunizations, health programs are typically Saybrook College. underfunded. This is because have been found to result in the most significant improvements f u n d i n g i s p r e d o m i n a t e l y for overall health. These types directed towards tertiary care, You can contact her at amber. of reforms also tend to help the w h i c h t e n d s t o b e h e a v i l y email@example.com. UNICEF/Govt. of India
By Amber Tang
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Diagnosing Lyme Disease By Sreeja Kodali
measures. At the 2012 HHS Federal Research Update on Lyme Disease Diagnostics, Dr. Joseph Breen of the National Institute of Health (NIH) and National Institute for Allergy and Infectious Disease (NIAID) discussed the disadvantages of tests based on detecting the immune response to B. burgdorferi as opposed to detecting the infectious agent itself. These tests are “less than optimal for early disease because it can take weeks for a detectable immune response to be sufficiently measured.” This delay in diagnostic capability prevents treatment during the earliest stages of Lyme disease, when treatment is most effective. Another disadvantage of current tests that Dr. Breen discusses is that current serum diagnostics “don’t reliably change with treatment.” The only way “to measure effective treatment” is symptomatically, which is not consistent. An inability to measure the effectiveness of treatment is crippling, as many patients do not respond to the typical antibiotics. Dr. Breen describes their ideal, improved test as “combinations of more specific and sensitive peptide-based tests which tend to be cleaner results” that also retain “the sensitivity of what’s currently available.” He is hopeful that novel diagnostics can even move past serum diagnostics, possibly to measuring T cell response, which occurs sooner than antibody production.11 Dr. Breen highlights a few key extramural projects funded for their innovative strategies in improving Lyme diagnosis. Dr. Monica Embers from Tulane University, who conducted the critical study in macaques that showed persistent B. burgdorferi after antibiotics, is exploring “a more refined” diagnostic method
by targeting new “protein antigens” detection to a remarkable 94% therefore has not been confirmed as a way to measure treatment sensitivity and 100% specificity. to meet the required standards response. According to her NIH This novel cultivation method of clinical accuracy. The “CDC project proposal, Embers plans seemingly made detection easier recommends that laboratory tests to use attach multiple antibodies with classic “immunostaining, PCR, cleared or approved by FDA be to each fluorometric bead, as and direct DNA sequencing.”14 But used to aid in the routine diagnosis opposed to pairing one, in order this serum preparation process of Lyme disease,” discouraging to detect multiple B. burgdorferi only created more controversy against the new method and other peptides. She plans on detecting in the already contentious field unapproved tests that chronic Lyme C6, “the most successful standalone of Lyme research. Dr. Barbara patients often use as alternatives in diagnostic antigen for Lyme seeking a diagnosis.17 disease,” as well as four The need for new additional antigens whose Lyme diagnostic tests is presence shifts through the undisputed. Unreliable and inaccurate tests have course of the infection. Her led to false-positive cases hope is that the targeting of multiple B. burgdorferi where patients have received antigens with a “multiplex high doses of antibiotics platform” in diagnosis will needlessly; false-negative produce a more sensitive cases where patients and specific assay that can develop late-stage Lyme or better trace the course of arthritic Lyme from a missed the infection. The project is diagnosis; and ambiguous anticipated to be complete in cases of chronic Lyme where July 2017.12 patients claim to have Lyme with no sound biological Another NIH-selected evidence. The consensus study is underway at regarding improvements Yale University, where for Lyme diagnoses is Dr. Linda Bockenstedt is that development of more seeking to “improve upon sensitive and specific current serologic tests by tests should be a research developing a new diagnostic priority. Ideally, a diagnostic cytokine assay.” Similarly test shou l d b e a b l e to to Embers, Bockenstedt Borrelia burgdorferi, the main causative measure the effectiveness plans on targeting a new agent of Lyme disease. of treatment, the stage of range of B. burgdorferi Lyme, and even the strain antigens “expressed in the skin” and measuring the body’s Johnson of the CDC evaluated of B. burgdorferi. Unfortunately, c y t o k i n e r e s p o n s e t o t h e s e the new culture method, and by controversy continues to riddle antigens. Bockenstedt hopes that tracing a DNA sequence found Lyme disease research as seen with a cytokine assay will supplement in European strains of Lyme, the new culture method. In a few current serologic tests to improve concluded that “positivity due years, NIH- and-NIAID-supported sensitivity and specificity, and to laboratory contamination of research by scientists like Dr. additionally measure treatment patient samples cannot be ruled Embers and Dr. Bockenstedt will response. Bockenstedt’s results are out, and further validation of the hopefully develop more accurate also expected in 2017.13 new culture method is required.”15 and reliable serologic tests with new While more comprehensive In response to the assessment, the target antigens and bring muchserologic assays are still being original research group published needed, undisputed advancement investigated, scientists have a defense.16 Nevertheless, public for Lyme disease diagnosis. already made strides in some analysis and critique of the Sapi www diagnositic areas. In February group’s work persisted, and the 2013, a University of New Haven CDC continues to oppose the new Sreeja Kodali is a freshman in research group led by Dr. Eva Sapi culture method. In a short news prepared a batch of B. burgdorferi release, the CDC emphasized that Saybrook College. samples from humans using a the culture method is not yet special cultivation method that approved by the U.S. Food and You can contact her at was observed to improve sample Drug Administration (FDA), and firstname.lastname@example.org. Centers for Disease Control
Before 1977, Lyme, Connecticut was afflicted with an epidemic: children with skin lesions, headaches, stiff necks, myalgias, arthalgias, and fatigue. 1 These symptoms later developed and months after the brain, heart, and muscular system were affected too. This unexplained phenomenon plagued patients until Dr. Allan Steere of Yale School of Medicine and his research team in 1983 identified the causative agent, a new spirochetal bacteria called Borrelia burgdorferi found in black-legged ticks.2 While research has made significant progress in Lyme disease (most cases when diagnosed within the first couple of weeks can be cured with antibiotics), some Lyme patients still suffer inexplicably.3 Later stages of untreated Lyme do not respond well to antibiotics.4 This unexplained phenomena still plagues patients. Another patient group that identifies with the term chronic Lyme disease but has no positive B. burgdorferi insists the mistake lies not with their persistence but in diagnostic tests. The activists are not wrong in faulting diagnostic measures. Late stages of Lyme are less treatable because B. burgdorferi is discovered too late, a diagnostic failure. Certain tests produce too many false positives, 5 causing doctors to place patients without Lyme on high dosages of antibiotics. Other tests tend to produce false negatives, 6 allowing the disease to persist and develop into a later stage in misdiagnosed patients. Thirty-one years later, patients still suffer from Lyme disease inexplicably. Improved diagnostic measures should reduce false positives and negatives. They should be sensitive, specific, and reliable. Improved diagnostic
measures should also credibly determine whether an identifying chronic Lyme patient actually has B. burgdorferi. Improvements in diagnostic measures, the critical first step in arresting Lyme disease for late stage patients and understanding chronic Lyme, will greatly alleviate suffering. Current Lyme diagnostic procedures, according to the Centers for Disease Control (CDC), begin with symptom identification, which is substantiated by blood tests. Both symptoms and positive lab tests are needed for a diagnosis. One cannot be used to diagnose without the other. Laboratory blood tests are “not recommended for patients who do not have symptoms typical of Lyme disease” due to the unreliability of these tests. 7 Symptoms alone cannot be used to diagnose because they are very broad. If the symptoms -- bull’s eye rash, stiff neck, headache, fatigue, or joint pain -- are present, tests that detect serum from B. burgdorferi antibodies follow. 8 As for tests, the CDC recommends a two-step process: an immunoassay, then Western blot. An immunoassay, such as an ELISA (enzyme-linked immunosorbent assay), is typically used first. But its high rate of false positives makes it unreliable when used alone.9 If a positive ELISA or similar assay result is produced, the test is followed by a western blot, a more thorough assay that searches for antibodies of multiple B. burgdorferi proteins. Another secondary test is PCR (Polymerase Chain Reaction), which will search for the bacterial DNA in joint fluids. While reliable, it is still not up to par with blood or urine samples.10 The CDC recommends this compound of tests to minimize false results. But the scientific community acknowledges the need for better diagnostic
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INDIA By Akhil Upneja
different healthcare systems to extend accessibility to the poorest of the poor. One such system was implemented in India in 2008. To attempt to provide the rural poor with access to health care, the Indian government has
Ramnath Bhat/Wikimedia Foundation
1.22 billion. That is the number of people around the world living off less than two dollars a day. 1 These people live in severe poverty and work simply to provide sustenance and shelter for their families. In India, the harsh poverty conditions are particularly pronounced with 217.2 million people in rural villages living below the poverty line. 2,3 As a result of their low incomes and the remoteness of their villages, the rural poor in India cannot access medical facilities, let alone an expensive, unaffordable luxury like health care. As a consequence of the hefty price of health care and the subsequent widespread lack of coverage in poor areas, devastating statistics abound, such as the fact that nearly 43 out of every 1000 babies in rural areas of India die before they reach their first birthday.4 In light of these startling statistics and the apparent, often unnecessary, pain and suffering in the world, developing countries Women in rural India are constantly investigating for their families.
