“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

The Rise of Global Mental Health

The constitution of the World Health Organization (WHO) opens with a definition of health that underscores the importance of “mental…well-being.” Even still, mental health has struggled to achieve parity in global health. For much of its history, the field of mental health developed parallel to public health. Mental health, and the lack of it, was nebulous and eluded the gold standards of clinical measurement like bioassays and microscopy. As a result, psychology and psychiatry (components of the larger field of mental health) were shunned by other disciplines for a perceived lack of scientific basis and over-emphasis of sociological factors. Those with mental disorders, cognitive and developmental impairments were thusly cared for largely by religious institutions and, eventually, asylums rampant with inhumane treatment and neglect. 

Psychiatric patients in Bucharest sleep two to bed with feet bound;
Image Credit: Bernard Bisson

By the 1970’s the United States was moving toward deinstitutionalization and curiosity about how to effectively study and treat mental illness in the context of culture. Mental health research worldwide began engaging with patients as active participants with “lived experience.” The sharing of epidemiological data around mental health indicators became more fluid. The push for data-driven and evidence based decision making in global mental health produced big payoffs. The 1990’s saw both the WHO’s first World Mental Health Report and the first iteration of The Global Burden of Disease study

These publications highlighted the sheer burden of poor mental health. Of the ten leading causes of disability, five were mental illnesses, including the leading cause of disability in the world: unipolar major depression. Self-inflicted injury was among the top ten leading causes of premature death in developed countries. While the psychiatric epidemiological data continued to underscore the need for new interventions and novel funding mechanisms for global mental health, not much has changed. Last year, the Lancet Commision on global mental health and sustainable development released a 45-page report outlining a global health crisis that is severely underfunded relative to its burden on society. Even in developed countries, only 20% of individuals living with depression will receive adequate treatment. In developing countries, the number is a dismal 4%. But only 1% of global health development funds are allocated to mental health programs. That comes out to just $0.85 per year of healthy life lost to mental illness, compared to $144 for HIV/AIDS programming and $48 for malaria and tuberculosis. 

Even if the funding existed, global health education has yet to produce a reliable pipeline of mental health professionals with the skills necessary to address the crisis. Educators at schools of public health in the United States have identified that mental health is still not adequately integrated into public health curriculum. Johns Hopkins remains the only school of public health in the country with a dedicated mental health department. While the majority of other public health programs offer coursework that have mental health as a component of its curriculum, few programs offer tracks or courses that have mental health as its primary focus, leaving students interested in the field to piecemeal their education together through independent study and practicum/thesis work. 

(Read the study on mental health in schools of public health here)

The evidence is clear that global mental health should be recognized as a global health and global development priority. Despite the lack of full acceptance by the global health donor community and larger public health community, the field of global mental health has continued to grow. Organizations like the Movement for Global Mental Health serve as collaboration spaces for mental health researchers and advocates. The Lancet Commission on Global Mental Health continues to produce calls for action that elicit drastic, even if short-lived, spikes in mental health earmarked development assistance. And just this year, the field’s superstar, the Peter Piot or Paul Farmer of global mental health, Dr. Vikram Patel was awarded the prestigious John Dirks Canada Gairdner Global Health Award

“...All countries can be thought of as developing countries in the context of mental health

Patel et al.

We are living in the age of a changing climate, protracted humanitarian crises, and a global population that is increasingly forcibly displaced from their homes. The burden of mental health problems will continue to pose a threat to health that will require the unique skill set of the field of global mental health. Leaders like Dr. Patel continue to advance the global mental health agenda in an effort to realize the complete definition of health that lies at the core of global health. For those of us for whom global mental health is our calling and passion, we must continue to push for our place at the table when the global health agenda is being set. 

Note: One of the photographs used in this blog appears elsewhere on the internet in an unredacted form. However, to protect the privacy and dignity of those who appear in the photograph, I’ve elected to hide their faces.

