Leading Voices in Public Health – Allen Dyer, MD, PhD

So again, my name is Randy Wykoff. It’s a
pleasure for me to welcome all of you here. We’ve got a really interesting and
important topic this evening. Over the past couple of years, with the exception
of the election we’ve just been through, probably the single most important news
item that’s been going on in the world are the number humanitarian crises around the world. Whether it’s
war, civil war, hurricanes, earthquakes, there’s just been a lot of crises,
humanitarian crises, in the world, all over the world, and while we sometimes pay attention to the short-term consequences, we very seldom think about the long-term
impact of what’s really going on, and we’re very fortunate this evening to
have someone who is an international perspective expert in the long-term
consequences of humanitarian disasters. Dr. Allen Dyer has worked for many years
in Iraq. In fact, in 2014 was recognized with a special award for humanitarian
assistance to the people of Iraq. He’s worked in Greece, Haiti, China, Japan, other
locations. Some of you in the room know Dr. Dyer because he was previously here at
ETSU. He left to become, to be the senior health advisor for the International
Medical Corps, and then moved from there to George Washington University School of
Medicine where he is today. He’s a remarkably accomplished person in
the field of global health and international and global psychiatry. We’re very fortunate to have him here with us this evening. So please join me in welcoming, Dr. Allen Dyer. Thank you very much, Randy, for a very nice
introduction and thank you all for coming.
It’s a great pleasure for me to be back at ETSU and a tremendous honor to be part
of this distinguished lecture series, Leading Voices in Public Health. The
story that I want to tell tonight is actually a story that has its origins
right here in East Tennessee. In 2001, early in 2001, read before 9/11 2001, ETSU
received a grant from the Meridian foundation in Washington to help the
Kurds develop and improve the medical infrastructure. This was a very
prestigious grant. A number of important universities, like Harvard, competed for
the grant, but we got the grant.The way it worked was in the early years 2001,
2002, 2003, a number of delegations from Kurdistan came to Johnson City. Many of us made friends with the Kurdish physicians, friendships which endure to this day Then, as you all know, in 2003 there was a
war that was started in Iraq, and for a while it was impossible to go there, for
us to go there, but around 2006/7, we were able to travel to Iraq. I remember
the moment that I received the invitation.
It was a general invitation that came across my email and, from the chair of
the department, and it said they’re looking for someone to teach psychiatry
in Kurdistan, and I thought, I have a lot of friends in Kurdistan. You know, some of
these things you ought to think on and sleep on and talk with your spouse
before you make any moves, but I said if I don’t act on this right now, someone
else might act on it, and so I sent the email right back within a minute and I
said I’m interested in doing this, and then five minutes later I called the
chair of the department I said, “did you get my email?!” and she said, “yes, I got the
email,” and so so I was on and and made some wonderful friendships with some
Iraqi/British physicians who were doing a similar kind of thing that just
happened to be scheduled at the same time I was and with some Iraqi
physicians. And so this work has continued from from 2001 until the
present time. I’ve been to Iraq ten times now, most recently in February of last
year, and there are plans for ongoing projects. What we had hoped would happen is happening that, as we help the Iraqis develop their infrastructure and improve
their health system, that they would take over some of the issues that we were
helping them with and that’s happening, and similarly, of course, the trajectory
is, in terms of the military realm in the political realm as well, that’s a
complex story but it’s the Iraq story that I basically want to tell, and it’s
a story that has its origins here. PTSD is the obvious correlate of war
trauma, but my work in global health has increasingly impressed me that the
distinction between health and mental health is an artificial distinction for
reasons that I will elaborate in subsequent remarks. These are a couple of
pictures from my early trips to Iraq. The left picture is the bath party
headquarters in Baghdad, which is one of the first military targets of the war. In
fact, I think we all watched on CNN that night when the skies lit up and and
missiles were being fired in rockets and bombs and so forth. The picture on right,
on the right, is a Kurdish boy on the tank that the Kurdish Peshmerga captured
from Saddam Hussein’s army in the years, early years, and I wonder what the little
boy is thinking. One imagination might be, “maybe I will live in the world of peace.” Another imagination is, “maybe I’ll grow up to be a famous Peshmerga soldier like
my father,” and most boys’ fathers and in Kurdistan have been Peshmerga soldiers. My experiences working with Iraqi health
professionals since early 2001 and teaching in Iraq since 2007, impressed on
me the ongoing stress that people have been endured. I was impressed in my first
trip to Iraq in 2007 by the stories people told about the horrors of life
with the uncertainties of possible loss of one’s own life, but the inevitable
loss of friends, murders of family members, often in the most gruesome and
grotesque manner. One family whose stories I can tell because their family
friends and they’ve given me permission to tell this story,
people that left Baghdad, they spoke English. Because they spoke English they
were thought to be collaborating with the Americans. They abandoned a beautiful 400 square meter house, just left everything behind, which they’re able to
do and able to get jobs because she was a dentist and a dental professor and he
was a gymnast and a physical education professor. Internally displaced people,
IDPs. They had a number of health problems. She had headaches persistently.