created a program titled Rasthriya Swasthya Bima Yojna, or RSBY for short. The purpose of the RSBY program is twofold. The first purpose is to provide quality medical access to rural families living below the poverty line. The second purpose is to financially protect rural families from falling even further into poverty. Although RSBY is well intentioned, I argue that in both of these purposes, the RSBY program has failed so far. In providing quality medical access to the rural poor, the RSBY program has been inadequate due to a significant lack of health infrastructure. In financially protecting families living below the poverty line, the RSBY program has not focused on the real costs that cause financial catastrophe for the rural poor. By first providing massive funding for the creation of RSBYlevel hospitals and then expanding the RSBY program to cover both inpatient and outpatient procedures, the RSBY program can achieve water maximum good in India. Moreover, it can serve as a
heading to get
Trinity Care Foundation
Examining the Efficacy of the RSBY Program in Providing Healthcare for the Rural Poor
A health worker examines a student in Bangalore City, India. model for other countries facing the significant problem of providing health services to the impoverished. In summary of RSBYâ&#x20AC;&#x2122;s function, initially, insurance companies submit bids to the government to become insurance providers for the program. Through this competitive process, the companies with the cheapest financial bids and highest quality ratings are selected. The bids are paid yearly to the selected insurance companies by the federal and state governments such that the federal government pays 75 percent of the cost and the state government pays for 25 percent. After the insurance companies have been selected, public and private hospitals are approached to become RSBY providers. In order to be empanelled, they must meet certain requirements, such as having a sufficient number beds for inpatient procedures and having the ability to make electronic modifications to accept patients with the RSBY card. Finally, the process reaches the rural poor. An enrollment station is set up in each village, whereby each rural family living below the poverty line can sign up to receive a card containing each family memberâ&#x20AC;&#x2122;s fingerprints,
photographs, and the equivalent of 600 US dollars. For the next year, cardholders can enter any empanelled hospital and use their card strictly for inpatient costs, such as hospitalizations for disease recovery or surgeries. Cardholders can renew their cards every year to get a new $600 budget for medical usage. A lack of adequate health infrastructure nullifies any benefits RSBY could have generated for the rural population living below the poverty line. My definition of health infrastructure has two components: the first, facilities such as hospitals, and the second, doctors to keep them running. First, there are simply not enough facilities close to villages to make the RSBY program effective. As outlined above, hospitals have to meet certain requirements to become empanelled under the RSBY system, and further, the rural poor can only access subsidized care through these empanelled hospitals. Currently, the empanelled hospitals are too far away from villages for the system to be effective. In fact, even if every single inpatient hospital near villages in India was empanelled, 63
percent of Indiaâ&#x20AC;&#x2122;s rural population would have to travel farther than five kilometers to find any type of inpatient healthcare facility.5 The types of illnesses covered under RSBY that affect the rural Indian population oftentimes require immediate inpatient care and surgery. As such, the fact that almost two thirds of rural villagers in India must travel more than three miles to reach any inpatient hospital has profound implications for the health of the rural poor. Dheera Sujan and Searada Lahangir provide an example that accurately highlights the crux of the problem. A villager in the Indian district of Orissa was in her third trimester when she suddenly went into labor. In order to get to the nearest inpatient hospital, she had to be carried by her relatives in a bamboo basket to a location ten kilometers away, from which it was a thirty-six kilometer bus ride to the nearest hospital. By the time she got to her final destination, she had developed severe complications and died while giving birth.6 The impact of having to travel so far to receive care, as tragically represented in the previous example, is appropriately reflected
reasons: job security and financial stability. In rural hospitals, before the RSBY system was implemented, there was only job security and a significant lack of monetary gain to be had. However, both job security and financial stability are fulfilled when doctors practice abroad in developed countries or in the hearts of urban cities, causing physicians to stay away from poor, rural hospitals. Therefore, a lack of financial security for doctors proves detrimental to the success of the RSBY program. It does not matter whether the poor have cards or not if there is a lack of physicians to attend to their needs. Now that we have thoroughly examined the RSBY’s progress toward achieving its first goal of providing quality medical care to those living below the poverty line, we can move on to its second stated purpose of providing financial risk protection for the rural poor. An analysis of the efficacy of RSBY in achieving its second stated purpose of providing financial risk protection for the rural poor reveals that coverage under RSBY is focused on covering the wrong costs. Recall that the $600 subsidy solely covers inpatient hospitalizations and surgeries rather than outpatient medicines and diagnoses. The theory behind this is that the large costs of surgeries and hospitalizations quickly encumber families. This theory is unfounded. It is not these one-time costs that cripple families financially, but rather the incremental, outpatient costs for medicines that build up over time. This is confirmed in a robust study conducted by Peter Berman, Rajeev Ahuja, and Laveesh Bhandari analyzing the millions of Indians each year that fall below the poverty line due to out-of-pocket medical costs. The study concluded that almost four fifths (79.3%) of impoverishment due to health spending is a result of “outpatient care which involves relatively
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small but frequent payments,” while only one fifth (20.7%) of impoverishment is due to health spending through inpatient procedures.9 This study explains that poverty due to medical care occurs as a result of the slow and steady buildup of medicinal debt rather than one major operation or surgical procedure. Another study conducted by Renu Shahrawat and Krishna Rao confirmed this conclusion by analyzing the effects of eliminating out-of-pocket costs for the inpatient and outpatient cares of Indians above the poverty line. This study concluded that if the out-of-pocket costs associated with inpatient care are removed, there is “a negligible fall in the poverty headcount ratio and poverty gap.” In great contrast, if
The impact of RSBY in reducing inpatient costs is... even less for the rural poor than it would be for any other income quintile.
the costs associated with outpatient care are removed, “only 0.5-1.5% of people fall into poverty due to spending on health,” effectively eliminating the number of people becoming impoverished due to health care spending.10 Even with the complete elimination of outof-pocket costs for inpatient care, Indians above the poverty line still fall below the poverty line at the same rate, implying that inpatient care is not at the center of financial bankruptcy. On the other hand, removing out-of-pocket costs for outpatient care and medicines
Ramnath Bhat/ Wikimedia Foundation
in the gradient of utilization rates of RSBY when compared to the distance to empanelled hospitals. A prime example of this is illustrated in the district of Deoghar, where all of the empanelled hospitals are located in one city called Deoghar City. Xiaohui Hou and Robert Palacios from the World Bank show that utilization is dramatically higher in the blocks closest to the hospitals and significantly lower in the blocks farthest from them.7 In sum, the vast distances that villagers must travel to get to any hospital nearby for immediate inpatient procedures jeopardize the well being of the rural poor and inhibit the success of the RSBY program. Along with a lack of quality medical facilities near rural areas of India, there is a dearth of doctors willing to tend to the rural poor. Before RSBY went into effect, most Indians living in poverty would only go to the hospital when diseases were so far advanced and injuries were so complex that they could not be fixed at home. Such complicated cases would generally go unpaid, as the poor did not have enough money to front costly procedures. A vicious cycle ensued where the poor would undergo costly surgeries, be unable to pay, and leave doctors undercompensated for their hard work. As a result, many physicians chose no to venture into rural villages and vacant positions abounded. A news article by Radio Netherlands Worldwide nicely summed up the logic behind doctors’s unwillingness to work in rural villages: “In a country where every middle class parent harbours ambitions for their child to get into medical school, there are simply too few people willing to sacrifice the prospect of lucrative careers abroad or in the urban centres for a life of deprivation in the country areas.”8 The majority of middle-class Indian parents encourage their children to become doctors for two
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Paddy rice workers in rural India. protects the rural poor from falling further below the poverty line. There is a slight problem with applying the aforementioned statistics on inpatient and outpatient costs to the population the RSBY program serves. The sample from which the statistics are derived comes from individuals that live above the poverty line and then fall below the poverty line as a result of health spending. However, the RSBY program only administers cards to those already living below the poverty line. There is a way to reconcile the statistics with the target population: by analyzing the proportions of health expenditure that those living above the poverty line and those living below the poverty line pay for inpatient procedures versus outpatient procedures. If it is the case that the impoverished living below the poverty line are paying the same or a greater proportion of their health expenditure on outpatient costs as compared to Indians living above the poverty line, then the results of our statistics can be extrapolated to those living below
the poverty line. Remarkably, the poor actually spend the most on outpatient costs as a proportion of their health expenditure (88%) when compared with every other income quintile. Looking specifically at the proportion of health expenditure that the rural poor spend on outpatient costs associated with medicinal drugs, “the share of drugs in out-of-pocket (OOP) payments was highest for those below the poverty line (88%) and this progressively declined with rising economic status, with those in the top 20% of the APL quintile spending 62% of OOP payments on drugs.”11 Therefore, the impact of RSBY in reducing inpatient costs is, theoretically, even less for the rural poor than it would be for any other income quintile. A way to ground these conclusions is to examine the change in catastrophic headcount ratios in rural India over the years that the RSBY system was utilized. The catastrophic headcount ratio or rather “the percentage of households making out-of-pocket (OOP) expenditure greater than
