World Suicide Prevention Day 2019

Author’s Note: This article discusses suicide and may be triggering for individuals with lived experience. While resources will be presented later on, this website has a list of country specific resources for those who need them. If you or someone you know is struggling with passive or active suicidal ideation, please reach out for help. 

The National Suicide Prevention Hotline in the USA is 1-800-273-8255.

Every 40 seconds someone, somewhere in the world, takes their own life. That amounts to over 800,000 deaths per year. On September 10th each year, World Suicide Prevention Day, the world comes together to reflect on the lives lost and bring suicide prevention to the forefront of the conversation. 

What Suicide Looks Like Around the World

Like most things in global health, there’s no single causal factor and no “one-size-fits-all” solution. Preventing suicide globally will require an understanding of the way individual, interpersonal, societal, and cultural factors interact to affect suicidality. High income countries, on average, have higher rates of suicide than low- and middle- income countries (LMICs), with the exception of LMICs in South-East Asia where the regional suicide rate is the highest in the world (17.7 deaths per 100,000 people). While rates may be higher elsewhere, suicide isn’t just a problem for high-income countries. The majority of suicides actually occur in LMIC settings, highlighting these countries as important stakeholders in the global conversation around suicide. 

Image Credit: World Health Organization (WHO)

Like the rates themselves, at-risk sociodemographic groups vary from region to region. Suicide is the second leading cause of death, globally, for young adults (18-29 years of age). Middle aged men in high-income countries generally have a higher risk, while adolescents and aging adults in LMICs are more likely to take their lives. 

Globally, males are 2-3 times more likely to complete suicide than women. This has long been blamed on differences in care seeking behaviors and socially acceptable coping mechanisms deemed acceptable for different genders. But it’s important to keep in mind that women are generally more likely to experience suicidal ideation and more likely to attempt suicide. Men, however, have historically used more lethal methods of suicide and more likely to take measures to prevent intervention. 

The means of suicide attempts vary drastically and adapt to environments. Pesticide poisoning accounts for about one-third of global suicides. Almost all of these deaths occur in rural subsistence farming communities. Self-inflicted firearm injuries account for a large proportion of suicides in the Americas. Urban contexts with much stricter firearm regulations, such as Hong Kong and Singapore, experience a higher number of deaths related to jumping from buildings and bridges. 

What We Can Do

Suicide may look differently depending on where we sit on a map, but the truth remains that the pain and suffering that causes and is caused by suicide cuts across every sociodemographic variable and exists in every corner of the world. Despite its inclusion in both the WHO’s Mental Health Action Plan and the United Nation’s Sustainable Development Goals (Target 3.4), suicide remains a low-priority agenda item for policy-makers worldwide. Only about 40 countries currently have national strategies or action plans in place to respond to suicide, and even fewer of these are in LMIC settings where the majority of suicides occur. 

While national strategies with government engagement will be crucial to eliminating suicide, suicide prevention requires multisectoral and multilevel approaches that treat suicide as the complex public health problem that is. It is the community and the individuals close to a victim of suicide that will suffer the most in the aftermath and have the most power in targeted prevention efforts delivered to the individual. 

Primary care professionals, especially those serving communities that are underserved by specialists, can and should be more familiar with using depression screeners like the Patient Health Questionnaire or Beck Depression Inventory to assess suicidality in the exam room. Educators can advocate for school-based intervention and encourage (not punish) help-seeking behaviors. And while we can’t all be psychiatrists, suicide crisis line volunteers, or counselors, we can all be kind people to those around us. Use today to raise awareness for the issue. Educate yourself (and others) about suicide prevention resources available in your community. As friends and family members, we can all do a better job of dismantling the stigma around mental health and identifying when those close to us are experiencing acute stress or grief that may serve to trigger or exacerbate existing suicidality. 

Where we live might affect what suicide looks like, who is at risk, and how often it happens. Our professional roles may dictate at what level we help break the cycle. But today is a reminder that we are all responsible, as stewards of humanity, for reducing the number of suicides in our world. In the time it took you to read this article, five people will have taken their own life. Every suicide death is one too many, so now is the perfect time to consider: what will YOU do to make sure it doesn’t happen again?

Looking for a starting point? I’ve compiled a wealth of resources that may be helpful, in addition to the links embedded in the text throughout the article. 

