Why we need a paradigm shift in suicide prevention

By Frederik Løgstrup Magnusson and Christian Ulrich Eriksen


The global state of suicide

In 2016, self-harm was the cause of 817,100 deaths globally across all age groups, a decrease of 3,000 from 2006. This excludes traffic injuries and other unintentional injuries (Naghavi et al., 2007). An estimated 10-20 million suicide attempts occur every year (Hendin, 2008; Naghavi et al., 2007). As such, suicide is a major global health issue that needs to be addressed in prevention efforts. Traditional approaches to suicide prevention include treatment of mental illness, restricting access to lethal means of suicide, etc. But why are social factors and societal structures rarely included in the discussion about suicide or the prevention thereof? It is known that the risk factors for suicide are multiple, and the primary risk factors include mental disorders, past suicide attempts, social isolation, family conflict, unemployment and somatic illness (Van Orden et al., 2010), with a prior suicide attempt being the most important factor for suicide (World Health Organization, 2014).

As one of the most tragic human events to occur, suicide is undeniably interlinked with mental health. By a huge margin, 90 percent, suicide victims also suffer from mental disorders (Cavanagh et al., 2003), and it is not implausible to think that the remaining ten percent suffer from subclinical afflictions. But even though mental illness is present in all or nearly all of completed suicides, being a major risk factor for engaging in suicidal behavior, it does not exclude other factors from playing an important role. Mental illnesses have complex etiologies with multiple genetic and environmental factors influencing the development of these diseases. It is plausible that social factors and societal structures contribute to the burden of mental illness and thus, indirectly, to suicidal behavior.



On a structural level, factors such as inequality have been linked with suicide rates. A study from Brazil, comparing suicide rates to the Gini Index, a measure of income inequality, within municipalities, suggested that higher inequality was connected with higher suicide rate, with each 10-point decrease in the Gini Index predicting a 5.5 percent decrease in the suicide rate. The Gini Index measures income inequality on a scale from 0 to 100, with 0 being the most equal income distribution and 100 being the most unequal (Machado et al., 2015).

In the US, an increase in the suicide rate has been observed from 2006 to 2014, and in the same period, an overall increase in suicide attempts has taken place. This observed increase in suicide attempts has been found to primarily affect younger adults with lower levels of formal education, a history of violence, and those with a range of mental disorders, such as depression and anxiety (Olfson et al., 2017).

In a WHO study including more than 100,000 respondents from 21 countries, the researchers did not find a large difference in the prevalence of suicidal ideation, planning or attempt between developed and developing countries, but they did find that people with suicidal ideation would more often develop a plan to attempt or actually attempt suicide in developing countries compared to developed. On the other hand, unplanned suicide attempts made up a larger proportion of all attempts in developed countries. The same researchers also found that women were more likely to exhibit suicidal ideation and, in developing countries, to plan suicide attempts. Unemployment was shown to predict planned suicide attempts in both developed and developing countries (Borges et al., 2010)


Stigma, marginalization and belongingness

Marginalized and discriminated groups in society experience the highest levels of suicide. The stigmatization that these groups face from society can both directly influence the risk of suicide, by delaying or preventing treatment for suicidal thoughts and behavior (Pompili et al., 2003), but also indirectly through people belonging to these marginalized or discriminated groups internalizing the negative beliefs that the wider public holds against them. This phenomenon is called self-stigma, and it leads to shame, hopelessness, social isolation, and low self-esteem (Oexle et al., 2016). Social isolation predicts suicidal ideation, attempts and lethal suicides very reliably, while strong social connections, such as marriage, having children, and a large number of family and friends is a predictor of the opposite (Conwell, 1997; Dervic et al., 2008; Trout, 1980; Van Orden et al., 2008).

One group that can face stigmatization is people with mental illnesses. We could speculate that if the risk of receiving a damning stigma when seeking mental health care is too high, it may be better for a sufferer of depression or other mental illnesses to forego care-seeking, in terms of reducing the risk of suicide. Stigmatization and the resulting marginalization may exacerbate this risk, rather than reduce it.

A prominent theory of suicide and suicidal behavior is the Interpersonal Theory of Suicide. The primary thesis of the theory is that lacking a sense of belongingness and perceiving oneself as a burden are the major psychological factors that ultimately will lead people to engage in suicidal behavior. Being lonely and not having reciprocally-caring relationships leads to a sense of thwarted belongingness. According to Van Orden et al. (2010), this represents a state, rather than a stable trait, which is affected by intra- and interpersonal factors. In other words, thwarted belongingness, which can lead to suicide, is caused by the social network a person is situated in, the person’s mode of interpreting the world, i.e. whether he tends to believe he is being rejected, and his emotional state, working together.

One example of not experiencing reciprocally caring relationships is social control, which is the overregulation of behavior. The role of social control was investigated in a study in Iran, where it was found that the provinces with lower levels of female education, female labor force participation, and urbanization had the highest rates of female suicide (Aliverdinia and Pridemore, 2009). This finding stresses the fact that caring interpersonal relationships are crucial for mental health and wellbeing, and including work on culture and gender in suicide prevention activities could be a feasible way to move forward.



In summary, while we recognize the interlinkages with psychopathology and the salutary effects of various behavioral and pharmacological interventions, we argue that it is one-sided to see suicidal behavior as a problem merely rooted in psychopathology. Rather, social issues within a society or community contribute to the prevalence of both suicidal ideation, planning, and attempts.

We believe that the impact of economic inequality, stigmatization, marginalization, and social control should be taken into account when planning and implementing measures to prevent suicide. While absolute wealth appears to be less important when comparing countries, inequality within countries and regions seems to have an impact on the prevalence of suicide. Likewise, stigmatization, marginalization and social control are detrimental to mental health and a cause of attempted suicide.

As such, suicide cannot be thought of solely as the result of a lack of access to high quality mental health care, though that may play an important role as well. Governments and policy makers must consider social security and social services, when they seek to mitigate the risk, and not name pathology or rash decisions as the root cause of every suicide. Likewise, stigmatization and marginalization must be addressed, and tolerance in communities and society must win out, if suicide is to be addressed successfully.