10 percent of their total household expenditure.”12 A study done by Sakthivel Selvaraj and Anup Karan in Economic and Political Weekly analyzed catastrophic headcount ratios in districts where the RSBY system was implemented, called “intervention districts,” in the years before and after the initiation of the program. They compared these ratios to the same numbers in districts where the RSBY system was not implemented, called control “non-intervention” districts. The results are clear: in the poorest income quintiles, there was in fact a rise in catastrophic headcount in districts where RSBY was implemented, versus stability or a decrease in “non-intervention” districts.13 Therefore, even for patients that needed help to pay for inpatient procedures, an increasing percentage of the rural poor needed to pay more than 10 percent of their household expenditure on medical care. Why is this true, when the RSBY card gives 600 dollars every year for inpatient procedures? Examination reveals
14 that patients still had to pay massive amounts out-of-pocket after the inpatient procedures were complete. In the Patan District of Gujarat for example, almost half of patients (44%) had to pay money after their procedures, with the median payment totaling 80 dollars. What were the costs? “The [patients] were asked to purchase medicines and diagnostics.”14 80 dollars for a family living on two dollars a day is an insurmountable burden and consequently explains why families continue to face financial catastrophe even after inpatient procedures are “covered.” Therefore, the efficacy of RSBY was severely hindered by its lack of regard for the real causes of financial catastrophe, namely outpatient medicines and diagnoses. This lack of regard increased financial catastrophe in districts where the RSBY system was implemented. How do we change the RSBY program for the better? I believe it is a two-step process. The first step is to make the RSBY cards cover both outpatient and inpatient care. By not changing the amount of money provided but allowing Indians to use that money on medicines and diagnoses, financial risk protection will be maximized and catastrophic investments will be minimized. It is clear through the numbers that both inpatient and outpatient out-of-pocket costs are the reasons why families living below the poverty line are struggling. By giving the rural poor flexibility, the inalienable right of good health is achieved. Secondly, the Indian government should invest heavily in creating rural hospitals, such that there should be a hospital within five kilometers of every village in India. This process will add two major benefits. The first is to provide quality medical facilities to everyone in India, in turn increasing utilization and creating a healthier, more productive workforce. The second major benefit is that more new
GLOBAL HEALTH TODAY hospitals will attract doctors to stay in India rather than leave for more lucrative jobs in the West. It seems that the major reason physicians leave India is for monetary reasons, and in the past, rural doctors did not get a lot of pay because patients did not have money. With the endless job opportunities that the new hospitals will create, as well as the monetary gain that results from an efficient use of the RSBY program, rural doctors will start to earn enough money to secure financial stability. With the changes suggested above, I think the RSBY system is one that should be strongly considered for any other country having problems extending adequate health care access to citizens below the poverty line. A modified RSBY system truly benefits all parties involved. For the government, there are large short-term economic costs in preparing infrastructure. However, these costs are more than compensated for in the long-term by a more productive workforce, financially secure job opportunities for the medical field, and an overall healthier populace. For insurance companies, the system is beneficial because they expand their businesses to a segment of the population that previously did not have access to insurance. Hospitals also benefit from renovations to fit RSBY standards and an influx of doctors. Finally, for the rural poor, the benefits are unparalleled: close hospitals, adequate access, a jumpstart to pay for medicines and surgeries, and a healthier standard of living. The Rasthriya Swasthya Bima Yojna is a commendable program in its objectives of providing medical care access and preventing financial catastrophe for the rural population living below the poverty. Currently, the program meets neither of these stated objectives. There is a significant lack of adequate health infrastructure for the program to be utilized efficiently. This lack
of health infrastructure presents itself in the form of a lack of actual medical facilities, as well as a lack of medical doctors willing to leave lucrative careers abroad to tend to the rural poor, where money used to be scarce. The RSBY also fails because it restricts usage of the biometric card to only inpatient procedures, while financial catastrophe generally occurs due to outpatient medicines and diagnoses. Further, even for those inpatient costs that it attempts to cover, the RSBY misses certain out-of-pocket costs that are financially crippling for families living below the poverty line. To maximize utilization and efficiency of the system, I suggest that the Indian government focus on building infrastructure to increase utilization of the system. In addition, I suggest that the Indian government make the funds on the RSBY card more flexible. To that effect, the money should cover outpatient costs such as medicinal drugs that have been proven to be the real cause of financial catastrophe in the lower quintiles. Although the Indian government and other governments that adopt the system will have to invest significantly in the short term, by making these improvements, the long-term impacts far outweigh the short-term costs by creating a healthy, wealthy, and happy populace.
Akhil Upneja is a sophomore in Morse College. You can contact him at akhil. email@example.com.
GLOBAL HEALTH TODAY
SWITZER LAND Regarding Health System Reform By Emily Thacher EXECUTIVE SUMMARY Twenty years ago, the Swiss health sector faced two key problems: rising inequality and rising costs. In an effort to strengthen solidarity and contain costs, the Swiss passed a major healthcare reform bill called LAMal in 1994. Inspired by the French and German systems, it established meaningful universal coverage through a regulated private market. The reforms were successful at expanding access to care while maintaining quality and choice, but costs remain high. Between 1995 and 2012, health expenditure per capita more than doubled in real terms. Containing costs is the most critical issue in the Swiss healthcare system, but preparing for the shifting burden of disease and improving data on health inequities are also important objectives. MOTIVATIONS FOR REFORM Twenty years ago, the Swiss health sector faced two key problems: rising inequality and rising costs. Both problems resulted from the rise of for-profit insurance
companies. Traditionally, the Swiss bought into private insurance plans through their employers. Because these insurers were not selective about whom they covered, very nearly all employed people had health insurance. In the 1980s, however, the few for-profit insurance firms began buying up the old nonprofit plans. Tending to their bottom line, these firms increased premiums, refused to cover high-risk people, and denied expensive claims. By 1993, spending had skyrocketed, even as coverage had dropped. Swiss per-capita spending on healthcare was second only to the United States. Moreover, nearly 400,000 Swiss, or about 5% of the population, did not have health insurance.1 For some, healthcare was catastrophically expensive or even unaffordable. To the Swiss, this was unacceptable. Switzerland was not only a rich country—in 1993 it had a GDP per capita equivalent to $36,027 2014 USD2—but also a country that believed strongly in the principle of solidarity. The fact that healthcare was accessible to some but not to all was a violation of a core national
value. The problem would only worsen if costs continued to rise. HEALTH REFORM In an effort to strengthen solidarity and contain costs, the Swiss passed a major healthcare reform bill called LAMal in 1994. With LAMal, policymakers struck a balance between the two Swiss values of capitalism and solidarity. Inspired by the French and German systems, it established meaningful universal coverage through a regulated private market. 3 Universal Access to the ‘Basic Package’ The primary goal of reform was to ensure all Swiss citizens access to essential care. In order to accomplish this, the law requires that all individuals purchase health insurance from a private insurer. Insurers must charge all people the same price for a given health plan; individuals who cannot afford the premium even for a basic plan receive tax-financed subsidies from their cantons. Insurers are required to accept all applicants and cover them for a ‘basic package’ of services. The list of services is determined by
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Courtesy of The World Factbook The World Factbook The World Factbook
Though health coverage in Switzerland is universal, care is administered through the country’s 26 cantons. the federal government on the bases of appropriateness, medical effectiveness, and efficiency.4 Because insurers must accept all applicants and charge them the same premiums, it is necessary to equalize risks between insurers. A government body is therefore responsible for redistributing funds from lower to higher risk health plans. The transfers are determined on the basis of age and sex of enrollees.5 Containing Costs While Maintaining Choice The second goal of reform was to contain costs without limiting consumer choice more than necessary. The reform tried to control costs by limiting profit and preventing overutilization. Profits are kept low in two ways. First, insurers are prohibited from making a profit on basic plans that cover no more than
the basic package. Second, the various insurers are supposed to compete with each other to drive down premiums. Patients are also discouraged from getting unnecessary care in two ways. First, patients can only seek care from providers that are in their canton of residency and are accredited to receive reimbursement for providing basic treatment. Second, deductibles and copayments share the immediate financial burden with the patient. The federal government sets a minimum and maximum deductible of about $300 and $2600 USD; the insurer sets the level within this range. Once the deductible has been met, the patient still pays 10% of the remaining costs, unless these costs amount to more than about $730 over the year. In order to allow individuals the freedom to choose from among a diverse range of options, everyone
also has the right to purchase supplementary insurance to cover anything beyond basic care. For these supplementary plans, insurers are permitted to make a profit and deny certain individuals coverage.6 This gives individuals greater ability to choose the care they want—yet that freedom comes at the expense of equality, since not all Swiss are able to afford supplementary plans. Service Provision and Payment Healthcare service provision is generally organized at the cantonal level, with only a moderate amount of federal supervision. Cantons have relatively little power over primary care provision, while they have increasingly more over hospital-based care. In all cantons, primary care providers typically work in independent practices and are paid by insurers on a fee-