Helping Individuals At-Risk:

List of International Suicide Crisis Lines
Learn the Signs Factsheet (Take 5 to Save Lives)

Helping Someone in Crisis (Take 5 to Save Lives)

Find a Mental Health First Aid Course (USA)

Suicide Prevention: A Resource for General Physicians (Available in Multiple Languages)

Get Involved in World Suicide Prevention Day:

Download and post a WSPD banner in your native language

“Light a Candle” for victims and survivors of suicide

Post on social media using the hashtags: #wspd, #suicideprevention

Data:
Look up your country’s suicide rates

Suicide Factsheet (WHO)

Suicide Prevention: A Global Imperative (WHO)

World Suicide Prevention Day Fact Sheet (IASP)

National Prevention Strategies:
Does your country have a national action plan for suicide prevention? 

National suicide prevention strategies: progress, examples and indicators (WHO)

Evidence based strategies for safer access to pesticides (WHO)

Realizing the full potential of pharmaceutical industry partnerships

Successful partnerships between pharmaceutical companies and global health organizations have been increasing access to medicines and vaccines since the 1970s. From early partnerships in the Expanded Program on Immunization, to GAVI, the Vaccine Alliance and Access Accelerated the research-based pharmaceutical industry, which spends over $149 billion on research and development (R&D) every year, has an important role to play in global health.

Over the last 50 years the pharmaceutical industry has learned that global health is about more than just medicines and vaccines, and with the integrated nature of the Sustainable Development Goals, public-private partnerships are increasingly important. According to the International Federation of Pharmaceutical Manufacturers and Associations, the industry understands that global health requires building and supporting strong health systems, developing public health education and strengthening standards and regulations. This is why in 2018, 17 out of the 20 largest pharmaceutical companies (accounting for 70 percent of global pharmaceutical revenues) developed a business strategy, supported by goals and targets, to address access to medicines in low-and middle-income countries (LMICs), according to an Access to Medicine Foundation report

Good, but not good enough

However, much of the increased access to medicines has been made by a small percentage of pharmaceutical companies, and has overwhelmingly been focused on a handful of diseases. Of the 20 companies assessed by the Access to Medicine Foundation report, five companies (GlaxoSmithKline, Johnson & Johnson, Merck KGaA, Novartis and Sanofi) were found to be conducting 63 percent of R&D on products urgently needed by people in LMICS; and nearly all of the R&D from these companies was focused on five diseases: malaria, HIV/AIDS, tuberculosis, Chagas disease and leishmaniasis. 

While overall, pharmaceutical companies are entering LMIC markets, the industry still puts profits first.  Between 2008 and 2018 more medicines for profitable non-communicable diseases were developed for people in high-income countries, than medicines for diseases of poverty. Additionally, only four out of 20 pharmaceutical companies supported international trade agreements designed to ensure the world’s poor benefit from innovative medicines and vaccines. 

Closing the gaps

Public perception does matter to the pharmaceutical industry. According to the Reputation Institute, between 2017 and 2018 the pharmaceutical industry saw a 3.7 percent decline in its reputation score, and overall the industry had a significant decline in the public’s perception of industry transparency, openness and authenticity. The decline of public trust and confidence in the industry has also led to a decline in the public’s willingness to buy by eight percent between 2017 and 2018. One way to improve company reputation is through global health partnerships, and with recent negative media attention on the industry, between the opioid epidemic and price-fixing drugs, it is no secret that the industry could use a reputation boost.

So how can the global health community capitalize on this? The Access to Medicines Foundation has an effective recipe for engaging pharmaceutical companies in global health: one, setting clear priorities endorsed by global health experts; two, advocating for publicly funded mechanisms to reduce investment risk and shape less profitable markets; and three, finding sustainable funding support from multiple donors, including the government. One example of a mutually beneficial partnership is GAVI, which used pooled procurement mechanisms to encourage pharmaceutical companies to enter fragile markets in LMICs to strengthen the global vaccine market. 

In 2018 the reputation scores for the top 22 pharmaceutical companies were made public, creating an opportunity for global health organizations to engage poorly ranked companies. Global pharmaceutical sales are expected to reach over $1 trillion by 2022, so resources for global health partnerships are abundant, and organizations should consider targeting partnerships with companies impacted by negative public perception; turning a bad reputation into increased affordable access to life-saving medications. 