Aliverdinia, A., Pridemore, W.A., 2009. Women’s Fatalistic Suicide in Iran: A Partial Test of Durkheim in an Islamic Republic. Violence Women 15, 307–320. doi:10.1177/1077801208330434

Borges, G., Nock, M.K., Haro Abad, J.M., Hwang, I., Sampson, N.A., Alonso, J., Andrade, L.H., Angermeyer, M.C., Beautrais, A., Bromet, E., Bruffaerts, R., de Girolamo, G., Florescu, S., Gureje, O., Hu, C., Karam, E.G., Kovess-Masfety, V., Lee, S., Levinson, D., Medina-Mora, M.E., Ormel, J., Posada-Villa, J., Sagar, R., Tomov, T., Uda, H., Williams, D.R., Kessler, R.C., 2010. Twelve-Month Prevalence of and Risk Factors for Suicide Attempts in the World Health Organization World Mental Health Surveys. J. Clin. Psychiatry 71, 1617–1628. doi:10.4088/JCP.08m04967blu

Cavanagh, J.T.O., Carson, A.J., Sharpe, M., Lawrie, S.M., 2003. Psychological autopsy studies of suicide: a systematic review. Psychol. Med. 33, 395–405. doi:10.1017/S0033291702006943

Conwell, Y., 1997. Management of suicidal behavior in the elderly. Psychiatr. Clin. North Am. 20, 667–683.

Dervic, K., Brent, D.A., Oquendo, M.A., 2008. Completed Suicide in Childhood. Psychiatr. Clin. North Am. 31, 271–291. doi:10.1016/j.psc.2008.01.006

Hendin, H., 2008. Suicide and suicide prevention in Asia. Dept. of Mental Health and Substance Abuse, World Health Organization, Geneva.

Machado, D.B., Rasella, D., dos Santos, D.N., 2015. Impact of Income Inequality and Other Social Determinants on Suicide Rate in Brazil. PLOS ONE 10, e0124934. doi:10.1371/journal.pone.0124934


Naghavi et al., 2017. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. https://doi.org/10.1016/S0140-6736(17)32152-9

Oexle, N., Rüsch, N., Viering, S., Wyss, C., Seifritz, E., Xu, Z., Kawohl, W., 2016. Self-stigma and suicidality: a longitudinal study. Eur. Arch. Psychiatry Clin. Neurosci. doi:10.1007/s00406- 016-0698-1

Olfson, M., Blanco, C., Wall, M., Liu, S.-M., Saha, T.D., Pickering, R.P., Grant, B.F., 2017. National Trends in Suicide Attempts Among Adults in the United States. JAMA Psychiatry 74, 1095. doi:10.1001/jamapsychiatry.2017.2582

Pompili, M., Mancinelli, I., Tatarelli, R., 2003. Stigma as a cause of suicide. Br. J. Psychiatry 183, 173–174. doi:10.1192/bjp.183.2.173-a

Trout, D.L., 1980. The Role of Social Isolation in Suicide. Suicide Life. Threat. Behav. 10, 10–23. doi:10.1111/j.1943-278X.1980.tb00693.x

Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S.R., Selby, E.A., Joiner, T.E., 2010. The interpersonal theory of suicide. Psychol. Rev. 117, 575–600. doi:10.1037/a0018697

Van Orden, K.A., Witte, T.K., Gordon, K.H., Bender, T.W., Joiner, T.E., 2008. Suicidal desire and the capability for suicide: Tests of the interpersonal-psychological theory of suicidal behavior among adults. J. Consult. Clin. Psychol. 76, 72–83. doi:10.1037/0022- 006X.76.1.72

World Health Organization, 2014. Preventing suicide, a global imperative.

Put the Fork Down! – A Mindful Eating Path Towards Better Health

Written by Danielle Agnello LinkedIn Twitter: @DannyAgnello_GH

Edited by Sinéad O’Ferrall Twitter: @SineadOFGH

What is Mindfulness?

Today’s mindfulness eating experiment is about eating in a way that involves becoming aware of that reflexive urge to plow through your meal like Cookie Monster on a chocolate chip bender. 

We live in an incredibly busy world, the pace of life is often frantic, and our minds are always running wild, we are always doing something. So, I would like you to take a moment and think about the last time you did nothing, and I really mean nothing. You weren’t watching TV, nor texting or emailing, you were just engrossed in – stillness.

Do you eat like the Cookie Monster?

Mindfulness and Mental Health

Collectively, we worry about maintaining a healthy physical body, but overlook maintaining a healthy mind. We rely on the mind to be happy, content, and emotionally stable as individuals, and at the same time to be kind and considerate in our relationships with others. That same mind that allows us to be focused, creative, to help us perform our best in anything that we do, does not receive the same level of care or concern as our physical body, and we often do not take the time to look after it.

This lack of attention, does of course often result in stress and contributes to mental illness. Our mind starts spinning away with all different types of emotions, and a lot of the time we don’t really know how to deal with that. The sad fact is, that we are so busy, so caught up that we are no longer present within the world in which we live in. The result is we are missing out on some of the most beautiful and important moments that are in fact, life. The crazy thing is that people just assume that is how life is, but that’s really not how it has to be.


I was 13 when I went to my first meditation class, and since that day I have discovered, in my own journey and struggles, that meditation was not a type of aspirin for stress or depression; but that is is more a preventive measure. Many people have different methods of dealing with stress, some people bury themselves in work, others turn to friends or families, some use drugs or other substances to just quiet their minds. However, one plausible, practicable, achievable and scientifically proven technique, is the act of being Mindful.

Mindful Eating

One thing that we do on a daily basis, multiple times of day, is eating. So what better way to practice being mindful then pairing it with the consumption of vital nutrients. Hence, Mindful eating was born. This is not a diet, nor the act of giving anything up, it is a process of enjoying eating more intensely. Sounds pretty good, doesn’t it? 