Global Mental Health: How Are We Doing? (WHO)

31,285 Human Rights Violations and Counting: Hypocrisy in America’s Liberal Bastion

On February 8, 2019, city councilors in Los Angeles met to approve a resolution declaring LA a “city of sanctuary.” It was hailed as a victory amid growing political tension and derision, a “symbolic welcome sign,” according to Councilman Gil Cedillo, that was supposed to “set the tone for the way we want our residents to be treated.” However, for the 31,285 Angelenos who are experiencing homelessness, Los Angeles is anything but a sanctuary.

You know you’ve stumbled into LA’s Skid Row the moment you arrive. Trash clings to the streets in heaps, stacked haphazardly against rows of tents so densely packed it’s difficult to find the sidewalk. It’s a stark contrast to the dazzling city skyline that frames the neighborhood. This isn’t a part of Los Angeles you can see from the sterile aerial shots that punctuate film and television, but it’s the reality of a county with over 10,000,000 residents and wage growth that can’t keep up with the rising cost of living.

Everyone in Los Angeles, from City Hall to residential streets, agrees that more must be done. Inevitably, however, most attempts to build temporary or permanent supportive housing in Los Angeles is met with public resistance. NIMBY, the acronym for “Not in My Back Yard,” refers to the opposition of development in one’s own neighborhood, even if they would otherwise support such a project somewhere else. NIMBYism is rampant in LA’s complex and powerful network of neighborhood associations and councils. When city officials met with residents of Sherman Oaks, a wealthy neighborhood on the west side of the city, to show proposals for homeless housing projects, residents turned out in force to oppose the plans. One resident went so far as to propose his own solution to the need for emergency shelters in Los Angeles:

“You want me to have compassion for people who don’t care about themselves?…I’m proposing maybe you build a reservation for these homeless somewhere out in the desert…when we interned the Japanese during the Second World War, we didn’t intern them in the city”.    

Much of this resentment and stigmatization comes from the deeply held American belief in the “prosperity gospel.” In other words, those who work hard and are free from vices are protected against material scarcity. Homelessness, then, is a personal failing and not a societal one. It’s time we reframe homelessness.

Public officials, public health professionals, and advocates across Los Angeles need to change the way we talk about homelessness to end the rampant NIMBYism in the city. It’s time to adopt a rights-based approach that focuses on the systemic failures that are determinants of homelessness. We need to abandon the “treatment first” approach to combating homelessness, where we attempt to fix the precipitating effects of inadequate housing (substance abuse, mental illness, poor health) before providing stable housing. Instead, programmatic and policy efforts should focus on “housing first” approaches that satisfy basic human needs before attempting to solve complex behavioral and lifestyle issues. The model is evidence-based and, unlike many interventions designed to combat homelessness, it’s effective. Investments in housing first approaches reduced homelessness by 91% in Utah, and research efforts in Seattle show that the savings generated by reducing the need for crisis intervention services more than makes up for the cost of housing first projects.  

Image Credit: The Spotlight

Los Angeles has the opportunity to lead by example in a world that is growing increasingly less empathetic to the plight of the vulnerable. However, we cannot be the city that birthed the “Me Too” movement and turn away from the fact that half of all women who are homeless report that they are domestic violence survivors. We cannot say that we are a city that believes that black lives matter when we know that while only 8% of LA County identifies as black or African American, they make up over one-third of the unsheltered population. It is unconscionable that our city turns out in force for Pride but fights efforts to house homeless youth, nearly half of whom cite whom they love as the reason they are homeless.

In December, Los Angeles hosted the UN’s celebration of the 70th anniversary of the Universal Declaration of Human Rights, a document that states in no uncertain terms that housing is a right of every person everywhere. If we are to be taken seriously in our defiance of increasingly discriminatory national rhetoric, we must do better here at home.

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
-UDHR, Article 25.1

Read more about evidence based messaging campaigns around homelessness.