 

Perspectives on Global Health from Pharmacists Around the World, Part Two

As healthcare continues to morph and adapt based on the requirements of kind, compassionate, evidence-based care, pharmacists are playing a vital role in ensuring patients needs are met in countless regions across the earth. In this four-part IH Blog series, the pharmacy role accompanied by profession-related challenges and pharmacist-led global health initiatives will be explored within a profession that is often underappreciated. The following perspectives, shared by practicing pharmacy professionals from the United Arab Emirates (UAE), Cambodia, and the United States of America (USA) aim at highlighting various aspects of healthcare that should be properly addressed by governmental bodies, NGOs, and all stakeholders by both sustainable political will and empowering solutions. 

This second installment focuses on medication quality in each of these areas and the thoughts that pharmacists from these respective nation states have been willing to share with IH Connect.

The onset of the biomedical and synthetic medication era brought with it a formerly unknown hope for the betterment of humanity’s health. The introduction of antibiotics like the beta-lactam class, vaccinations to completely eradicate diseases like smallpox, medications with unique mechanisms of action to regulate hypertension and diabetes, and more recently, targeted oncology medications to successfully attack cancer cells have all contributed to vastly improving patient care across the globe. However, with this tremendous advancement, novel complications have arisen that have plagued health care professionals in devastating arenas. For the pharmacy profession, specifically, the quality of medications has emerged as an additional concern in the treatment and dispensing process. Although a majority of nation states have regulatory bodies to monitor the quality of medications, low quality medications frequently find themselves in the hands of patients. This often leads to substandard care, furthers health inequalities, creates distrust in healthcare workers, promotes drug resistance, and damages the solemn promise every health care professional strives to follow – to properly care for those afflicted with various ailments. The perspectives and ideas that are shared in the following text explores medication quality throughout various parts of the world and initiatives that aim at addressing this determintental issue. 

Dr. Moeung Sotheara, Ph.D. 

Clinical Research Assistant & Part Time Lecturer – University of Health Sciences

Phnom Penh, Cambodia 

Access to high-quality medicines in many countries is largely hindered by the rampant circulation of counterfeit and substandard medicines. The use of counterfeit and substandard medicines represents a worldwide public health concern, and its prevalence is particularly high in developing countries. In Cambodia, the Ministry of Health reported in 2001 that 13% of medicines were spurious/falsely labeled/falsified/counterfeit, with 21% being substandard and 50% unregistered.

This crisis affects commonly used lifesaving medicines such as antibiotics, analgesics and anti-parasitics. The impact of poor-quality medicines is enormous ranging from increased adverse effects to increased morbidity and mortality. Poor-quality antimicrobials in particular has led to multi-drug-resistant malaria and bacterial infections which result in a huge burden for the country’s health sector. The high prevalence of poor-quality medicines has possibly contributed to the loss of confidence in health systems and health workers due to repeated treatment failure.

Among the reasons for the high rate of fake drugs in Cambodia are corruption, weak law enforcement, poverty and high sales taxes with self-medicating being often the driving force behind counterfeit drug markets. Counterfeit drugs mostly enter Cambodia through illegal drug outlets. The counterfeiting of drugs in Cambodia usually appears in the form of finished pharmaceuticals imported from neighboring countries, rather than the counterfeiting of bulk drug ingredients. This is due to the country’s lack of manufacturing capacity. Substandard drugs on the other hand are the result of limited implementation of good pharmacy practice regarding the distribution and the storage of pharmaceuticals which results in the deterioration in medicine quality.

Efforts have been made by the Cambodian government to tackle this problem. In 2015, the Cambodia Counter Counterfeit Committee (CCCC) was established and has been in charge of tracking counterfeit and substandard medicines circulating in the country. In 2018, the CCCC confiscated 138 types of illegal goods and substandard medication in 10465 packages from a pharmaceutical company in the capital city, Phnom Penh. The government is also working with its neighbors to decrease the number of fake drugs smuggled across the borders of Southeast Asia. Non-licensed drug outlets have been gradually disappearing, especially in the capital, either due to closure or accreditation, resulting from a strengthening of regulatory efforts. These initiatives are supported by pharmacists in communities by creating a front line against the distribution of counterfeits in the Kingdom through educating the public about the dangers of fake pharmaceuticals. 

Nazgul Bashir, B. Pharm

Registered Pharmacist – Super Care Pharmacy

Dubai, United Arab Emirates

Maintaining a healthy environment, reducing the healthcare cost, and using effective treatment options are all linked to medication quality. In any community, city, or region there are countless investments undertaken to improve the quality of healthcare overall. The Institute of Medicine defines health care quality as “ The degree to which healthcare services for individuals and populations increases the likelihood of desired health outcomes and are consistent with current professional knowledge.”