Like meditation, mindful eating has its roots in Buddhist teachings. It aims to reconnect us deeply with the act of eating, aiding us in the process of checking in with ourselves, “Does my body need this? Why am I eating this? Is it just because I’m so sad, or because I am stressed out?” Mindful eating is based on the idea that there is NO wrong way to eat, but rather varying degrees of consciousness about what we are eating and why. The goal is to base our hunger on physical cues, that empty burn you feel in your tummy, rather than emotional ones that result in comfort or binge eating.

Mindful Eating – more than just food on the brain!

This practice has been growing, and in the eyes of some experts, the act of simply eating slowly and relishing each bite can be a remedy to slow the stampede towards increasing rates of obesity. For instance, a monthly mindfulness lunch hour has been incorporated at Google, and self-help guru Oprah Winfrey is a huge advocate of it. Also, research has been conducted at Harvard and Cornell investigating the effects of this simple practice. One study tracked more than 1,400 mindful eaters and it showed them to have lower body weight, a greater sense of well-being, and fewer symptoms of eating disorders.

Lets try it!

Now you have an idea of what mindful eating is, let us practice this all together with a nice snack. If you are hungry, grab a snack, preferably a healthy one and take a deep breath.  So to begin, I want you to first gaze at your piece of food, musing on it, holding it up and seeing how each layer looks, the color of it, noticing how heavy it is, all while you wait patiently to taste it.

Dog food
Take time to gaze at the food before tasting it.

Now that you have eaten with your eyes, you can take a forkful of food and place it in your mouth. This my friends is your first nibble of food. Now is the hard part, “put the fork down.” I know it is challenging, because that first bite was so good and the next one is calling to you. Resist it. Leave the fork on the table. Chew slowly. Don’t speak, don’t think, just tune into the texture of the food, the flavor of the carrot, or the crunch of the nuts. Notice the beautiful color of the cake on the plate. As you are eating, you are paying attention to the sensation and purpose of the food that is in your mouth.

Now that you have fully appreciated your first bite, I invite you to pick up your fork, and put another piece into your mouth. This is that second bite that your mind was longing for. Slow down your chewing, remember to put your fork down. Enjoy the texture and flavor of your food, contemplate the spices, the crunch, the sweetness, warmth and tenderness of the food.

Before you pick up your fork once more, I want you to also think about the origins of this food. The thousands of farmers, the rays of sunshine, the truck drivers and chefs that have worked countless hours to get this piece of food, here onto your plate. I want you to connect with the story of behind your food. Who grew the ingredients for this? How? How did it get here?

colour food
What is the story behind your food?

So now you are free to continue eating this way for the rest of your meal or snack, and while you are eating please enjoy this experience, the pleasures, and the frustrations of the practice of mindful eating.

It can be so simple – Eat. Respect. Appreciate. Repeat & Bon Apetite!

Putting Global Mental Health on the Agenda

Written by Christian Ulrich Eriksen, MScGH, & Jane Brandt Sørensen, PhD Fellow

Edited by Sinéad O’Ferrall & Helen Myrr

The University of Copenhagen’s School of Global Health is conducting a one-day seminar: “Who works on Global Mental Health in Denmark – an exploratory stakeholder seminar” on Wednesday, 21 October 2015 at Center for Sundhed og Samfund (Health and Society). While focus and resources remain scarce for mental health in the international development agenda, international or transnational coordinated efforts are even scarcer.

The objective of the seminar is to kick-start the debate on this lack of response and to hopefully gather concrete tools for advancing the agenda. As part of this exercise University of Copenhagen’s School of Global Health will map stakeholders in Denmark – NGOs, policy makers, academics, journalists, health professionals, students and others – with a Global Mental Health focus as (part of) their agenda. In doing so, we hope to provide a starting point for strengthening and establishing new avenues of collaboration and move forward in increasing awareness about the topic in Denmark and beyond.

In the run up to the seminar, we have gathered a collection of informative and inspirational resources on global mental health, which hopefully will instigate fruitful discussions and prove useful in understanding some of the dilemmas and opportunities in working on these issues.

Social determinants of mental health

The World Health Organization estimates that mental and substance use disorders directly account for around 7% of the global disease burden. Mental Health conditions bring grave implications on the quality of life for the affected and their surroundings, and especially in low- and middle-income countries they bring serious challenges to already strained healthcare systems. In these settings poor mental health is oftentimes exacerbated or triggered by already stressful and challenging life-situations, which can be due to poverty, physical health issues and disasters, making prevention and response highly complex and multifaceted. The following short film on pesticide self-poisoning in a rural area of Sri Lanka, clearly highlights the complex nature of mental illnesses.

NCDFREE Sri Lanka Video

The resource gap

The largest challenges faced by many low and middle income countries in dealing with the increasing burden of mental illnesses are the paucities of both mental health care professionals and services available to people with mental illnesses. Mental health services are, especially in low and middle income countries, not allocated the needed resources to cater to the need for treatment and prevention. Thus, new approaches need to be sought and attention drawn to the topic to combat the challenges faced. In the TED-talk below, the psychiatrist and mental health care advocate, Vikram Patel, shares his views on how to approach global mental health.

Vikram Patel’s Ted Talk 

Putting mental health on the agenda

Though the focus on mental health is increasing, it is still rarely brought up in the popular media, which further removes the issue from the political agenda. The following clip is an exception to this, and it showcases how mental health issues can be mediated to the general public in a nuanced and informative way.

John Oliver report on Mental Health 

Further readings

If you are inspired to do some more reading, we recommend this special section in the journal Transcultural Psychiatry, which has a specific focus on communities and mental health, as well as the Lancet series on Mental Health from 2007  and 2011.

An interview with Dr Sandro Demaio on Advocacy & Campaigning in Global Health

By Henry Mark

Thanks for taking the time out of your busy schedule to talk with us! Can we take you back to you first experience of advocacy and campaign, when was it and what was it on?

I think I was always a campaigner. In fact when I was 7, I remember baking cookies and then walking about the streets near my house selling them door to door with two friends. We were “raising money for Africa” I think a little naïve, but quite a fun start now looking back.

As a medical student, my first big campaign work was as the President of the Asian (and Pacific) Medical Students’ Association and on the Board of YEAH, Australia’s peak HIV and sexual health awareness organisation. Both experiences really tested my skills in public speaking, communication, leadership and engaging with wide, diverse audiences on some challenging topics.

