Borders magazine

BORDERSReflections on

the Global Burden of Disease

Week 3 : G loba l Burden of Disease Research wi th Dr. Vic Neufe ld

Seema MehtaPalika Kohli

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Seema Mehta (co -creator) i s spec ia l iz ing in the d is -ease s tream in the McMas -ter G loba l Hea l th MSc Pro -g ram. She has a par t icu lar interest in g loba l ped iatr ic and materna l hea l th , and en joyed learning and de -bat ing about the natures o f in fect ious , surg ica l and non -communicab le d isease burden.

Pa l ika Kohl i (co -creator) i s spec ia l iz ing in the g lo -ba l izat ion s tream in the McMaster G loba l Hea l th MSc Prog ram. She is espec ia l ly interested in g loba l ped iatr ic and psy -ch iatr ic hea l th , and en -joyed the focus p laced in th is course on the soc ia l determinants o f hea l th in the g loba l context .

Week 4 : G loba l Burden of Chronic Disease wi th Dr. Josh Manolakos Seema + Palika

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As the in ternat iona l com-muni ty cont inues to focus i t s effor t s on combat ing the g lobal burden of infect ious d i seases , a growing burden of non-communicable d i s -eases (NCDs) has emerged re la t ive ly unnot iced in the deve lop ing wor ld . Al though often thought to d i spro-por t ionate ly affect high-income count r ies and o lder ind iv idua l s , Dr . Manolakos ’ lec ture prov ided impor tant fact s to d i spute thi s line of reasoning . Card iovascular d i seases , cancers , chronic resp ira tory d i seases and d iabetes affect a ll age groups and a ll reg ions . Cla iming 38 million li ves every year , approx imate ly 80% of the deaths a t t r ib -u ted to these d i seases now occur in low- and middle- in -come count r ies . In addi t ion , 16 million of these deaths occur before the age of 70 .

Thi s idea s igni ficant ly cha l -lenged my prev ious ly he ld be lief s - that obes i ty , un-heal thy d iet s , phys ica l in -act iv i ty and tobacco smoke as r i sk factors affect Nor th Amer ican communi t ies more than the g lobal communi ty . As a resul t of rap id un-p lanned urbanizat ion , the g lobalizat ion of unheal thy li fes ty les and the age ing of the g lobal populat ion , non-communicable d i seas -es have become a s igni fi -cant cause of mor ta li ty and morbid i ty wor ldwide . I t i s an i s sue that undoubtedly requires more at tent ion .

In low and middle- income count r ies , vulnerable and socia lly d i sadvantaged people get s icker and d ie so oner than ind iv idua l s of higher s ta tus . As a re-sul t of low access to edu-cat ion and serv ices and

products that can protect them f rom impor tant r i sks , they are d i spropor t ionate-ly affected by NCDs when compared to ind iv idua l s who have the necessary knowledge and resources to manage these act iv i -t ies . Therefore , a l though we share the modi fiable behav ioura l r i sk factors as a g lobal communi ty , the management , prevent ion s t ra teg ies and socioeco-nomic impacts that resul t f rom the d i sease are not qui te equally d i s t r ibu ted . As a set of d i seases that are eas ily preventable and manageable wi th low-cos t li fes ty le modi ficat ions , I be lieve that NCDs should be targeted wi th edu-cat ion programs , po licy changes on the sa le of to -bacco and cer ta in fo ods and fina lly , pat ien t leve l knowledge t rans la t ion .

Palika KohliThi s we ek ’ s lec ture was about the env i -ronment and g lobal hea l th , two top ics I have be en in teres ted in separate ly but haven ’ t ever exp lici t ly connected . Dr . Chr i s t ian Kraeker ’ s presentat ion s lides served to cover a myr iad of top ics , and I read through them before turning to the ar t icle pos ted for us . The s lides served as a go od ref resher on the ba-s ics of g lobal warming , mak ing ment ion of the gre enhouse effect , foss il fue l s and o il f rack ing . H i s s lides a l so exp lore how the deve lop ing wor ld i s impacted by climate change , and highlight some impor tant env ironmenta l changes that have resul ted f rom g lobal warming : r i s ing temperatures , increas ing flo od-ing , droughts , heat waves and s torms . The par t of hi s lec ture that focussed in par t icular on water , was te and hyg iene was where there was the mos t over -lap wi th the ar t icle we were ass igned to read, Ta lk ing Dir ty – The Po li t i c s of Clean Water and Sani ta t ion , by Drs . Barry and Hughes . Thi s ar t icle prov id-ed a succinc t and hi s tor ica l account of water sani ta t ion . I t goes on to prov ide a g lobalized account of var ious water -re la ted illnesses that ar i se f rom i s sues