More specifically, medicine quality has two major roles: patient safety and effectiveness of treatment. Consuming a poor quality medicine will not only increase the risk to patient safety, but will hinder the proper treatment of patient. This can cause a patient to suffer more and increase the cost of treatment. Being a pharmacist and dispensing a low quality medication will also result in losing a patient’s trust. Since pharmacists have the role of dispensing medications, it is vital to ensure the medicine is in highest quality.

Quality of pharmaceutical products, mainly medicines, poses a serious challenge to the entire healthcare sector including drug manufacturers, distributors and dispensing pharmacists. According to the World Health Organization (WHO), the influx of fake or counterfeit medicine is a major concern in the market over all the globe.

Medicine in the United Arab Emirates (UAE) is manufactured so that medications go through systematic quality checks which are checked and re-checked several times while maintaining records in order to avoid any health hazard, Quality assurance teams then conduct self inspection or hire a third party to undertake inspections. The health regulations make sure that medicine distributed meet the standards of the listed quality and accepted internationally. On the other hand, imported medicines have similar criteria for safety and quality management. 

In order to further address low quality medications, the UAE Ministry of Health unveiled a new machine to detect imported drugs and inspect fake or counterfeit drugs. This machine is known as the TruScan RM Analyzer. It’s high tech detector is used to identify low quality drugs that pose health threats to the community. The device is helpful for chronic disease medicines such as diabetes, heart problems or even cancer drugs. The TruScan RM Analyzer also helps inspection regulators in the country to make informed and timely decisions for the release of drug shipments which are entering the country. In addition, UAE has been fighting the spread of low quality medicines in the country by taking many measures like high quality control labs and research on medicines and healthcare products.

Dr. Bryce Adams, Pharm D., RPh.

Oncology Medical Science Liaison

Washington D.C., United States of America

In the United States, the quality of medications isn’t commonly considered in the process of treating a patient. This is because of laws and regulations that are in place to ensure the quality of the medication. However, this wasn’t always the case. Up until 1906, there was no law requiring medications to be pure. That changed in 1906 with the passage of the Pure Food and Drug Act. This required medications to be labeled correctly and to meet purity standards put forth by the United States Pharmacopeia. 

This act greatly improved the quality of medications produced in the United States as manufacturers were required to list the ingredients that are used in the creation of medicine, and the ingredients and manufacturing process must meet certain standards. However, there is still a market for counterfeit medications as patients search for ways to reduce the cost of medications. It is estimated that 19 million US citizens purchase medicine outside of the current regulated system (e.g. from unlicensed sources such as foreign online pharmacies).  One recent example is with counterfeit Avastin, an anticancer drug, that was found to have no active ingredient. Another example is the recent opioid epidemic. Street drugs are being laced with fentanyl leading to increased overdoses and mortality. 

Recently, there have been discussions to allow for greater importation of medications into the United States. While this could potentially reduce the cost of medications, it could also increase the risk of counterfeit medications. Medications originating from outside of the United States makes it harder for the Food and Drug Administration (FDA) to regulate the quality and purity of medications. 

Patients in the United States can reduce the risk of receiving counterfeit medications by picking up their medications from their local pharmacy and can feel comfortable knowing those medications are of high quality. If cost is an issue, a patient can discuss their options with the pharmacist. There may be a cheaper alternative or an assistance program that can help offset the cost of the medication.

IH Section Webinar 8/20: Insights from Managing a Health Systems Development Program (HSDP) Grant

Dr. Iyabo Obsanjo, the Co-Director for African Development at the College of William and Mary will discuss her involvement with a World Bank-funded Health System Development Project in Ogun State, Nigeria. She’ll share what worked and what didn’t from her perspective as the Commissioner for Health, in addition to describing areas where Health System development funding is lacking.

Date: Tuesday, August 20, 2019
Time: 11 AM – 12 PM ET

Register to attend here

This webinar is hosted by the APHA IH Section’s Health Systems Strengthening Group. The objective of the working group is to provide a venue for interested global health professionals to learn about systems sciences, collaborate around research and practice activities, and advocate for increased consideration of system sciences in education, practice, policy and evaluation for strengthening health systems. We welcome interested members (APHA membership is not a prerequisite) with expertise and/or interests in applying systems thinking approaches and methods to strengthen health systems, in both developing and developed countries. 

Find out more about the Health Systems Strengthening Group  

“Tejas means friend” and other lies we tell ourselves.