What were your main inspirations and motivations for co-creating NCDFREE?

130308_NCDFree-ID-Final-square copyNCDFREE was created out of inspiration, and frustration. NCDFREE is a global social movement I co-founded in 2013 and it aims to put global health and NCDs on the map for millennials – linking it with urgency and poverty. The inspiration came from the incredible young change makers around the world I had, and still have the privilege to work with on NCDs. I wanted to tell their stories and through these, tell the story of NCDs. The frustration came from continually being met with the false perception that NCDs were diseases of affluence and laziness – when in fact they’re linked with poverty, poverty entrenchment and are a risk to economic development.

Looking back now can you pick out a couple of key moments in the early days that have been so important to the success of NCDFREE?

Our first big success was having a great team. NCDFREE is not a one man show, it is about the collective inspiration, action and dedication of a wide team. The second was our crowdfunding campaign. We made a YouTube clip and told the world our idea – NCDFREE. We said if they like it, support it. Evidently they did, because we raised US$60,000 in 30 days.

Many people who are passionate about a particular cause or issue will perhaps find the idea of creating their own campaign or social movement intimidating. What advice would you have for them?

Be passionate about it. Believe in yourself. Work with others. Don’t replicate for replications sake. Remember the words of Mead.

“A small group of thoughtful people could change the world.

Indeed, it’s the only thing that ever has.” 

 Margaret Mead

Looking more generally at advocacy work in global health, do you think we risk developing a culture of one-upmanship as different sectors and health challenges compete for attention?

Good question. NCDFREE is a social movement, not an organisation. We are about bringing attention to an issue and to great people doing great work. Global health and its determinants are interlinked, complex and there are strong forces with vested interests in seeing NCDs continue to rise. Working together is the only way forward, and the only way we will get true transformative change.

Following on from this, how can we maintain a balanced approach to tackling global health issues?

I am a strong believer in looking at determinants and not diseases. We need to be focusing on the complex systems that cause disease, long before they do. This means health professionals and experts working with all sectors, but in tangible ways. NCDs offer a great platform for this because they include a wide range of diseases, which have strong multi-sectoral solutions. These include changes in advertising, transport, our food system and more – from across business, science, politics and even the private sector.

Finally, after the highly successful face of NCDs campaign, can you give us a sneak preview of what’s coming from NCDFREE in the remainder of this year?

We have a big year coming! We’re currently releasing our latest NCDFREE comedy films and just commissioned a new short film in Sri Lanka. Soon we will launch a new concept in Melbourne – the ChangeMaker’s Long Lunch. Then again in Sydney. We have a bootcamp in Sydney in March and are beginning plans for another in Copenhagen in August. We’re teaming up with partners to be at the Milan World EXPO, the EAT Stockholm Food Forum and will shortly launch a course on NCD Diplomacy with Ilona Kickbusch and the Geneva Graduate Institute.

You can keep up to date with NCDFREE or join the movement by finding us on Facebook where you can also sign up for our newsletter. NCDFREE belongs to everyone and we look forward to 2015: a huge year for our planet, and for Global Health.

Again thanks to Sandro for taking the time to talk with us. We are all excited to see what 2015 brings for global health and NCDFREE.

You can follow Sandro on twitter

Happily Ever After?

Written by Daniel Jeannetot and Sophia Röckel on behalf of the United Nations Youth Association of Denmark Global Health Working Group

Edited by Julie Franck and Sinéad O’Ferrall


Folks are usually about as happy as they make their minds up to be.” [Abraham Lincoln]

Have you ever asked yourself what makes your day a happy day? Is it staying in bed forever? Meeting Friends? Maybe going for a run in the park?

What if these decisions were not yours to make? Life happens spontaneously. Some of the plans you make might not pass the test of reality.

Maybe you have been looking forward to that football match for weeks, but you did not plan on breaking your leg. Or being diagnosed with cancer makes you wonder about your future.

At first glance those conditions, like many others, seem to be primarily physical yet that would be missing parts of the bigger picture. They say a healthy mind comes in a healthy body. However, does that not imply an unhealthy body can lead to an unhealthy mind?

Mental disorders are “generally characterized by some combination of abnormal thoughts, emotions, behaviour”. Think of anxiety, schizophrenia, depression, as well as disorders due to drug abuse. It is estimated that 8 million deaths worldwide could be linked to mental disorders. However, the crux is that mental disorders don’t necessarily lead to death but rather have a negative impact on your quality of life. Indeed, 183.9 million DALYs (Daily-Adjusted Life-Years) are lost globally every year. In high income countries, mental disorders account for the highest number of DALYs lost.

Nonetheless, these numbers only represent the individuals diagnosed with mental conditions, and not everyone impacted by it. Families taking care of affected relatives need to provide ongoing physical and emotional support, which can have negative impacts on their social and professional life. Additionally, they often carry the associated stigmas and discriminations due to mental conditions.  And this does not take into account the economic charge put on families.

It is important to understand that people affected by mental disorders often are aware of the situation they put their relatives in, and therefore tend to isolate themselves, hoping to decrease the burden. In the end,  a suicide is committed by a person with a mental condition every 40 seconds, which ultimately leads to even greater suffering for the relatives.

The ripples of mental illness also spread throughout society as depression, anxiety, nervous breakdowns, etc, with enormous costs for the wellbeing of a society. According to the Director of the National Institute of Mental Health, Thomas Insel: “the global economic costs of mental illness over the next two decades would exceed the costs of cancer, diabetes and respiratory ailments combined”.

Mental health, however, is not just the absence of mental disorders. It is rather a “state of well-being in which an individual realizes his or her own abilities”. In a sense, a mentally healthy person is a happy person. While mental disorders consist of numerous sets of conditions, reasons to be happy overwhelmingly outnumber those conditions.

The United Nations joyfully agree with us and marked the 20th of March as the International Day of Happiness.


The Global Health Group of the United Nations Youth Association of Denmark (UNYA DK) works to raise awareness among youth about global health issues. We are part of UNYA DK, which is a youth-led association working for meaningful youth participation in UN related issues.