GLOBAL HEALTH TODAY for-service basis. Hospital-based care provision and payment, however, varies greatly between cantons. Until 2012, hospitals in most cantons were paid on a per diem basis. Public hospitals were also eligible for cantonal funding while private hospitals were not. A new reform law passed in 2007, however, has caused all hospitals to receive payment from insurers through a diagnosis-related group (DRG) system. The DRG system compensates the hospital on a case basis instead of a fee-for-service model. This system incentivizes use of best practices and discourages long hospital stays.7 OUTCOMES OF REFORM The reforms were successful at expanding access to care while maintaining quality and choice, but costs remain high. Health indicators have tended to increase since the reform, although only marginally because they were very high to begin with. From 1994 to 2012, life expectancy at birth increased from 78 to 83 years, giving Switzerland the fifth highest life expectancy in the world. Similarly small improvements were observed in the maternal mortality ratio and infant mortality rate.8 Health system performance indicators have also been favorable. The 5% of the population that was uninsured in 1993 is now covered,9 there has been about a 25% increase in the number of physicians per capita,10 and patient satisfaction indicators are unusually high.11 Costs, however, have increased, and out-of-pocket spending has decreased only marginally. Between 1995 and 2012, health expenditure per capita more than doubled in real terms. Over the same period, total health expenditure and public health expenditure as percents of GDP grew from 9% to 11% and 5% to 7%, respectively. Meanwhile, out-of-pocket expenditure fell from its 1995 level of 33% of health expenditure, but only to 28%. 12
REMAINING CHALLENGES AND RECOMMENDATIONS Containing costs is the most critical issue in the Swiss healthcare system, but both preparing for the shifting burden of disease and improving data on health inequities are also important objectives. The primary driver of high costs has been the expansion of the basic service package without attention to cost-effectiveness. The federal government currently determines service inclusion on the bases of effectiveness, appropriateness, and
The best response is not to expand hospital capacity. Instead, more emphasis should be placed on preventing disease through public health efforts and primary care.
efficiency, but the process is not transparent. Initially conceived as a package of truly basic services, the package now includes a far wider range of services, some of which are not cost-effective. In order to contain growing costs while providing the maximum health benefit, the federal government should add cost-effectiveness to its list of criteria.13 A further consideration is Switzerland’s aging population and shifting burden of disease. As the populace has become more sedentary and adopted a less balanced diet, obesity, hypertension, and other risk factors for noncommunicable disease
have risen. At the same time, new medical technologies keeping people with chronic diseases alive longer. As the burden of chronic disease increases, demands on the hospital system are likely to surpass current capacity. The best response, however, is not to expand hospital capacity. Instead, more emphasis should be placed on preventing disease through public health efforts and primary care.14 Finally, new and better data must be collected to determine the level of inequity in the system. Because each of the cantons functions semi-autonomously, there is not strong central data collection. Improved data collection and sharing systems are needed to determine whether the systems’ fragmentation is masking important health inequities. 15 FINAL COMMENTS Switzerland’s health reforms over the past two decades have balanced the demands of solidarity and capitalism. Swiss citizens enjoy universal coverage as well as a high level of choice among providers. Nonetheless, the disregard for cost-effectiveness and lack of data on health equity are dangerous to the health system’s long-term sustainability and will need to be addressed in the near future.
Emily Thacher is a junior in Berkeley College majoring in History of Science, Medicine, and Public Health. You can reach her at firstname.lastname@example.org.
GLOBAL HEALTH TODAY
Enduring Disorder: PTSD in Gazan Children
By Sophia Kecskes “I miss the sea, I miss my friends, I miss ice cream, I miss happiness and joy. I MISS MY ORDINARY LIFE,” tweeted Farah Baker, a 16-year-old girl from Gaza who self-describes as a “modern Anne Frank.”1 With 199,000 followers, this young girl spreads awareness about the nature of her life in the Gaza Strip. Especially popular this summer, Farah’s Twitter features live tweets about her experiences living in fear during Israel’s Operation Protective Edge,
a conflict that ravaged the area from July 8, 2014 until an open ceasefire was announced on August 26, 2014. 2 In the Gaza Strip, Farah is far from being a unique case—43.8% of people are under the age of 24.3 This demographic represents a generation of youth who have spent their entire lifetime in turmoil. Children and adolescents who grow up in such hostile environments never forget the images they see, bombs they hear, and insecurity they feel—all of which become a pervasive part
of daily life. One view on this conflict is exemplified in a recent Arab Psychiatry Journal article, which contends that Israelis engage in systematic psychological warfare, methodically humiliating and demoralizing Palestinian populations, as well as instilling a deep sense of insecurity through bombings.4 Further, land ownership has great psychological importance in Arab culture; the lack of land control felt by the Palestinians results in a great loss of honor.5 More than half of youth ages 15-
UN Photo/Shareef Sarhan
Israeli Defense Forces
As an air siren sounds, children from the Gazan town of Kiryat Malachi sprint for shelter.
18 living in the Gaza Strip experience partial or full posttraumatic stress disorder (PTSD). 6 The causes of this tragedy are multifaceted but can almost universally be attributed to the constant presence of violence in youth’s lives.7 A 2008 study of 1,137 children discovered that 97% of youth had heard the sound of bombs and explosions and 84% had witnessed shelling from tanks, artillery, or military planes.8 73% of kids have also personally witnessed political violence.9 In addition to the direct impacts of violence, women face additional risks for PTSD due to factors such as an increased likelihood of sexual violence, physical and mental abuse, human trafficking, and prostitution.10 Women suffer from PTSD during conflict at greater rates than men; during the Lebanese Civil War from 19751990, rates of PTSD among women were in fact six times higher than those among men.11 While rates of PTSD among Gazan children are comparable to those of refugee children fleeing previous conflicts in Cambodia, Lebanon, South America, and Bosnia and Herzegovia, 12 the Gazan situation is unique because of the prolonged nature of the conflict. Instead of just an eight year civil war, as was the case in Cambodia, these Palestinian children have never lived without exposure to trauma. While it’s vital to aid all children suffering from mental illness due to unnecessary conflict, the Palestinian case requires specialized, long-term attention. The impact of violence in Gaza is exacerbated by children’s proximity to the fighting. With an area of 139 square miles, Gaza is the same size as the American cities of Detroit, Portland, Las Vegas, and Philadelphia. The population density in this small area is about the same as in Boston, Massachusetts— there are 1.82 million people total living in the Gaza Strip. 13 With no safe area for escape, many
UN Photo/Shareef Sarhan
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Top: Flares light up the night sky of Gaza City. Bottom: The destruction of family homes is a primary cause of PTSD in children. children are even drawn into the fighting; some join the Palestinian army while others participate in the “national struggle” in less tangible ways, such as by helping to initiate and organize uprisings and demonstrations against Israeli forces.14 Through such direct engagement, Gazan children are more directly affected than children who solely observe the violence, which is the case in many recent conflicts— including Iraq, Afghanistan, and Syria. Researchers explain that Gazan children have “grown up too
fast” and have become “children of stones,” 15 reflecting a youth desensitization to violence. This in turn impacts familial relationships. Considering that El Hamula (one’s extended family’s support) remains integral to Palestinian culture, the perception that parents and other family members cannot protect children from violence and displacement pushes children to the more rapid assumption of responsibility for their own lives and for their families’. Insecurity and the inability to trust one’s elders for protection have deep
20 psychological impacts on children.16 The societal and individual costs of this mental health epidemic remain unclear, but it is estimated that 20% of Gaza’s population (approximately 360,000 people) will need long-term treatment for mental health disorders, long after conflict is resolved.17 Children who suffer from PTSD are at a higher risk of developing attention deficit disorder, becoming violent, performing poorly in school, suffering from addiction, and resorting to extreme criminal behaviors or radicalism. 18 Such problems become more serious in the Middle East, due to the prevalence of such strong sub-currents of terrorism and extremism; radical groups are more likely to recruit individuals with mental health challenges.19 An example of this phenomenon was demonstrated in 2009,when John Horgan, the director of the Pennsylvania State University’s International Center for the Study of Terrorism, conducted interviews with 60 former terrorists to explore their motivations for terrorist activities. Main themes discovered
GLOBAL HEALTH TODAY through these interviews correlate very closely with the causes and symptoms of PTSD. Horgan found that those who are more open to terrorist recruitment and radicalization tend to: “ F ee l a n g r y , alie nate d or disenfranchised, identify with perceived victims of the social injustice they are fighting, believe that joining a movement offers social and psychological rewards such as adventure, camaraderie and a heightened sense of identity, and believe that engaging in violence against the state is not immoral.”20 For these reasons and many more, it is imperative that the international community acts swiftly to stem the spread of PTSD and take action to rehabilitate kids already impacted. PTSD and other disorders only get more severe as one continues to endure violence. According to the United Nations Relief and Works Agency (UNRWA), after the conflict in 2012, rates of PTSD among Gazan children doubled.21 PTSD further worsens when one experiences extreme poverty, insecurity, deprivation, lack of education, and
a weak support network.22 In spite of these grim facts, not all hope is lost; through school-based counseling, the UNRWA has begun to address trauma-related issues.