of access ibili ty to sani tary water . I es -pecia lly li ked thi s ar t icle because i t d id a go od job of us ing s ta t i s t i c s to pa in t a s tory . For example , the authors ment ion arsenic po i soning in Bangladesh to il -lu s t ra te how scarce sani tary water i s in some reg ions of the wor ld . They la ter return thi s po in t after descr ibing other ways in which water - re la ted d i seas-es can be t ransmi t ted , and note how thi s ins tance of arsenic po i soning was the “ larges t occurrence of po i soning in a s ing le populat ion” (786) . The au-thors d i scuss the many d i fferent types of water - re la ted illnesses that ex i s t , includ ing illnesses due to waterborne pathogens , inadequate water , water -based in termediate hos t s ( i . e . d i seases t ransmi t ted through aquat ic sna il s ) , wa-ter -bre eding– insect vectors and fina lly waterborne tox ins . They conclude by lo ok ing at changes occurr ing in a g lo -ba lized contex t , po in t ing to ini t ia t ives such as the UN MDGs and the Tokyo G8 summi t as ev idence of the impor-tance of s tar t ing the conversat ion on water sani ta t ion . s tep in dealing wi th i t .

Week 5 : Water, Sani ta t ion and Hea l th wi th Dr. Chr is t ian Kraeker

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Week 5 : Water, Sani ta t ion and Hea l th wi th Dr. Chr is t ian Kraeker, cont inued :Seema MehtaHaving only ever li ved in a count ry where clean wa-ter and sani ta t ion are rare i s sues , i t i s d i fficul t for me to imagine the magni tude of waterborne tox ins , water -bre eding insects , water - re la ted infect ions and other in -adequate sani ta t ion i s sues that make people s ick around the wor ld . In Canada, I tu rn on my faucet and fe e l con-fident that I w ill not cont ract a dangerous d i sease and compla in only of the temperature of my dr ink ing wa-ter and the length of showers that I can take before my ro ommate wakes up in the morning . For thi s reason , I fe e l that i t i s d i fficul t to capture the at tent ion of the g lobal communi ty on an i s sue that many of us cannot re -la te to . How do you bes t se ek commi tment f rom funders and nat iona l leaders on thi s top ic? How can we be-come more aware and reminded of our pr iv ileged s ta tus?

I t i s no surpr i se that the water and sani ta t ion cr i s i s i s among the mos t neg lected of the Uni ted Nat ions ’ Mil -lennium Development Goals . However , the fact that we cannot eas ily re la te to thi s faraway i s sue should a llow us to ga in a par t icular perspect ive on i t . A bas ic neces-s i ty that requires a lmos t no second thought to us i s s im-p ly not ava ilable to more than 2 .6 billion people around the wor ld–an unimaginable d i spar i ty . In thi s way , access to clean dr ink ing water should be cons idered a human r ight s i s sue and not s imply a top ic of d i scuss ion . How-ever , i t i s clear that the universa l rea li ty does not reflec t

thi s pr incip le . We cont inue to a llow for some par t s of the wor ld to enjoy 400 li ters of water a day while more than 35% of the wor ld ’ s populat ion will never se e thi s much clean water in the ir li fet ime . As a resul t of be ing a major cause of illness and death , water sani ta t ion i s sues are a determining factor for socioeconomic i s sues such as edu-cat ion , pover ty and economic oppor tuni t ies . In addi t ion , improved sani ta t ion can reduce child mor ta li ty by more than 30% and s igni ficant ly reduce the g lobal burden of illness . A lack of g lobal inves tment in water and sani ta t ion i s one of the mos t impor tant threats to human well be ing wor ldwide and i t i s a problem that we cannot ignore .