To celebrate the International Day of Happiness, we are running a campaign on social media. Follow @UNYADK_ GH on Twitter and read our daily #HappyNews on awesome happy health facts. And, starting from the 13th of March until the International Day of Happiness “Humans of Copenhagen” are going to share their stories about mental health on the UNYA DK Facebook page .

All Roads Lead to Krakow

By Larisa Damian

As half of the first year students of the Global Health programme at the University of Copenhagen are getting ready to embark upon the field trip to Poland, scheduled in May-June, everyone is anticipating the experience with a complex mix of feelings. After all, most of us are headed towards a month of novelty. What should we expect? What kind of a learning experience are we preparing for? Who are the people we are going to meet on our way? Of course, the underlying emotions are very positive, but there is also some anxiety lingering at the back of our minds. ‘Resfeber’ is a Swedish word that describes the turmoil a traveller experiences before starting a journey, when anxiety and excitement are woven together. I wish I had an English equivalent for it, because that would be exactly the word I’d have used to describe this contemplation.

For me though, going to Krakow is going back to one of the places that contributed to the person I am today. In 2009, I did an internship with the Community of Hope Foundation. This is an initiative that has developed a centre for adults with autism, and since the main goal of our trip is to get acquainted with the medical system of a middle-income Eastern European country, I thought it would be useful to share with my colleagues a positive story of  the great things that can be done, even in a system with little to no support.

Rynek Główny: the main market square. Photo by Larisa Damian

In spite of the fact that over the past decades mental health care services have improved significantly, they are poorly integrated within the health care system, and there is a shortage of mental health care professionals. Moreover, the quality of health care provision differs tremendously across the country. Autism is a very good example of how the system may fail its beneficiaries. Although nowadays there are a number of facilities that provide services for children with autism, as soon as these patients turn 18 they become invisible, as psychiatric facilities are not prepared to mitigate their needs and the social system is incapable of integrating them.

The centre I worked for was created exactly to alleviate these problems. It is called ‘The Life Farm’ and provides accommodation, work options, and therapy and rehabilitation activities for all the beneficiaries enrolled in the program. The project began as a consequence of the inability of the Polish system to deal with autistic patients once they were no longer considered children. According to the European Autism Society:

“Life Farm is a kind of village community opened to adults with Autism from Krakow and surrounding neighbourhoods. As part of the long-term project, residents and other adults with Autism will be able to engage in vocational training to prepare them for the open job market, as well as participating in trade and handcraft workshops and an organic farm. Some people also benefit from professional training and apprenticeships conducted outside the centre.”

My job at The Farm was to guide the residents during the workshops and to assist in the creation of several educational tools and programs. I also had the chance to visit a few other facilities for people suffering from other mental health problems, such as a centre for children with autism,  a psychiatric hospital, and an asylum for men with both mental and physical disabilities. In each of these situations I was faced with two of the main features of the approach to healthcare in a country like Poland. On one hand there are the difficulties that both health care providers and patients encounter as a consequence of a medical system that is continuously changing, more than 20 years after the fall of communism. On the other hand, there is the resilience that characterises these people, and their ability to find answers to questions that have never been officially asked, such as what do we do with these people who don’t fit in any of the categories our systems are ready to serve, or can we do something even though nobody’s done it before?

The Krakow Ghetto Memorial. Photo by Larisa Damian

So when you’re asking yourselves what it is going to be like, my experience says that while you’ll encounter quite a number of mind boggling problems and irregularities in health care provision, you’ll be amazed by the creativity of people and by projects such as the one I just mentioned. The Jagellonian University is located in a beautiful old building in the heart of the city, in the middle of all that Krakow is. As for Krakow itself, it’s nothing short of spectacular. Castles, rivers, hidden turquoise lakes,  legends about dragons, art cinemas, and, most strikingly, a reminder of the astounding survival skills of our species; both the old Schindler factory and the Nowa Huta district built during the communism years as a centre for heavy industries have left their prints on the collective memory of the city. And me? I am looking forward to being carried around the streets of Kazimirez once again, as the sun sets and some Klezmer music resonates outside a souvenir shop by a synagogue.

Inaction is a matter of mass destruction

By Larisa Damian

I learnt the word ‘tumour’ when I was 8. My father was diagnosed with a cancer that metastasised to the brain and passed away 9 months later. It was the early 90’s in post communist Romania, an era when health care for cancer patients was hindered not only by the limitations of technology and research at the time, but also by the lack of access to the best diagnosis and treatment options available. I cannot help thinking that with the knowledge and advancements in science acquired in the intervening years the situation could have looked different. Maybe with today’s surgical paraphernalia his tumour would have been operable. Or maybe his brain would still have been too affected to operate on, but the new pharmaceutical therapies and a better palliative care approach would have helped to lessen his suffering. Any which way, I would assume that if my parents had access to the information on this disease that is accessible to the public today they would have understood that the changes in his sense of wellbeing that took place over the year that preceded the diagnosis were abnormal and would have caught the tumour at an earlier stage.

As an individual, as a daughter, this is not a fair story. As a global health professional in training though, I couldn’t be happier to see such progress in tackling a disease, despite the fact that there is still a difference into what is accessible for cancer patients in low/middle income countries compared to high income countries. It’s amazing how much the situation has improved in these past 2 decades since my father’s diagnosis and the same trend has been observed in the approach to other NCDs, such as heart diseases and diabetes.

Now let’s stop for a moment. Allow me to engage you in a game. Imagine that there were patients suffering from disorders that have known a similarly tremendous advancement in understanding their underpinnings, but that these patients’ access to health care was hampered by insufficiently available public information, and a level of stigma so high that it affects even the clinical personnel who are supposed to treat them. Imagine that someone you knew was affected by illness and they wouldn’t seek help because they didn’t know they were sick, or dismissed their symptoms as being mere figments of their imagination. Even worse, imagine that they or their families and friends realized they were ill, but were too afraid or embarrassed to ask for medical assistance. Imagine that there were patients who struggled with their disorder without benefiting from adequate treatment, in spite of the availability of new age drugs and other effective, evidence-based therapeutic interventions. Imagine that an 8 year old child would lose her father to suicide, after a long, difficult battle with depression that could have been addressed if only he had benefited from specialized health care. As an individual, as a daughter, as a global health professional in training, this is not only an unfair story, it is utterly appalling. Unfortunately though, this is not a simple game of the imagination, but a submersion into the stark reality of the too many people who are suffering from psychiatric disorders.