Twenty percent of Gaza’s population will need long-term treatment for mental health disorders.
Several other aid organizations, such as International Medical Corps, have also pledged their assistance.23 However, more needs to be done, considering that longterm assistance and relationship building with single counselors are most helpful for traumatized children. The international community must aid Gaza to create a comprehensive, national development plan that prioritizes mental health care, reduction of poverty, improved legal systems to combat women’s abuse, and a more stable education system. Most importantly, however, it is vital that the Gaza Strip does not become reentangled in conflict. The impacts of such violent engagements spread far and wide, regardless of how minimal the official death count is. With every violent image on TV and with every threat screamed into the radio, children are harmed.
www Muhammad Sabah
Children near Khan Yunis, a city in the southern Gaza Strip, carry water bottles during a water shortage.
Sophia Kecskes is a sophomore in Pierson College and a Global Health Fellow. You can contact her at sophia. email@example.com
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Burns in Peru: A Neglected Global Health Crisis By Rachel Perler This summer, I interned at ANIQUEM (Asociación de Ayuda al Niño Quemado), a Peruvian NGO that is working to change the national approach to burn injuries and their care. The organization was founded in 1999 by a pair of doctors from Lima with the mission to reduce the prevalence of burn accidents in the Peruvian youth population through community education initiatives.1 Burn injuries are a significant but neglected global health challenge, particularly in low- and middle- income countries where cultural cooking practices and overcrowded dwellings present a high risk of burns.2 Each year, an estimated 195,000 people die from fire-related injuries alone.3 Even more die from “scalds, electrical burns, and other forms of burns.”4 Yet non-fatal burns, which are common and can cause profoundly negative psychosocial effects, have not been well-studied in lowand middle-income countries. Existing research shows that severe burn injuries can be devastating -- they disproportionately affect poor women and children and often require a long, costly process of physical and psychological recuperation.5 Lack of proper care following a serious burn injury can have profound physical and psychological effects, including serious physical disfigurements,
disabilities, and mental illnesses like depression or PTSD.6 Furthermore, the stigmatization of burn scars often affects the economic potential of burn victims, who often find it difficult to obtain work even years after recovery because of their physical appearance.7 In Peru, there is very little epidemiological data on the prevalence of burns and almost no data at all on the ability of burn victims throughout the country to access and afford appropriate medical care. A clinical guide to burns issued by the Peruvian Ministry of Health uses U.S. burn statistics to outline the prevalence of burn injuries -- about 0.8% of the United States population presents burn injuries each year.8 The guide also acknowledges that the statistics for Peru are “not so precise.” 9 Considering that burns disproportionately affect poor people in low- and middleincome countries, it is likely that the prevalence of burns in Peru, a middle income country in which 25.8 percent of the population lives below the national poverty line, is significantly higher than the given U.S. figure.10,11 For Peruvians who suffer burn injuries, acute care is covered by the universal Basic Health Insurance Plan and is typically very effective at reducing the acute threats of severe burn injuries, including infection and death.12 In
Lima alone there are approximately 700 burn cases per year, most of which occur in children under 5, and 90% of these patients survive.13 Yet once acute care ends, there are few government resources set aside for physically recovered patients, many of whom are children who must then grapple with the scars -- both physical and psychosocial -that their injuries have left behind. ANIQUEM is working to address the complex problem of childhood burns and change the standard of treatment in Peru. Although the NGO has maintained its emphasis on prevention, ANIQUEM shifted its focus in 2002 when it opened a rehabilitation center offering completely free services of “physical therapy, psychosocial rehabilitation, and social reintegration.” 14 At ANIQUEM, children and occasionally adults receive comprehensive care for an average duration of 24 months which focuses on the complete mental, physical, and spiritual recovery of burn patients and their families. 15 Although no comprehensive studies have examined the outcomes of ANIQUEM’s care, the organization’s patient records suggest that those who adhere to treatment exhibit marked diminishment in scar complications. Records show that patients who undergo psychological treatment often find success overcoming mental illnesses
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much less every lowand middle-income country in Latin America. Existing health systems in Latin America must recognize the need to fund extended physical and psychosocial rehabilitation services for burn patients, and centers like ANIQUEM must be created throughout the continent. Furthermore, more research must be done specifically on the demographics and risk factors of burn injuries so that effective treatments Peru. Severe burn injuries disproportionately and prevention strategies can be devised. So far, we know that burn to reach the center.16 So far over two thousand patients have been injuries are closely linked to poverty 19 treated at ANIQUEM; the number and that they are preventable. In the future, research should of Peruvian burn survivors who have not been able to access examine how the most effective rehabilitative services for financial burn prevention interventions or geographic reasons remains should be devised to serve the populations most at risk, how the unknown.17 The World Health Organization lifelong physical and psychosocial estimates that up to 265,000 consequences of burn injuries annual deaths can be attributed might be alleviated, and how the to burns, the majority of which stigmatization of burn injuries occur in low- and middle-income might be lessened in Peru and Latin countries. 18 However, the scope America in general. of data on the effects of nonfatal burns in low- and middle-income www countries is narrow, partially because epidemiologists often lump burns together with a variety of other accidents under the label “injuries.” ANIQUEM’s situation shows that burns are an important standalone global health issue with profound physical, psychological, Rachel Perler is a sophomore in social, and economic implications. Pierson College and a prospective ANIQUEM represents a successful model of a community-based burn Environmental Studies major. rehabilitation and treatment center, but a single center of this kind is You can contact her at rachel. not sufficient to serve all of Peru, firstname.lastname@example.org.
Children sitting on a curb in Caraz, affect Peruvian children under 5. associated with their burns, and anecdotal evidence suggests that families who use the NGO’s social services feel more prepared to deal with the challenges, physical and psychosocial, that burn patients must face for the rest of their lives. ANIQUEM’s services are limited by several factors. First, a general lack of data stunts the organization’s progress. Little cost-effectiveness and outcomes data exist to guide ANIQUEM’s community-based burn prevention education workshops. Second, lack of funding curbs the quality and number of treatments available to patients at ANIQUEM. The NGO’s budget is derived almost entirely from donations and fundraisers with very limited federal funding. Yet ANIQUEM is the only organization of its kind in Peru, and its services are in high demand: on average, one new patient is admitted for treatment per day, 90% of whom come from families with a low socioeconomic status, many of whom are indigenous, and many of whom travel hours
Questioning Fundamental Assumptions By Richard Skolnik One of the most important lessons that I have learned professionally is the importance of questioning fundamental assumptions. This lesson arose on a number of occasions, both when I worked at the World Bank and afterwards. One of the most interesting examples of this was the work we did on HIV at the World Bank not long after anti-retroviral drugs (ARVs) began to be used in high-income settings. A lot of the discussion around HIV in low-income countries at that time focused on how ARVs would never be affordable or cost-effective for use in these countries. This was painful but “obvious” to everyone, since most of the countries on which we worked spent very little per person per year on health and ARVs at that time cost more than $10,000 per person year of treatment. For the most part, this notion was accepted in the development community. In retrospect, this is slightly surprising. By this time, pharmaceutical donation programs already existed for leprosy and onchocerciasis and could have served as models for how to get drugs to low-income countries. Yet, at least initially, no one talked about a similar approach for HIV. The world began to look at this differently only when a number of early HIV advocacy groups and advocates made the failure to provide AIDS affected people in low- and middle-income countries into a moral and ethical issue. Essentially, they felt it was immoral to give access to lifesaving AIDS drugs to people in high-income
countries, while denying them to people in low- and middle-income countries. Thus, they helped lead the world to reject the idea that “these drugs would never be affordable” and instead asked “what it would take to make them affordable.” This led to the development of donation programs for AIDS drugs, as well as negotiated prices, and finally to generic anti-retroviral drugs that were often developed and approved on a compressed timetable. A similar issue arose over the treatment of people affected by
There can be great value in being unwilling to accept commonly taken approaches that do not adequately serve the poor.