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Week 6 : Infect ious (Non -Neg lected) Diseases wi th Dr. Jef f Pernica Seema + Palika

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Dr . Pernica ’ s lec ture on infect ious d i seases in a g lobal hea l th contex t a llowed me to bet ter conceptua lize and conso lidate concepts that I have learned in o ther courses thi s semester - vaccine immunology and abor ig i -na l hea l th . As one of the wor ld ’ s thre e larges t k ille rs , tuberculos i s has infected over one- third of the g lobal populat ion and cont inues to cla im a lmos t two million li ves a year . I t i s an infect ion that conta ins a var iety of r i sk factors and puts infants , immunocompromised ind i -v idua l s and HIV/AIDS pat ien t s a t a greater li ke liho od for acquir ing the illness . Al though i t has succe eded in dras t ica lly reducing the incidence of thi s d i sease , the Bacille Calmet te-Geur in vaccine deve loped in 1921 i s now var iably effect ive . Wi th a success ra te rang ing f rom 0-80% across geographic reg ions , thi s fa ilu re i s of par t icular impor tance to low and middle- income nat ions that exper ience d i spropor t ionate ly high rates and a l -ready su ffer f rom low socio-economic condi t ions . As an impor tant i s sue , the deve lopment of a new vaccine to target Tuberculos i s i s v i ta l to the heal th of the g lobal communi ty . In Canada, the rate of TB infect ion has be en among the lowest in the wor ld for many years . However , desp i te thi s decreased incidence Abor ig ina l populat ions cont inue to exper ience much higher ra tes of infect ion than non-Abor ig ina l populat ions . Due to overcrowd-ing in hous ing , limi ted access to heal th care and other impor tant hea l th inequi t ies , Firs t Nat ions and Inui t popu-la t ions are current ly a t increased r i sk for be ing infected wi th TB and deve lop ing the act ive form of the d i sease .

Often cons idered to be “a d i sease of the po or , ” Tuber -culos i s often d i spropor t ionate ly affect s d i sadvantaged communi t ies and in do ing so , creates even worse condi -t ions for ind iv idua l s affected by the d i sease .

HIV/AIDS i s another infect ion that i s respons ible for mil -lions of deaths every year . Wi th access to to o l s that can eas ily t reat the infect ion and lab tes t s that can quick ly d iagnose the d i sease , a major barr ier to adequate con-t ro l of HIV i s the d i s t r ibu t ion of these resources to hard to reach communi t ies . In a formal debate wi th my vac-cine immunology classmates recent ly that was left w i th -out a winner , i t was a l so in teres t ing ly d i scussed whether i t i s more sui table for HIV/AIDS fund ing to be targeted towards educat ion campaigns or vaccine effor t s .

Week 8 : G loba l Burden of Neg lected Disease wi th Dr. Mar tha Ful ford Palika + Seema

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Dr . Ful ford ’ s lec ture on the neglected t rop ica l d i s -eases (NTDs ) was ex t remely thorough . She began by prov id ing the hi s tor ica l contex t on d i scourse and per-cept ions of t rop ica l d i seases , and then d i fferent ia t -ed NTDS f rom other t rop ica l d i seases . I rea lly li ked thi s par t of her lec ture , because here , Dr . Ful ford focussed on the influence of language in po licy -mak-ing , and the impact i t can have on drawing at ten-t ion to areas that ne ed i t . She d i scussed how NTDs are defined , and how they are d i scr iminant : that they are mos t preva lent in areas of pover ty , and fur ther cont r ibu te to the cycle of pover ty . People who su ffer f rom NTDs can be impacted by impaired growth and in te llec t , which often leads to reduced socia l s tand-ing , a lower li ke liho od of rece iv ing an educat ion , lower worker product iv i ty and ul t imate ly a lower socioeconomic s ta tus . Thi s fu r ther means that fu ture generat ions have a higher li ke liho od of remaining in an area where fu ture generat ions can cont ract an NTD. Signi ficant ly , thi s area of impact i s a lmos t exclus ive ly focussed on thi s group of people , and rare ly impacts people be long ing to more affluent populat ions .

Dr . Ful ford worked to get us think ing about how fund ing for d i seases works - who i s inves t ing , who i s profi t ing and who i s ac tua lly rece iv ing ne eded t reatments . She rea lly highlighted how “neglected” li tera lly refers to the fact that these d i seases re-ce ive less fund ing , and have less ava ilable/ acces-s ible t reatments - that i s , they are defined by the

lack of awareness sur round ing them . Her d i scuss ion was very open , and she a llowed our class to exp lore var ious ideas , encourag ing our ques t ions , no mat ter how se eming ly off - top ic they were . At one po in t , she spoke to current events , and sa id , “ I don ’ t even want to think about the s i tuat ion in Syr ia r ight now. ” The s t r i k ing thing was that she was speak ing in par t icular about the heal th s i tuat ion of people in Syr ia , and when she sa id i t , I thought to myse l f that thi s i s what g lobal hea l th i s about - think ing about those condi -t ions , cons ider ing the people who are su ffer ing while they t ry to li ve , and ul t imate ly work ing to he lp them in thi s endeavour .