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We live in exciting times. Last month researchers at the University of Washington at Saint Louis published the results of a study that indicates that schizophrenia is not a single disease, but a cluster of 8 genetically separate disorders, each one with its own symptoms. These genetic variations predict a 70 to 100 percent risk for a person to develop the disease, making it almost impossible for carriers to avoid the diagnosis.  Still last month, another article published by scientists at Northwestern announced the development of the first blood test to diagnose depression. The internet and social media help us connect more easily than ever. Open access and initiatives such as Coursera slowly reshape the way we access information. Movements like TED talks bring to light examples of people who tell their own story of psychiatric illness or of scientists who better clarify what we’re talking about when we’re talking about mental health. From a global health perspective Vikram Patel of King’s College’s Institute of Psychiatry eloquently discusses the struggles faced by developing countries, whereas Joseph Pierre of UCLA addresses the fear of over diagnosis expressed in the Western world, especially in relation to the controversy emerging upon the launching of the fifth edition of the Diagnostic and Statistical Manual. As I am writing this, it is mental health awareness week in both Canada and Australia. At a more policy related level, Canada has taken the lead in implementing a fantastic strategy to address mental illness and, the WHO has launched a comprehensive action plan.

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I just received in my mailbox the October issue of the Psychologist, a BPS monthly publication.  It’s a special edition focused on the myths and facts around autism. I haven’t gotten the chance to read it as yet, but I did feel privileged to have even had the chance to be aware of it. It was a reminder that I am part of a community that acknowledges the existence of the elephant among us, and that pretending it doesn’t exist will not make it disappear. But the fact that too many elephants go ignored in their rooms baffles me. As the illustrator Marc Johns puts it, I am truly surprised that we seem to get by without polka dot elephants, serving us pie.


There isn’t any doubt that things are changing for the better, but I am afraid that we’re running out of time. I’m not saying that all the facts mentioned above (or many other similar one) are not good enough, because they are great. What I am saying is that if we want this information to reach the people who need it the most we must try harder. As academics or as professionals in the field we have to give up on the rotten practice of publishing articles for one another only for the sake of science and of circulating the information only among ourselves, and we have to give up on the passivity of waiting for our patients to visit our offices. It is our mission to take action. Most importantly, what I am saying is that it takes a lot of time even for the most efficient policies to have an effect and we’re already running behind time. So I take advantage of my privilege and I call you all to join the battle against mental illness. The time is now.

Sports Sponsorship’s Seedy Affair

Republished from Our Global Health by Jack Fisher 
As another entertaining summer of sport comes to an end, I can’t help but feel a sense of ache surrounding another ‘legacy’ which is left in it’s wake. Before a single ball was kicked in the 2014 FIFA World Cup in Brazil, I was plagued with the red and white of Coca Cola’s products, side by side with the tournament logo, in Tanzania. In the words of one regional Coca Cola employee: ‘It’s great, Tanzanian people can buy the coke and they can win the chance to be sent to the world cup’’. Inadvertently they can also be sent to a life of chronic disease management, co morbidities and early mortality. Therefore I pose the question, is it acceptable for physical activity to be associated with products related to extensive global morbidity and mortality ?Let’s paint the picture. The world biggest single sporting event, the 2014 FIFA World Cup Final, was watched by one billion people around the world. That means roughly 1 in 7 people were watching the world’s most popular sport come to a climatic end, while exposed to 120 minutes of advertisements from Coca Cola, Budweiser and McDonalds. Whether this manifests itself into an adult drinking 5 cold cokes while watching each game, or a child associating football with fast food, they both have an adverse effect on health.
Flickr: KennyWilliamson
Flickr: KennyWilliamson

However the FIFA world cup is not alone when it comes to perpetrators. UEFA also have similar negative sponsors, funding a range of regional tournaments including those include under 17 year olds. On a national level, the English football association’s last two sponsors have included McDonalds and Mars. Investing in grassroots on which level I ask ?

Outside of the footballing world, it is unfortunately a similarly bleak picture. The Rugby World Cup 2015 (Heineken), Tennis’s ATP Tour (Corona), Golf’s PGA Tour (Coca Cola and Michelob Ultra), Major League Baseball (Pepsi Cola and Gaterade) and American Football’s Super Bowl (Budweiser, Pepsi Co and Coca Cola) are all sponsored by endless empty calorie companies. Of course we could not forget to mention the Olympics and their continual mass sponsorship from McDonalds and Coca-Cola since Atalanta 1996.The frustration continues. Although it doesn’t just continue because of the fundamental immoral principle of associating physical activity, a principle taught as a health enhancing activity, along with these negative food and drink products. It doesn’t just continue because these major sporting events are promoting unhealthy practices in low and middle income countries, whom are less knowledgeable to the adverse effects of excessive sugar consumption and excessive alcohol consumption. The frustrations continues because we have been here before with the restrictions to tobacco marketing.

Thankfully tobacco companies are not currently present within the sporting realm. However it isn’t to say they weren’t until the 1982 FIFA World Cup where R.J. Reynolds (Camel & Winston cigarettes) were a major funder. Furthermore it’s concerning to know that tobacco companies were a major sponsor of Formula 1 up to 2007. This in itself is a case of concern, as this is over 50 years after the British Medical Journal produced damning evidence against tobacco consumption. Do we have to wait 50 years for sports organisation to consider junk food as harmful as tobacco ? Furthermore, I would argue that the sportsmen and women are similarly idolised compared to doctors in 1950. Therefore associating these harmful food and drink products, with healthy role models such as athletes, is a replication of using the gate keepers of health in the infamous ‘More doctors smoke Camels’ adverts.