drug-resistant TB. The official position of the World Health Organization at the time was to focus TB treatment on people who carried the most contagious form of TB that could be treated successfully with anti-TB drugs. The prevailing wisdom at the time was that by doing high quality treatment for this group, in a very cost-effective manner, that one could cure the overwhelming majority of TB patients and avoid the development of new cases of drug-resistant TB. This premise was strengthened by the fact that treating drugresistant TB was difficult clinically
and very expensive. Many of the same people who advocated on behalf of lowering the price of drugs for HIV also advocated for the treatment of people suffering from drug-resistant TB. They believed that ignoring patients with drug-resistant TB was morally unacceptable and epidemiologically unsound. Thus, they began to demand the treatment of drugresistant TB, call for lower prices of second-line TB drugs, and established programs to “show the world” how patients with drugresistant TB could be successfully treated. In a relatively short period, partly enabled by these advocates, the world changed its approach and began to treat people with drugresistant TB more actively. The lessons of both of these cases are clear. First, if you stick forever to the same assumptions and approaches, you will never enable needed change. Second, there can be great value in being unwilling to accept commonly taken approaches that do not adequately serve the poor and to ask instead what needs to be done to better meet the needs of these people. Finally, coupling your interest in enabling change with efforts to discover and implement more appropriate approaches can be a powerful way to alter commonly held assumptions and get key stakeholders to accept “another way of doing business.”
www Richard Skolnik, BA Yale College 1972, is a Lecturer at the Yale School of Public Health. You can reach him at email@example.com.
OCD and Me By Hannah Samson
The anxiety associated with these unwanted and disturbing thoughts can be extremely intense, causing the compulsion to be both ritualistic and repetitive.
symptoms can be categorized into specific clusters. Common patterns include obsessions of contamination, with accompanying cleaning compulsions; obsessions with symmetry or order, with accompanying ordering behaviors; obsessions of saving, with accompanying hording; somatic obsessions; aggressive obsessions with checking compulsions; and sexual and religious obsessions.7 Obsessive-Compulsive Disorder is theorized to be a disorder of the affective loop of the basal ganglia,
the brain’s control center for psychomotor behavior. The basal ganglia controls motor learning, sequencing, and movements, attention allocation and filtering, working memory, and implicit learning and memory. 8 There are two pathways in the affective loop of the basal ganglia; both pathways project affective input to the thalamus. However, one pathway (the indirect pathway) passes through more brain areas, relative to the opposing pathway (the direct pathway). OCD is said to result from a neurotransmitter imbalance between the direct and indirect pathway throughout the basal ganglia.9 Excessive relative activity in the direct pathway of the basal ganglia affective loop has been suggested to cause obsessive thoughts that become “trapped.” 10 Once thoughts are trapped, they become obsessions with compulsions to follow. The affective basal ganglia loop provides excitatory projections from both the orbitofrontal and cingulate cortex to the caudate nucleus and ventral straitum. 11 Then, the caudate nucleus sends an inhibitory projection to the globus pallidus, which sends inhibitory projections to the thalamus.12 To complete the loop, the thalamus projects back to the cortex.13 An increase in the first inhibitory step in the caudate nucleus might cause the second step in the globus pallidus to become less of an inhibitor on thalamus, leading to an overactive circuit.14 This “overactive circuit” is believed to cause recurrent thoughts and worries that remain imprisoned in the affective basal ganglia loop. In order to quell the anxiety caused by these persistent thoughts and worries, one performs an act he/ she believes will release those unwanted thoughts. However, due to the loop’s biological dysfunction,
these thoughts and worries return. This creates a horrible “catch 22” scenario in which one’s thoughts and worries reappear along with the subsequent actions in an attempt to dismiss the undesirable thoughts. The frequent reoccurrence of
Not everyone with OCD has a fear of contamination. Not everyone with the common cold experiences the same symptoms. OCD resonates differently across individuals.
the thoughts and worries leads to them becoming crippling obsessions, while the reoccurrence of the subsequent actions results in ritualistic compulsions. While the aforementioned theory is just a hypothesis, I believe it is the most encompassing explanation the scientific community has developed. Not only does it delineate the neuroscience of the disorder, it also explains OCD’s clinical systems in terms of the disorder’s overwhelming obsessions and devastating compulsions. Honestly, that’s what OCD is: both overwhelming and devastating. I was diagnosed with the illness when I was 14 and not a day has done by wherein I don’t think about it and its impact on my life. So, let’s start by addressing OCD’s most common misconceptions. No, I do not wash my hands until they bleed; no, I do not bleach everything before I
touch it; and no, I’m not constantly distract me from learning today in terrified of getting contaminated school so I better tie them just right.” with a lethal illness. As mentioned I would rationalize my compulsions above, obsessions of contamination by telling myself they were normal and their accompanying cleaning and universal. I convinced myself compulsions represent one subset that my (ridiculously) “type A” self of potential symptoms. Not was necessary in order to promote everyone with OCD has a fear of a productive and successful life. contamination. Not everyone with My relatively benign symptoms the common cold experiences the persisted until eighth grade. In eighth grade, for whatever same symptoms. OCD resonates differently across individuals. For reason, my symptoms became me, my biggest symptoms included debilitating. They started to impede obsessions and compulsions my everyday life. I spent an absurd i n v o l v i n g o r g a n i z a t i o n a n d amount of time creating lists and schedules for everything and symmetry. Being generally organized and organizing objects so they aligned preferring items to be linearly either perfectly perpendicular or aligned doesn’t merit an OCD parallel to a reference corner or diagnosis. However, when one’s desk edge. It was in eighth grade that my desire to organize and align becomes immobilizing it is a strong mom began to see my compulsions indication that this individual may as crippling rather than an excess of organization. She noticed have OCD. My earliest memory is one of everything I owned had its place and me at my Grandma and Grandpa’s objects could not be moved without Southampton house in which I subsequent distress. She realized I was scheduling my day…down to would spend a superfluous amount the minute. I was obsessed with of time arranging and re-arranging my day’s organization; I sectioned everything in my room. Though out specific times to go to the she expressed concern, I continued bathroom, eat, change clothes, to rationalize my thoughts—a etc. Whenever the schedule would not go as planned, I would erupt into an anxiety attack and consider the whole day ruined. I was 4 years old. When getting ready for school in the morning, I would tie my shoes for upwards of 30 minutes until the “tightness” of both shoes felt perfectly equivalent. I was obsessed with a general feeling of overall symmetry. I would rationalize my actions by claiming, “I do not Demonstration of an EEG device, used want my shoes to today in neurological research on OCD. Janne Moren
Until recently, scientists thought mental disorders were solely caused by environmental factors. However, modern neural-imaging technology suggests that mental illnesses are “disorders of brain circuits.”1 The advent of enhanced imaging techniques allows neurologists to specialize studies specifically on neural circuits and their connectivity, or the lack thereof, rather than more broadly on environmental influences. In past decades, little could be discovered about abnormal brain circuitry because old electroencephalograph (EEG) technology (the recording of electrical activity along the scalp) revealed minimal detail about circuitry function. 2 With the invention of higher-tech imaging techniques and the high resolution EEG, neurologists can meticulously map area-specific brain function. They can now study “the mind via the brain.”3 Unraveling the biology of mental disorders is important because it can lead to discoveries about how to cure symptoms and ultimately prevent their occurrence. Mapping patterns of cortical activity reveals information about mental function that is not apparent through mere behavior observation. The development of modern neural imaging mechanisms has morphed the way neurologists interpret mental illnesses. Recent records of neural activity seem to indicate that abnormal brain circuitry is a cause for some mental disorders. An example of a mental illness that has been explored via neural imaging mechanisms is ObsessiveCompulsive Disorder (OCD). Those who have ObsessiveCompulsive Disorder experience persistent obsessions and subsequent compulsions in order to alleviate the anxiety that the
debilitating obsessions produce. Obsessions are intrusive thoughts or images, while compulsions are behaviors or mental acts that are executed with the goal of preventing or reducing the distress caused by the obsessions.4 Moreover, patients with OCD experience the continual intrusion of thoughts that cannot be dismissed although individuals generally perceive such thoughts as foreign and irrational.5 The anxiety associated with these unwanted and disturbing thoughts can be extremely intense, causing the compulsions to be both ritualistic and repetitive in order to discharge the obsessive thoughts. 6 OCD
26 hallmark reaction of one with the illness. The summer before my freshman year of high school, I started to notice how my thoughts and compulsions were impacting my everyday life. I couldn’t focus
I am not my OCD and it does not define me....Taking control of my “OCD voice” would set me free from the confines of my own mind.
while in my room because I was fixated on the placement and position of objects. My mom noticed my symptom increase and took me to a neurological behavior center to meet with an OCD specialist. Before, when I wanted to downplay my irrationality, I would have rejected my mom’s gesture. However, I went with no resistance because deep down I knew I needed help and no longer wanted the imprisoned thoughts and worries to dictate my days. In my first session, I was diagnosed with the illness through a combination of self-report surveys and observation. After my diagnosis, my OCD specialist began to explain the therapeutic treatment process. She informed my mother and me that I would begin Cognitive-Behavioral Therapy (CBT). CBT allows patients to use their brain power in order to control their obsessive thoughts and compulsive behaviors rather than letting the condition control them. CBT incorporates Exposure and Response Therapy as well. This form of CBT slowly increases an OCD patient’s contact with the obsession that triggers compulsion.