Week 9 : G loba l Burden of Surg ica l I l lness wi th Dr. Br ian Cameron Palika + Seema

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The firs t ha l f of thi s we ek ’ s class covered a lec ture by Dr . Cameron , who turned the focus of the class onto the impor tance of the surg ica l burden of d i sease . He spent a go od por t ion of hi s lec ture demons t ra t ing the impor tance of s ta t i s t i ca l measurement to he lp dr ive home the impor-tance of surg ica lly t reatable illness and d i sease . For exam-p le , he exp lored methods of ca lcula t ing DALYs to ind icate how much people wi th surg ica lly t reatable d i seases su ffer on a g lobal sca le . While I got a li t t le los t amongs t the numbers , thi s much I unders to od : there i s a s igni ficant num-ber of people su ffer ing f rom illnesses that can be t reated and even cured by surg ica l procedures . The ir burden often means that while they surv ive on a day- to-day bas i s , the ir qua li ty of li fe i s great ly reduced . Most po ignant ly , Dr . Cam-

eron argued, thi s reduced qua li ty of li fe i s PREVENTABLE .

Dr . Cameron ’ s ta lk made me cons ider my uncle , Dr . Har i sh Kohli , who pract ices as an or thopaedic surgeon in the ci ty of Dehradun in Ind ia . I have spent a great deal of t ime wi th him , and have se en how powerfully he impacts and improves the li ves of hi s pat ien t s . What I have never cons idered be-fore i s how limi ted hi s reach i s – he i s located in a reason-ably affluent ci ty , and many of hi s pat ien t s have to t rave l in f rom the outsk ir t s of Dehradun to rece ive hi s t reatment . Moreover , what he i s able to do for hi s pat ien t s i s limi ted by what they can afford , though I have se en him cover pa-t ien t expenses on hi s own mul t ip le t imes (a commendable , though non-sus ta inable , pract ice ) . Dr . Cameron rea lly high-lighted an area of g lobal d i sease that i s often over lo oked .

The second ha l f of the class cons i s ted of a debate be-twe en that was led by Dr . Hunter . The argument focussed on which area of g lobal d i sease should rece ive fund ing : infect ious , chronic and surg ica lly t reatable d i seases . While the debate highlighted and impor tant and rea li s t i c ques -t ion , I found myse l f in a mora l quandary as I li s tened to my pe ers speak - why do we have to cho ose? Who makes these cho ices? And based on what cr i ter ia? There don ’ t se em to be any easy answers to these ques t ions , though I apprecia ted the oppor tuni ty to vo ice them at a ll .

Week 10: G loba l Burden of Ped iatr ic Disease wi th Dr. Andrea Hunter Seema + Palika

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Dr . Andrea Hunter d i scussed the ep idemio logy and ro ot causes of under - five mor ta li ty on a g lobal sca le in a unique way . By engaging in small group d i scus -s ion , we were able to reflec t on our ex i s t ing knowl -edge base and percept ions of the top ic while as -sess ing our own pr iv ileges . An in teres t ing ques t ion that had my par t icular group s tumped was : how do you make thi s i s sue impor tant to someone who has no idea about i t? Al though we bra ins tormed p lenty of ideas , we fe ll shor t on many accounts . As Dr . Hunter d i scussed , thi s very idea i s one of the mos t impor tant i s sues sur round ing d i spar i t ies , d i seases and deve lop-ments in the pediat r ic populat ion .

Four of the mos t preventable d i seases - neonata l deaths , acute resp ira tory illnesses , malar ia and d iar -rhea- cause the mos t child deaths . In addi t ion , mal -nu t r i t ion over lays approx imate ly 40% of a ll childho od deaths under the age of 5 , genera lly caus ing a hos t of o ther s igni ficant complicat ions . Unfor tunate ly , re -sources to prevent malar ia are often offered to na-t ions wi th high preva lence rates but get mi sused in many ways . As a resul t , bed nets that get bought and shipped over to these count r ies are not often used for the purpose of protect ion . Inadequate access to fo od and breas t fe ed ing , po or materna l hea l th and knowl -edge and nut r ien t -deficien t d iet s are a ll broader i s -sues that affect the preva lence of d i sease .