If you hear me speak more than a few sentences, you’ll hear the unmistakable accent. And as soon as I can find a natural way to fit it into the conversation, I’ll tell you flat out: I’m from Texas.

As a Texan, I was required to take one year of Texas history in the seventh grade, a statewide tradition since 1946. In Texas history, you’ll undoubtedly learn a few facts that every one of us 29-million Texans has engraved in our hearts.

1.     You don’t pick bluebonnets. They’re a sacred part of our state’s landscape.

2.     Texas was a sovereign nation once: the Republic of Texas. 

3.     California may have more people, but we’re bigger in size.

4.     “Tejas means friend”.

I’ve always found the root of the state’s name to be fascinating, because it has evolved with the land itself and represents the story of Texas. The word traces back to the Caddo word for “friend”, taysha. That word would be misspelled and mispronounced to be Tejas and eventually, Texas. For those of us whose hearts are deeply intertwined with the “Lone Star State”, the root of the word feels right. It embodies our roots, who we were, and the Southern hospitality on which we grew up. The origin of Texas’ name does NOT embody who we are today.

Texas has become the frontline of continued inhumane policy experimentation by the Trump administration. To deter undocumented entry to the United States and tamp down the number of asylum claims made at ports of entry, Trump and his nominated officials began separating children from their caregivers. 2,654 children were taken from their parents, guardians, and chaperones during the peak of this policy’s enforcement, and most of those children were detained in Texas.

The science around this matter is still developing, but one thing is certainly clear: this is bad news for the cognitive development and mental health outcomes of these children. In fact, the picture is becoming clearer that family separation policies produce rates of toxic stress and trauma that are as detrimental to the child psyche at the violence as the violence and insecurity they are fleeing. Researchers, and even the United Nations, cite evidence that separating children from their caregivers creates the type of emotional disturbance and dysregulation seen in survivors of torture.

We aren’t talking about acute emotional disturbance that will recede after reunification. The child’s brain has evolved to be incredibly respondent to its environment. Continued exposures to “fight, flight, or freeze” (especially in the absence of a trusted attachment figure) train the brain to bypass emotional inhibition and complex, rational thought to depend on more primitive survival mechanisms. This means permanent alteration of the brain, shrinking the prefrontal cortex and hippocampus (the parts of the brain that largely control decision making, working memory, and personality expression).  Their brains, and often their relationships with the parents, may never recover. 

“Here we have taken away what science has said is the most potent protector of children in the face of any adversity—the stability of the parent-child relationship”

– Jack Shonkoff

It’s not just theoretical damage happening in research studies void of a human face. Children inside these Texas detention centers have reported high rates of insomnia, decreased ability to concentrate, diminished literacy (even in their native languages), severe mood swings, and feeling constant states of panic and fear. And when they leave, their medical records (including any psychiatric care they’ve needed or received) are often incomplete. Many of these children will receive asylum in the United States, and we will have to face the mental health epidemic we created with a mental health system that is underfunded and culturally inadequate.

Sweeping separation of families and detainment of children was theoretically stopped, but the Human Rights Watch has found that nearly 200 children have been subject to the continuation of this policy since last year. There is no law on the books in the US that requires the separation of families at the border. This was a policy decision that can be rescinded as quickly as it was haphazardly implemented.

These children have often experienced trauma before they ever arrive at our border. They have left the familiarity and comfort of home. They are often physically vulnerable at the end of their migration journey. And they are welcomed with something that, for most of them, is even more traumatic: facing the hostility of a foreign country all alone.

This isn’t exclusively a Texan issue. ICE detention centers now exist in all 50 states. And it isn’t uniquely American, as 100 other countries have policies that allow children to be detained as part of standing immigration policy. But Texas has become ground zero for what the inhumane treatment of children looks like. Texas is no longer a land of Southern hospitality. It certainly isn’t embodying the state motto of “friendship”. And no one should be angrier about what’s happening in our home state than Texans ourselves. 

This article was written in memory of the children who needlessly died in Texas as a result of inhumane immigration policy. These faces represent the failure of all of us.

From top left to bottom right:

Mariee Juarez, aged 2, died after leaving a detention center in Dilley, TX

Carlos Hernandez Va’squez, age 16, died in US custody in Brownsville, TX

Jakelin Caal Maquin, age 7, died in US custody in El Paso, TX

Juan de Leo’n Gutie’rrez, age 16, died in US custody in Brownsville, TX