For example, someone worried about getting germs from things he/she touches would touch the undesirable object and then not wash his/her hands afterward, continuing that until he/she no longer feels anxious when doing so. On my first day of therapy, the specialist explained that I am not my OCD and it does not define me. She described a dichotomy between my “OCD voice” and my “rational voice.” She said it would be a difficult process because my brain would be “fighting with itself.” My “OCD voice” would tell me to do one thing but my “rational voice” would advise against performing that action. She also told me that while this process would be a difficult endeavor, it would also prove to be the most rewarding, as taking control of my “OCD voice” would set me free from the confines of my own mind. A week of obsessions and subsequent compulsions passed and I was back in the office. My specialist and I started to make a plan describing how we were going to overcome the illness together. We started by developing an understanding of how I would tackle my “OCD voice.” She said that I would naturally think of an obsession and then not perform the compulsion in order to face the anxiety that was to follow. Every time I resisted a compulsion I was re-wiring my brain and getting closer to silencing my “OCD voice.” I would tie my shoes just once and deal with the inevitable anxiety caused by the lack of symmetry. I would put a stapler on my desk crooked in relation to the desk’s edge, opposed to perfectly parallel to it, and deal with the subsequent and superfluous anxiety caused by a lack of aesthetic organization. I would not make daily lists and deal with the following anxiety caused by a lack of planning. More specifically, for as long as I can remember, I needed to have all of my pencils face the same way in my pencil case; if they weren’t
in order, I would get extreme anxiety and would move the writing utensils back immediately. One day, I decided to purposely mess up my pens and pencils and address the subsequent anxiety. It took just one day for me to rid myself of that obsession and compulsion. I separated OCD and me in eleventh grade and no longer needed to continue seeing a specialist. However, OCD isn’t something that goes away; I will have it forever. On occasion, I still struggle with organization and symmetry. On occasion, I find myself making lists and schedules, and aligning objects. When that happens, I employ the strategies acquired through CBT; I do the opposite of my “OCD voice” (i.e. – ignore the obsession and fail to perform the compulsion), deal with the subsequent anxiety, and further dichotomize OCD and me. Every time I disregard my “OCD voice,” it becomes quieter and quieter. It has become so quiet that I can barely hear it anymore; my OCD lays dormant and is certainty not empowering. Having OCD doesn’t make me sick, mentally unstable, or “crazy.” It makes me slightly disadvantaged. Maybe it takes me longer to plan out my day or organize a space, but everyone has something that makes him/her slightly disadvantaged: a cough, a broken leg, a broken heart.
Hannah Samson is a sophomore in Pierson majoring in Psychology. You can contact her at hannah. firstname.lastname@example.org
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INDIA: Examining the Efficacy of the RSBY Program in Providing Healthcare for the Rural Poor 1. “Poverty Overview,” World Bank, last modified October 7, 2014., accessed March 30, 2014, http://www.worldbank.org/ en/topic/poverty/overview. 2. “Rural Population,” World Bank, n.d, accessed March 30, 2014, http://data.worldbank.org/indicator/SP.RUR.TOTL. 3. This number of 217.2 million was found by multiplying the percent of the population living below the poverty line, namely 25.2 percent, according to World Bank data from 2012, with the rural population of India, which was 845,151,713 in 2012. 4. Backliwal, Amit, Mark Chang, Neeraj Vashisht, Amardeep Udeshi, Jasdeep Singh, Kushesh Gupta, Sarang Bhide, Amiee Adasczik, Ranga Iyer, Tapan Ray, Ranjit Shahani, and Manish Doshi, “Understanding Healthcare Access in India,” IMS Institute for Healthcare Informatics, June 2013, accessed March 28, 2014, http://www. imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Institute/India/Understanding_ Healthcare_Access_in_India.pdf. 5. Ibid. 6. Sujan, Dheera, and Searada Lahangir, “Indian Doctors Everywhere Except India’s Villages,” Radio Netherlands Worldwide, November 9, 2011, http://www.rnw.org/archive/indian-doctors-everywhere-except-indias-villages. 7. Hou, Xiaohui, and Robert Palacios, Hospitalization Patterns in RSBY: Preliminary Evidence from the MIS, working paper no. 6, World Bank, 2010. 8. Sujan and Searada, “Indian Doctors Everywhere.” 9. Berman, Peter, Laveesh Bhandari, and Rajeev Ahuja, “The Impoverishing Effect of Healthcare Payments in India: New Methodology and Findings,” Economic and Political Weekly 45.16 (2010): 65-71, http://www.epw.in/system/ files/pdf/2010_45/16/The_Impoverishing_Effect_of_Healthcare_Payments_in_India_New_Methodology_ and_Findings.pdf. 10. Shahrawat, Renu, and Krishna D. Rao, “Insured Yet Vulnerable: Out-of-pocket Payments and India’s Poor,” Health Policy and Planning 27.3 (2011): 213-221, doi: 10.1093/heapol/czr029. 11. Ibid. 12. Selvaraj, Sakthivel, and Anup K. Karan, “Why Publicly-Financed Health Insurance Schemes Are Ineffective in Providing Financial Risk Protection,” Economic and Political Weekly 47.11 (2012): 60-68, http://www.epw. in/system/files/pdf/2012_47/11/Why_PubliclyFinanced_Health_Insurance_Schemes_Are_Ineffective_in_ Providing_Financial_Risk_Protection.pdf. 13. Ibid. 14. Devadasan, Narayanan, Tanya Seshadri, Mayur Trivedi, and Bart Criel, “Promoting Universal Financial Protection: Evidence from the Rashtriya Swasthya Bima Yojana (RSBY) in Gujarat, India,” Health Research Policy and Systems 11.29 (2013), doi: 10.1186/1478-4505-11-29.
SWITZERLAND: Regarding Health System Reform 1. Reid, T.R., The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, New York: Penguin Group US (2010), 179-80. 2. “World Development Indicators,” World Bank, last modified January 30, 2014, accessed November 14, 2014, http:// data.worldbank.org/data-catalog/world-development-indicators. 3. Daley, Claire and James Gubb, “Healthcare Systems: Switzerland,” Civitas, last modified January 2013, accessed November 14, 2014, http://www.civitas.org.uk/nhs/download/switzerland.pdf. 4. “Oecd Reviews of Health Systems: Switzerland,” WHO OECD, last modified October 17, 2011, accessed November 14, 2014, http://www.oecd.org/els/health-systems/oecdreviewsofhealthsystems-switzerland.htm. 5. Daley and Gubb, “Healthcare Systems: Switzerland.” 6. Ibid. 7. Lufkin, Thomas and Stefan Stefaniak, The Introduction of Swissdrgs in Switzerland, Paianet: EMBA Healthcare Management Conference (2012). 8. “World Development Indicators,” World Bank, 2014. 9. Rovere, Mark and Bacchus Barua, “Opportunity for Health Reform: Lessons from Switzerland,” Fraser Forum, July/ August 2012, accessed November 14, 2014, http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/ research-news/research/articles/opportunity-for-health-reform-lessons-from-switzerland-ff0712.pdf. 10. “World Development Indicators,” World Bank, 2014.
11. “Oecd Reviews of Health Systems: Switzerland,” WHO OECD, 2011. 12. “World Development Indicators,” World Bank, 2014. 13. “Oecd Reviews of Health Systems: Switzerland,” WHO OECD, 2011. 14. Ibid. 15. Ibid.