Flickr: Classic Film
Flickr: Classic Film
If we continue to look at why tobacco was banned, then we see the following statement from Australia:

‘’Tobacco advertising is banned because it promotes a product that is highly addictive and lethal. 
The aim of the tobacco advertising ban is to help prevent smoking uptake and reduce smoking rates. The goal is to improve the health of all Australians. ‘’

Does sugar, alcohol and fast food not have addictive and eventually lethal qualities ? Would restricting advertising powers prevent their uptake and improve the health all people ? Does diabetes, cardiovascular disease and cancer kill many people each year and cost the economy and society billions per annum ?
Unfortunately this is not the mainstream consensus amongst these multinational corporate companies. However as the scientific body of evidence continues to grow against the mass consumption of these food and drink products, then these sporting organisations will have to re-evaluate their sponsorship positions. There is no doubt we will here the same fears heard over half a century ago from broadcast organisations that all doom will fall on them if these advertisements are removed from their media. Some may also argue that these same companies have nearly a half century more experience to manoeuvre and manipulate restrictions and regulations which governments may impose on them. 

However the reality is we are fighting a new fight. This fight is less visible than the fight on tobacco and may last many more decades. Regardless, it is essential to fight these challenges to prevent and alleviate current and future generations suffering preventable diseases, which are partly inflicted by highly profitable multinational organisations within and out-with the sporting realm. It will be difficult as smoking was seen as a more passive disease. However the concept of passive obesity and chronic disease is an interesting factor when considering similar advertising restrictions. 

Fundamentally these are multi million sports industries who make massive revenues within a capitalist society. They are using the healthiest fittest people in the world to advertise the worlds most unhealthiest foods. That in itself is fundamentally immoral and hugely damaging to society as a whole. Once again, we have seen this all before with Tobacco, so let’s not wait 50 years to pick up the pieces.
Flickr: Kol Tregaskes

Updates from the field – CVD focus

This week the Blog entries from Tanzania and Poland are courtesy of the groups working on the theme ‘cardiovascular disease’. It’s fair to say that both groups have had different yet insightful visits to far. We hope you enjoy reading about there experiences.

Could psychosocial prevention strategies be key to reducing CVD? 

By Lucas Pahlisch

As a global health studenttravelling to Central and Eastern Europe to study Cardiovascular Disease, it has been the most interesting struggle trying to make sense of all the data available for this part of Europe. By only looking at CVD death rate, one can be startled by the disparities existing between Central and Eastern European countries. Some of them have had their CVD death rate declining constantly since 1990 like Poland or Latvia. Others, like Ukraine or Russia were less fortunate and in 2011 had a CVD death rate more than twice as big as the lowest one in Central and Eastern Europe according to the European health for all database. One can they ask, why is Poland doing so much better?

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After 1989 and the dissolution of the Soviet Union, Poland became a sovereign country. It quickly started a vast economic reform to turn the country toward a capitalistic model. It is worth noting that during soviet time, there was no health promotion whatsoever. Poland was one of the former soviet countries that turned its economy the most successfully, and it is tempting to attribute its health success to this factor alone. For the comparison, Ukraine has a GDP of 3’867 USD per inhabitant and Poland has almost more than three times that amount with 12’708 USD per capita. However, there are a lot of other factors that influence CVD and CVD death rates, in Poland these rates started declining well before its economical success. Moreover, the improvement in medical equipment and notably angiography equipment cannot account for the decline in CVD as it also occurred well after the sharpest decline was noticed. Beside, even with this somewhat high GDP (compare to Ukraine), when visiting a cardiology unit in Krakow, lack of funding was still cited has an issue preventing clinicians from meeting every patients needs.

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Of course, Poland also implemented a number of prevention strategies in order to promote healthy behaviour regarding CVD risk factor, such as the anti-smoking program. However, the classical « lifestyle » risk factor cannot alone account for every CVD occurrence. More and more, psychosocial risk factor, such as stress, are under the scope of the scientific community. There is of course the famous type-A individual, a psychological profile matching someone who is never satisfied with his work and constantly challenging himself to perform better. Such mental states, which lead to a stressful life, have been linked with an increase risk of CVD. It is following such evidence that Andrej Pajak and Magdalena Kozela suggested that the perception people have on their country’s economical state can influence the population CVD death rate. It is such perception that could explain the difference observed between a number of countries in Central and Eastern European. Following this hypothesis, countries who perceived the economic changes following the collapse of the Soviet Union as benefit for their country would have a lower CVD incidence. And thus, having an open mind toward change may lead to better health.

Time for Tanzania to scale up the primary prevention

By: Lone B Rasmussen, Hillary Smith-Dam, Andrea Stanglmair, Pernille Klarskov Stage & Jack Fisher

Tanzania. A land covered in sunshine, rich in its wildlife and friendly people who greet you with ‘Jambo?. In many ways the region of Kilimanjaro shows some of the best health care services in all of Tanzania and funding have ensured great improvements in maternal health care, TB and HIV treatment to name a few. However, the country also shows another less addressed side, namely the growing problem of non-communicable diseases the population now face. Hypertension and diabetes are significantly undiagnosed and under treated within Tanzania and Sub Sahara Africa. Even in Kilimanjaro region where health facilities are generally good, proper diagnostic tools and awareness campaigns enlightening the issue of NCDs are at a minimum.

ln the cases where treatment is sought the clinical manifestations present themselves at a late stage when it is often difficult to prevent mortality. Tanzania is therefore now experiencing a double burden of disease of CDs and NCDs. Recent studies have shown that even some communicable diseases, such as malaria, can have an impact on the risk of developing CVDs later on in life. These finding increases the need for not only focusing on communicable and no-communicable diseases separately but to acknowledge the link between the two, and make sure that both receive equal attention.

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In many high-income countries the increase of cardiovascular disease have been associated with a diet high in saturated fat, sugar, salt, smoking, alcohol intake and physical inactivity. Lifestyle factors, or life conditions as some would argue, play a key role in the dramatic increase in hypertension within Tanzania. Ultimately globalisation and urbanisation has greatly attributed to companies such as Coca Cola to exploit and reap a vulnerable unregulated Tanzanian market. If you had no prior knowledge on Tanzania, you would easily think the national colours were red and white. Ranging from boutiques to bakeries, hospitals to hotels, emergency services to educational establishments, they all have the famous soft drink branding. It’s a simple but cunning marketing ploy to have everyday essentials such as tables, chairs, signs, parasols sponsored by Coca Cola. There is also little difference between urban, periurban and rural settings where the vast majority of outlets have Coca Cola easily available on the eye and in the fridge.

