A Little Bit Can Go A Long Way: A Reflection on Global Health Disparities

Dr. Chris Stout offers detailed examples of the impact that psychology can have in a global venue

By Chris Stout, PsyD

“Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” – Martin Luther King, Jr.

Dr. Stout talks with a group of people at San Pedro prison in La Paz, BoliviaThere is an alchemy to psychology that can produce an incredible set of opportunities and experiences. Throughout my career, I have personally chosen to focus on the opportunities and experiences produced within the area of global health disparities. But within this area, there is a great divide between behavioral healthcare, public healthcare, and primary healthcare that has long mystified me.

Having served on a Board of Health for almost a decade, along with completing a Fellowship in Public Health, I can tell you that the psychological aspects of our major public health issues - violence, health compliance/noncompliance, smoking cessation, mental illness, domestic violence, drug and alcohol use, you name it - all overlap with the successes and failures of public health endeavors. The State of Illinois’ Division of Mental Health got it right when they coined the phrase, “Without mental health, there is no health.”

The following are two detailed examples of the impact that psychology can have in a global venue. They highlight the amplified impact that a person or group of individuals can achieve to the betterment of those with whom they work.

Bolivia

The NGO I founded, Center for Global Initiatives (CGI), was invited to Bolivia to work with Flying Doctors of America to provide medical and dental care to prisoners and their families in La Paz. To do this, we visited a maximum security facility for women, called Miraflores. While the manifest mission of this trip focused on physical and dental healthcare, it ultimately illuminated the emotional needs of the youngest inhabitants of the prisons: the children of the inmates. In Bolivia, if you are an incarcerated parent with no one else to care for your child, your child comes to prison with you.

Miraflores, a maximum security prison for women in BoliviaIn prisons with lower security, the families of the inmates are allowed to come and go. The children can attend school, and the spouses are free to leave during the day for work or anything else. However, in Miraflores, no one leaves the prison; even the guards have places to sleep there. In order to provide for themselves and their children, the women must take in laundry or make and sell crafts to generate money. As for the children, they must go to school within the prison walls. These children do not get to leave. Not for school, not for visits, not at all. They are basically on house-arrest and sequestered in the prison.

During our mission, the teachers in the prison’s school approached the pharmacy volunteers to ask for the boxes that the medications had come in. They wanted to use them as toys for the children. They basically said, “Can we use your trash? Your trash will serve as our toys.” The children themselves, even in such circumstances, displayed a beautiful resiliency that made the unfairness of the situation stand out even more. We saw the obvious dedication these teachers had for the children, as well as the dearth of resources available for them to use with the children. We began to think of ways to help.

You can fly into Bolivia to fill a tooth, but you can't fly in to fix a trauma. We wanted these children to have as many positives as possible—good teeth, good hygiene, proper nutrition, and a psychologically healthy environment. While we may not be able to change political structures or systems, we can provide something more sustainable by starting small. What may seem little to one person can be huge to someone with nothing.

The Center decided to develop a “virtual” library of tools and resources for the teachers to be able to use with the children in the prison. They do not have internet access, but they do have a computer with a functioning CD-ROM drive. We are compiling materials in Spanish that include coloring-book images, picture cards for vocabulary building, and instructions for activities and noncompetitive games. We are also gathering Spanish-language journal articles on education and classroom management, appropriate parenting methods, and behavior management tools that could be used by the mothers and guards. This type of teaching tool is easily updated, enduring, and can be viewed on older computers. Along with the CD-ROMs, the Center will also be sending art supplies like crayons, colored pencils, and paper, as well as printer paper and ink.

The materials will also include activities that can introduce and teach resilience and adaptive coping mechanisms to the children. The activities, designed to teach communication skills, empathy and active listening can be implemented by the teachers and do not require any extra supplies or additional therapeutic training on the teachers’ part.

The Center's use of expressive arts to address the children's needs is the most unique aspect of this project. We thought creative arts, expressive arts, and music could help bring more life to the children and rejuvenate aspects of what “school” could represent for them. We have an orchestra instructor who volunteered to provide and translate music so the children can learn to sing.  Additionally, we are in the process of exploring basic and indigenous musical instruments and options for funding and transporting materials.

We are also working with a volunteer who is an art therapist to develop art therapy exercises that the teachers can use to help the children express and process their feelings. The art the children create could provide them with a way to emotionally work through their experiences in the prison. We wish to compile this artwork into a book and look for a publishing house willing to donate the proceeds to the prison school. We hope that it can aid in the sustainability of the project and result in more exposure for the plight of these children. The overall perspective throughout each of these efforts is to enhance what already exists, not disparage it. It is our job to build on the strengths of the prison school and its students.

Tanzania

Over the years, I have built a strong working relationship with Tanzanian children in a kindergarten we co-founded and in the Rombo District’s Huruma Designated Hospital. Quite simply, this stemmed from a personal relationship I had with a guide I met while on a climbing trip that predated the Center’s existence, but was catalytic to its coming into being. There was an amazing amplification effect of a few simple “interventions. These things any psychologist or individual could do and have an equally profound impact. 
 