One par t icular thing that resonated wi th me mos t dur ing Dr . Hunter ’ s lec ture was the idea that the child mor ta li ty ra te i s “ the saddes t go od news in the wor ld . ” Al though i t i s go od news that the child mor ta li ty has for the firs t t ime d ipped be low 10 million in the las t 10 years , the fact that we are ce lebrat ing thi s i s sad . How can we work to change thi s rea li ty? How can we demons t ra te to the g lobal communi ty that thi s i s an i s sue wor th pay ing at tent ion to?

Week 11: G loba l Burden of Materna l Hea l th wi th Dr. Asa Ahimbis ibwe Seema + Palika

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Women have be en g iv ing bir th for thousands of years but every day , 20 mothers s t ill d ie of preventable causes dur ing thi s natura l process in Uganda . Ins tead of present ing us wi th an array of s ta t i s t i c s , Dr . Ahumbis i -bwe asked us a s imple but thought -provok ing ques t ion : why does thi s happen? After he out lined the typ ica l we ek- long process of undergo ing labour , we began to bra ins torm . The leading causes of materna l death in -clude infect ion , pos t -par tum hemorrhage , obs t ruc ted labour and complicat ions wi th abor t ions , we responded confident ly . Al though he agre ed, Asa added long wai t t imes , po or inf ras t ruc ture , no running water or e lec t r ic -i ty , po li t i ca l ins tabili ty , cul tu ra l ideo log ies and lack of fund ing to our li s t . I t became clear to use then that in Uganda, the problems sur round ing materna l hea l th were complex and the so lu t ions would not be easy to achieve .

What resonated wi th me mos t f rom Asa ’ s lec ture was the idea that dy ing f rom childbir th has become normal -ized in Ugandan communi t ies . As a resul t of be ing so preva lent and mos t ly unavo idable for a var iety of rea-sons , women are a lmos t expected to go through pa in -ful , dangerous and li fe - threatening labour processes . To me, thi s speaks to impor tant gender equali ty i s sues and sugges t s that women as the bearers of li fe are not va lued in society . What can we do to change thi s ideo l -ogy and the current s t ra teg ies in p lace for undergo ing child labour? What would i t lo ok li ke for women to come in to a hosp i ta l and get serv ices that would a llow for her to de livery a heal thy baby and surv ive the process? Wi th a var iety of d i fferent s takeholders invo lved in the

i s sue , rea liz ing thi s goal would require the co operat ion of phys icians , po li t i cians , the heal th care communi ty and essent ia lly , the men in society . As Asa put i t , “no one p leads innocent . ” Dr . O’Shea unique ly depic ted the d i spar i ty that ex i s t s betwe en materna l hea l th care in Canada and care rece ived by women in Uganda by s ta t -ing that while 5 phys icians a t tended to hi s wi fe dur ing child labour , one phys ician in Uganda typ ica lly a t tends to more than 20 women at once for a s imilar procedure .

Week 12: Hemog lob inopathies wi th Dr. Made le ine Verhovsek Palika + SeemaDr . Verhovsek began our lec ture on g lobal hemato logy by prov id ing us wi th an agenda . Thus , she set up our d i scuss ion to be well - rounded r ight f rom the beginning , let t ing us know what we were in for . She s tar ted off wi th the bas ics : what hemato logy i s , what research in thi s fie ld enta il s , and then moved onto the impact illness of the blo od have on the g lobal populat ion , and fina lly the socia l determinants of hea l th that impact the way these illnesses are perce ived and t reated . I found myse l f ap-precia t ing Dr . Verhovsek ’ s background on hemato logy , as she s t rove to use laypeople language and v ideos to he lp exp la in her po in t s and prov ide contex t to the s ta t i s t i c s she presented . She focussed a great deal on anemia , par t icu -lar ly s ick le -ce ll anemia , as thi s i s an illness that has an ex tens ive g lobal burden . Dr . Verhovsek d i scussed types of anemia , how i t i s t reated , as well as i t s preva lence and incidence on a g lobal sca le , includ ing i t s socioeconomic impact (genera lly more preva lent in low- income areas ) . She rea lly drove home how ho li s t i c and impor tant hema-to logy t ruly i s ; firs t , how i t covers a range of i s sues , f rom anemic to blo od clo t t ing . One thing I rea lly apprecia ted was how she premised the second ha l f of her lec ture wi th the d i fferent ways in which symptoms of blo od d i seases