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There is no doubt that if NCD policies are to attempt primary prevention strategies within Tanzania, then rules and regulations are needed not only on soft drinks advertisement, but also relating to smoking and alcohol. The Tanzanian population should be provided with the knowledge on the consequences of consuming soft drinks, cigarettes and alcohol intake. Furthermore by increasing awareness campaigns at a school based level highlighting the importance of of getting blood pressure regularly measured is essential in educating the younger Tanzanian generation.  Two-thirds of the 33% of the SSA population, of whom are aged between 10-24 years of age, growing up in slum like conditions in a context of widespread poverty, rapid urbanisation, limited education opportunities and rapidly evolving transformations of traditional norms. As a result an accumulation of the environmental factors, lack of awareness, health services and national policies on the relationship with HTN and CVD, leaves TZ’s young adults as a high risk group for developing CVD complications throughout the life course. Therefore, by targeting adolescents behavioural risk factors by increasing awareness through primary education could be a starting point in tackling hypertension. Other similar school based interventions have been successful in raising awareness in other health challenges such as HIV and AIDs. Therefore this approach wouldn’t necessarily reinvent the wheel, but build on and adapt successful existing preventative strategies to delay and manage this essential health challenge.

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Thanks for reading. Tune in again next week for more !!

Merry Heart Attack and Happy New Depression

By Camilla Duus As, Marissa Ray and Anne Gotfredsen

Controversies of the Christ in Christmas aside – we are approaching a holiday that is recognized as a major festival and public holiday throughout greater parts of the world.


This and other festivals and celebrations are times to be merry, jolly, carefree and indulge in the good and even luxurious items available. In Denmark – our present location – the time leading up to, and throughout the month of December, is abundant with cookies, cakes, marzipan, nougat and chocolate, pork roasts, pork cracklings, duck and goose, caramelized potatoes, nut pâté’s, sauces and oranges and the list goes on and on and on and on….  Nothing screams holiday and celebration like lots of food. And we wouldn’t celebrate the season very well if we didn’t use every possible opportunity to treat ourselves and others to a little of everything – and then just one more cookie – now would we?

Historically the indulgence makes some sense: in post WWII my grandparents’ fondest memories of Christmas describe the magical event of receiving one orange in his Christmas stocking. That was extraordinary and lavish!

Happy Heart Attack Holiday

Today, however, in the era of Hypermarkets, online convenience shopping and irresponsible food waste, the stockings are overflowing with luxuries.


Somewhere in between the ‘yuletide carols’ and ‘sledging in the snow’, too much food fill our plates. Moving on to the mountain of presents lifting up the Christmas tree from the floor, we flush all of it down with sugary and alcohol beverages in an attempt to make room for dessert. Yet the news stories on Boxing Day that several ER patients with presumed heart attacks were discharged with the diagnosis ‘overeating’ becomes a laughing matter.

Research has shown that the Holidays have become a risk factor for death and has been deemed “The Merry Christmas Coronary and Happy New Year Heart Attack” phenomenon.

Have a Blue Blue Christmas…

Elvis Presley isn’t the only one suffering from a ‘Blue Christmas’. In fact, a lot of us experience stress, unhappiness and depression during the holidays. When stores and streets are crowded with Christmas decorations, weeks or even months in advance, there is time enough to be reminded of what the “perfect Christmas” looks like. Plenty of duties and demands to tend to like succeeding with the roast, finding the right presents, scrub the house spotless, have enough money for it all and finally find time to actually celebrate Christmas with your loved ones.


Here we can add an extra layer on our stress cake. Social demands in form of heightened expectations on joyful family togetherness, can be trying and increase the risk for conflicts. Christmas pressure can result in headaches, loss of appetite, poor concentration, bad temper, sleep disturbances, anxiety and feelings of unhappiness and depression. In addition, stress compromise your immune system, which makes you more susceptible to colds and other infections, especially if you are exposed to more people during the holiday. Longstanding stress can contribute to heart disease, stroke and cancer. If you live a stressful life during the rest of the year, a hectic Christmas can push your health in a seriously wrong direction.

As the holidays are so associated with social gatherings it can be very difficult for those of us being on our own, to avoid feeling lonely at this time of year. Not having somebody to celebrate the holidays with can be difficult and painful for many and often viewed as a “social failure”, even when the solitude is voluntary.  Holidays in general can be a hurtful reminder of what once was. The loss of loved ones by death, separation or conflicts, or being far apart from them can result in sadness and isolation.   Particularly older people are more likely to spend Christmas on their own for different reasons, which could be related to being alone and/or disability, bad weather, crowds and increased noise.

Holiday Accidents 

Every year your “beloved” neighbor strives to have the best Christmas decorations, but this year you’ve had enough. It’s snowy, dark, and cold but you don’t care, you’re going to climb the ladder and put up those Christmas lights and for once have the best display. You were almost finished with the second story lights when you lost your footing and you find yourself flat on the driveway pavement with a broken leg.


This scenario is all too common among the holiday season with an estimated 13000 people in the US alone being hospitalized for injuries related to holiday decorating.

Besides accidents relating to holiday decorating; alcohol consumption is another leading cause for injuries from the time between “Black Wednesday” and New Year’s Eve. It is estimated that 40% of traffic-related deaths occurring during the holiday season are alcohol related, a 12% increase from the monthly average in the US.

Data over the years has proven that the holidays is a time for increased visits to the emergency room due to holiday celebrations and preparation gone wrong. When you mix stress, joy, crowded family get-togethers, and increased alcohol consumption from the wonderful Eggnog; it’s a breeding ground for accidents.

Christmas is a time for celebration and festivities, but stay safe and take care of yourself. Send a card or call an old friend you haven’t talked to in a long time. Eat mindfully, take a walk and get some fresh air. Adjust your expectations and have a happy holiday!