A kindergarten for orphaned children in Tanzania, co-founded by Dr. Stout and Fr. Aloyce UrioMy dear friend Fr. Aloyce Urio is a Chaplin at a local hospital and in charge of a group of orphaned children. He and I are pen-pals in the most classic sense—ink on paper and a stamp. Over the years he’d query me about a child having a certain physical or emotional problem, and I would respond back with suggestions and mail him any materials I could get my hands on. If it was outside my skills, I would consult with an ad hoc team of friends in medicine, physical therapy, or any other relevant specialty for help.

Aloyce once mailed me a note about many of the children being manifestly sad and tearful. The caretakers did not know how to respond and felt that not discussing the children’s emotionality was best. I sent Aloyce a set of basic counseling materials on grief and loss, some group exercises, active listening, empathic responding, Rogerian methods, and other “counseling 101” materials—with the caveat that he should use his best judgment to adapt the Western-made materials to culturally relevant styles.

This seemed to be very useful for him. The caretakers felt supported and empowered to have tools, supervision, and the approval to discuss emotional issues with the children. Over time I learned that the children also experienced therapeutic benefit. But what happened next is a great example of a quite incredible, however unintended, consequence.

A Bishop who was responsible for the Region was visiting and happened to see the materials I had sent Aloyce sitting on his desk. After being asked what they were and learning more about them, he asked if he could borrow them to make copies and distribute to the other clinics, hospitals, and orphanages he would be visiting, and if Aloyce would be able to “consult” with his counterparts at those sites as a follow-up. The Center also used these tutorial coaching notes and copies of suitable materials to consult nursing students at Huruma Hospital on managing emotional health problems.

Something that took me perhaps three hours to compile and write, and cost less than nine-dollars to send, was now being used not only in Aloyce’s area, but with many, many other children who otherwise would not have such therapeutic and emotional support. This is what I mean by amplification. A small amount of time and postage cost yielded an immense impact on the staffs and the children in a number of villages, both now and in the future. I could never have planned nor imagined that would happen. This is the kind of thing that I encourage readers to think about if they are so inclined to be involved in this kind of work. The proverbial bang-for-the-buck can be exponential. Imagine the impact we could make in the lives of others if each one of us just did something like this just once in our lifetimes.

Because the orphaned children did not go to school, Aloyce believed their chances for a better life would improve if they could read and had knowledge-based skills and labor-based training. I agreed, and we set forth on creating a modest school. In 2005 we received word that the Ministry of Education had approved a kindergarten for the children, which Aloyce now manages. We continue to be on-call for any help we can give, and always for free. We even conduct fundraisers for them and are active in fiscally supporting the children in any and all ways, under Aloyce’s watchful and measured stewardship.

The Center’s philosophy for the projects it works on is to be a free consultant; we don’t want to have ownership of any projects. We want to help incubate them, greenhouse them, and then launch them. We will always be available if needed ever-after.

Charity or Social Justice?

Each person can best create change by sharing their knowledge, wealth, and a valuable resource. This kind of work is not limited to charity. While there is nothing fundamentally wrong with charity, much charitable work is more focused on the giver than the recipient. Many charitable medical missions involve a group of healthcare workers providing short-term care in a poor setting and leaving their work behind as they return to the United States, expressing gratitude for all their blessings and opportunities. Too often, those they cared for remain poor and unfortunate, unable to help themselves.

It is therefore important for us to reflect on our motivations for undertaking such work. We must look behind the veil of humanitarianism to understand how our own motivations may clash with the needs and desires of those whom we hope to serve.

The question for me becomes, ―how may we augment this desire?" Perhaps it lies in the concept of social justice? While charity limits our attention to the comfortable, familiar domain of the giver, social justice demands that we focus our attention on the often unseemly and disturbing world of those on the receiving-end. In charity we can send surplus supplies abroad, but to arrive at justice we must also look at activism within governmental systems, policy and political forces – all things psychology can do.

We are fortunate that ours is a profession that allows for doing well while doing good. We each have a responsibility to live up to the promise of our profession. It’s a tall order for psychology, but I know of no other profession better suited.

This article is based on a chapter Chris wrote for “Protecting Children from Violence: Evidence-Based Interventions.” Psychology Press, London. J.M. Lampinen and K. Sexton-Radek (eds).

About the Author:

Chris is the current Co-Chair of CIRP; Founding Director of the Center for Global Initiatives; and Clinical Professor in the College of Medicine at the University of Illinois at Chicago. He has published over 30 books including his most recent three volume set, The New Humanitarians (Praeger, 2009). Chris is also the recipient of humanitarian awards from APA, IPA, and PsySR and was named the 2009 International Psychologist of the Year by Division 52. Chris may be reached by email.