mani fes t and in ter fere wi th day- to-day li fe , often severe-ly reducing pat ien t ’ s qua li ty of li fe . She made me rea lize how illnesses of the blo od are not (perhaps obv ious ly , though not sa lien t ly ) loca lized , and impact a person ’ s ent ire body .The second par t of her ta lk focussed on how socia l and cul tu ra l fac tors impact the way su fferers of s ick le -ce ll anemia are t reated . Dr . Verhovsek in t roduced thi s idea through v ideos , firs t highlight ing the d i fficul t ies associa ted wi th su ffer ing f rom high leve l s of chronic pa in , and second focuss ing on i s sues of race and how they im-pact pat ien t s . Thi s was one of the firs t t imes I have be en exposed to i s sues of race in the fie ld of medicine . Dr . Ver -hovsek d id not shy away f rom s ick le -ce ll anemia pat ien t s ’ rea li t ies , as they are often black persons of co lour who are in ne ed of high doses of narcot ics . As i t tu rns ou t , everyone i s capable of mak ing judgments - be they lay-people or emergency ro om doctors . One of the v ideos Dr . Verhovsek showed depic ted a doctor whom I found po in ted out the bes t (and rea lly , only ) so lu t ion : i t doesn ’ t rea lly mat ter i f pat ien t s are drug-se ek ing , because of the doctor thinks thi s and i s mi s taken , then the doctor has bro-ken that one s igni ficant commandment– firs t , do no harm .

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Week 13 : G loba l Burden of Psychiatr ic I l lness wi th Dr. She i la Harms Palika + SeemaDr . Harms began wi th a lo ok at genera l concepts that we have a lready covered in one form or another : What are MDGs? she asked . What are they , speci fica lly? Beyond that (and perhaps more impor-tant ly ) : what do we think? Are the MDGs useful? How have they precip i ta ted change? How have they fa iled? How does Canada compare What do we think i s s igni ficant? Wi th every po in t we ra i sed , she would summar ize our ideas and present them back to us , effec t ive ly p lacing us in the spot light and emphas iz -ing her be lief that we, as g lobal hea l th s tudents , are the people who should be think ing about these i s sues .

Dr . Harms ’ presentat ion was ro oted in complex i ty theory - the not ion that

the i s sues we were d i scuss -ing i s , well , complex - we cannot jus t po in t to one ro ot problem to exp la in the ex i s tence of the g lobal burden of d i sease . The second ha l f of her presen-ta t ion focussed on her own specia li ty , g lobal psychia t -r ic d i sease , a top ic I have be en lo ok ing forward to s ince the beginning of the semester . I par t icular ly enjoyed how a lo t of Dr . Harms ’ lec ture was based on re levant li terature . For example , she began her d i scuss ion by ci t ing the t i t le of the firs t ar t icle in the Lancet ser ies on g lobal menta l hea l th : “No heal th wi thout menta l hea l th . ”

We broke down the WHO’s defini t ion of hea l th , and d i scussed the impact of the DSM V in the fie ld of psy-chia t ry around the g lobe .

Dr . Harms ment ioned how thi s defini t ion focussed in par t icular on cap i ta li s t and western not ions of produc-t iv i ty , something I rea lly apprecia ted , because thi s i s where our d i scuss ion got rea lly in teres t ing . She po in ted to the hi s tory of the DSM, unpack ing how the background of i t s cre-ators impacted the ir per -cept ions of menta l illness . Thi s not ion of in tersect ion-a li ty (Dr . Harms noted how the major i ty of the DSM I creators were o ld whi te Jewish men ) prov ided a great segue in to the case s tudy we spent the remain-der of the class on .

I t was a case she herse l f observed , of a young g ir l in Uganda who exper i -enced loss of consciousness and was se ek ing t reat -ment . The case de lved in to

the g ir l ’ s background , and d i scussed how she went to AIDS clinics to p lay wi th children in her communi ty , how her fa ther was an a lcoho lic who would beat her , and how her mother suppor ted her fa ther . She descr ibed the g ir l ’ s d iag-nos i s and how her psychia-t r i s t handled the s i tuat ion . I rea lly apprecia ted how Dr . Harms ’ brought the im-por tance of cul tu ra l contex t to light , as she asked our class to think of reasons behind the g ir l ’ s ac t ions , her fa ther ’ s ac t ions and even her family ’ s socio-economic s i tuat ion . Dr . Harms d id a wonderful job of showing our class how menta l hea l th and illness ex i s t s and i s deal t w i th on a g lobal sca le .

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