GAZA: Enduring Disorder: PTSD in Gazan Children 1. Anderson, Lane, “‘Modern Anne Frank’ Documents her Family’s Struggle…On Twitter,” Deseret News National, August 18, 2014, accessed October 27, 2014, http://national.deseretnews.com/article/2152/39modern-anne-frank39documents-her-familys-struggle-in-gaza8230-on-twitter.html. 2. Sherwood, Harriet and Hazem Balousha, “Gaza Ceasefire: Israel and Palestinians Agree to Halt Weeks of Fighting,” The Guardian, August 26, 2014, accessed October 27, 2014, http://www.theguardian.com/world/2014/aug/26/ gaza-ceasefire-israel-palestinians-halt-fighting. 3. Central Intelligence Agency, “The World Factbook: Gaza Strip,” World Factbook, last modified June 22, 2014, accessed October 27, 2014, https://www.cia.gov/library/publications/the-world-factbook/geos/gz.html. 4. Niaz, Unaiza, “Psychiatric Impact of Wars and Terrorism on Muslim Women,” Arab Journal of Psychiatry 25 (2014): 1-17, accessed October 27, 2014, http://www.arabjpsychiat.com/media/PDF/2014_n/the_arab_journal_2014. pdf. 5. Sait, Siraj and Hillary Lim, Land, Law and Islam: Property and Human Rights in the Muslim World, London: Zed Books, (2006), accessed November 9, 2014, http://books.google.com/books?hl=en&lr=&id=7fZEuiZGyZMC&oi =fnd&pg=PR6&dq=land+ownership+importance+ islam&ots=_ exZUwFNFV&sig=0y3WoiMIxzRhV2grlcCIwzzfFRM#v =onepage&q=land%20ownership&f=false. 6. Thabet, Abdelaziz, Omar El-Buhaisi, and Panos Vostanis, “Trauma, PTSD, Anxiety and Coping Strategies among Palestinians Adolescents Exposed to War in Gaza,” Arab Journal of Psychiatry 25 (2014): 71-81, accessed October 30, 2014, http://www.arabjpsychiat.com/media/PDF/2014_n/the_arab_journal_2014.pdf. 7. Quota, Samir and Eyad El Sarraj, “Prevalence of PTSD among Gazan children in the Gaza Strip,” Arab Journal of Psychiatry 2 (2004): 8-13, accessed November 9, 2014, http://arabpsynet.com/archives/op/opj2.qouta.ptsd. pdf. 8. Altawil, Mohamed, et al. “The Effects of Chronic War Trauma among Palestinian Children,” in Children: The Invisible Victims of War – An Interdisciplinary Study, ed. Parsons, M., Peterborough-England: DSM Technical Publications Ltd. (2011), http://en.ptcgaza.com/files/2011/05/Chapter-in-Book1-The-effects-of-ChronicTrauma-in-Palestine.pdf. 9. Thabet, et al., “Trauma, PTSD, Anxiety…,” 2014. 10. Niaz, “Psychiatric Impact of Wars…,” 2014. 11. Quota and Sarraj, “Prevalence of PTSD...,” 2004. 12. Jacobs, Harrison, “These Maps Show What the Gaza Invasion Would Look Like in Major US Cities,” Business Insider, July 25, 2014, accessed November 8, 2014, http://www.businessinsider.com/these-maps-show-what-the-gazainvasion-would-look-like-in-major-us-cities-2014-7. 13. Quota and Sarraj, “Prevalence of PTSD...,” 2004. 14. “WHO Appeals for US$ 8.7 Million to Rejuvenate, Improve Gaza’s Health System,” World Health Organization, October 14, 2014, accessed October 30, 2014, http://www.emro.who.int/pse/palestine-news/health-systemappeal.html 15. Singal, Jesse, “A Youth-PTSD Catastrophe is Brewing in Gaza,” New York Magazine, July 22, 2014, accessed October 29, 2014, http://nymag.com/scienceofus/2014/07/youth-ptsd-catastrophe-is-brewing-in-gaza.html. 16. Victoroff, Jeff, “The Mind of the Terrorist: A Review and Critique of Psychological Approaches,” Journal of Conflict Resolution 49 (2005): 3-25, accessed November 9, 2014, http://www.surrey.ac.uk/politics/research/ researchareasofstaff/isppsummeracademy/instructors%20/The%20Terrost%20mind.pdf. 17. DeAngelis, Tori, “Understanding Terrorism,” American Psychological Association 40.10 (2009): 60, accessed November 9, 2014, http://www.apa.org/monitor/2009/11/terrorism.aspx. 18. “Serious Upsurge of Post-Conflict Trauma in Gaza, says UN,” United Nations Relief and Works Agency, January 22, 2013, accessed October 29, 2014, http://www.unrwa.org/newsroom/press-releases/serious-upsurge-postconflict-trauma-gaza-says-un. 19. Allen, Nick and Inna Lazareva, “Gaza Conflict ‘Causing PTSD in Children’ after Seeing Dead Bodies and Witnessing Heavy Shelling,” Telegraph UK, August 7, 2014, accessed October 30, 2014, http://www.telegraph.co.uk/news/ worldnews/middleeast/gaza/11020070/Gaza-conflict-causing-PTSD-in-children-after-seeing-dead-bodies-andwitnessing-heavy-shelling.html. 20. “Gaza: Mental Health,” International Medical Corps, n.d., accessed October 30, 2014, https:// internationalmedicalcorps.org/sslpage.aspx?pid=1521#.VFHr74vF8dI.
PERU: Burns in Peru: A Neglected Global Health Crisis 1. “Nosotros,” ANIQUEM, n.d., accessed August 22, 2014, http://www.aniquem.org/nosotros/. 2. “Burns: The Neglected but Solvable Health Crisis,” ReSurge International, n.d., accessed August 22, 2014, http://www. resurge.org/ways_to_help/story_rethink_burns.cfm. 3. World Health Organization. “Burns.” Violence and Injury Prevention, n.d., accessed August 22, 2014, http://www. who.int/violence_injury_prevention/other_injury/burns/en/. 4. Ibid. 5. “Burns,” ReSurge International, n.d. 6. Wiechman, Shelley A., and David R. Patterson, “ABC Of Burns: Psychosocial Aspects Of Burn Injuries,” BMJ: British Medical Journal, 329.7462 (2004): 391-393, doi: 10.1136/bmj.329.7462.391. 7. Ibid. 8. Ministerio de Salud del Perú. “Guía Clínia: Gran Quemado.” Serie Guías Clínicas Minsal, 55 (2007), Lima: El Ministerio De Salud Del Perú, http://web.minsal.cl/portal/url/item/7222d6a3774f3535e04001011f01482e.pdf. 9. Ibid. 10. Dissanaike, Sharmila, and Maham Rahimi, “Epidemiology of Burn Injuries: Highlighting Cultural and Socio-demographic Aspects,” International Review of Psychiatry 21.6 (2009): 505-11, doi: 10.3109/09540260903340865. 11. “UN: Peru Posts One of Region’s Best Reductions in Poverty in 2011.” Andean Air Mail and Peruvian Times, November 28, 2012, http://www.peruviantimes.com/28/un-peru-posts-one-of-regions-best-reductions-inpoverty-in-2011/17551/. 12. Ministerio de Salud del Perú, “Guía Clínia: Gran Quemado,” 2007. 13. Ibid. 14. “Nosotros,” ANIQUEM, n.d. 15. Ibid. 16. “Estadísticas,” ANIQUEM, n.d., accessed August 22, 2014, http://www.aniquem.org/estadisticas. 17. Pichihua, Sofia, “En Perú, 15 Mil Niños Sufren Quemaduras,” Perú 21., n.d., accessed October 26, 2014, http://peru21. pe/noticia/670796/peru-15-mil-ninos-sufren-quemaduras-al-ano. 18. World Health Organization, “Burns,” n.d. 19. “Burns,” ReSurge International, n.d.
OCD and Me 1. Insel, Thomas, “Mental Illness Defines as Disruption in Neural Circuits,” National Institute of Mental Health, August 12, 2011, http://www.nimh.nih.gov/about/director/2011/mental-illness-defined-as-disruption-in-neuralcircuits.shtml. 2. Ibid. 3. Ibid. 4. Maia T.V., Cooney, R., and P. Bradley, “The Neural Bases of Obsessive–Compulsive Disorder in Children and Adults,” Development and Psychopathology 20.4 (2008): 1251-83, http://www.ncbi.nlm.nih.gov/pubmed/18838041. 5. Rolls, E.T, “Glutamate, Obsessive–Compulsive Disorder, Schizophrenia, and the Stability of Cortical Attractor Neuronal Networks,” Pharmacology, Biochemistry, and Behavior 100.4 (2012): 736-51, http://www.ncbi.nlm. nih.gov/pubmed/21704646. 6. Ibid. 7. Ibid. 8. Ring, H.A., and J. Serra-Mestres, “Neuropsychiatry of the Basal Ganglia,” Journal of Neurology, Neurosurgery & Psychiatry 72 (2002): 12-21, http://www.ncbi.nlm.nih.gov/pubmed/11784818. 9. Maia et al., “The Neural Bases...,” 2008. 10. Ibid. 11. Insel, Thomas, “Toward a Neuroanatomy of Obsessive-Compulsive Disorder,” Archives of General Psychiatry 50.6 (1993): 501, http://www.ncbi.nlm.nih.gov/pubmed/1514879. 12. Ibid. 13 .Ibid. 14. Ibid.