He had trouble maintaining his diet, gained a lot of weight, had
dermatological condition, skin rashes and so forth.
The children told the story or the mother told the story about the children
that one night American soldiers burst into the house and their faces were
painted like Halloween. At first they thought they were dreaming and they
couldn’t wake up, and then when they realized that they were awake and they
weren’t dreaming, they could no longer sleep without being in the same room
with their parents. So this was the kind of situation that they faced, but a
number of people told stories about their health problems, which they related
directly to the stress they experienced. There a number of people that I had had
correspondence with that I wanted to meet when I was in Iraq, and I asked
about them, and then people knew who they were, physicians in the in the country,
professors. Oh, he died of a heart attack, which was a story that happened more
than you would think it might happen, or something has happened to him, or he’s, no,
it wouldn’t be possible. So I was impressed by the
narratives about the anxieties that people faced, but also the health impacts: extraordinary incidence of heart attacks, cancer, headaches,
difficulty sleeping, dermatological conditions, diabetes, and difficulty
controlling weight. Stories which are told directly as part of the stress
under which they were living. Also, to note, was the extraordinary resilience of
the Iraqi people: strong family and community ties, strong religious faith, even as communities were disrupted, families, dislocated, and faith challenged,
or perhaps worse, politicized. So we hear a lot about the Sunni/Shia conflicts, the
sectarian violence which has become so much a part of the news of Iraq.
Sectarian violence and sectarian tension hardly existed prior to 2003. The stories
that people would tell was, if somebody wanted to marry, their son wanted to
marry as Shia woman, the question they would ask is not what
sect or what did their family believe about the succession of the Prophet
2,000 years ago. What kind of person was she? What kind of parent would she be to
our grandchildren? But that situation has has changed considerably. I’m ahead of myself on the slides here,
but just to note the comments that I made. Strikingly is the incidence of
cancer, which is seven to eight times the world rate. The epidemiologic numbers are
seven to eight times what you would expect, based on epidemiologic data alone,
so I’m gonna make some comments in subsequent slide, but I just wanted to
highlight that in red so that it would be in your mind. Susan Sontag reminds us
in her important book regarding the pain of others, that those beset by war and
murderous politics are located on the same map as those of us less directly
affected by such wars and murderous policies. Our privilege, she suggests,
might be linked to their suffering in ways that we might prefer not to imagine,
much as the wealth of some might imply the destitution of others. Painful images
such as these and the stories that people tell supply only initial
spark. So here you see the the Syrian boy that was washed up on the beaches in
Turkey. We were well aware of the migrations that were going on for two
years, but I think this picture captured, in many people’s minds, the gravity of
the situation, and made a difference in terms of the political and humanitarian
response. My remarks take up Sontag’s challenge to look closely at the
invisible wounds that wars and civil conflicts imposed on those involved.
Everyone is involved, both soldiers and civilians alike. Nomenclature can help us understand how
we conceptualize these situations, the ones we called traumatic, as a linguistic
shorthand for experiences that may be so painful that even talking about them
accentuates the pain. It has become convenient to talk about PTSD as a
diagnostic entity that encompasses the psychological difficulties that many
soldiers have experienced. The symptoms of this disorder, PTSD, are not just
suffered by soldiers, we have come to recognize. PTSD was studied and largely
defined by studying veterans of the Vietnam era conflicts. Notably, people who
experience sexual abuse in childhood have similar symptoms: flashbacks
intrusive memories, nightmares, hyper- vigilance. Civilians and war zones war
zones have been less studied but certainly no less affected. Now this
slide has a lot of information on it, and I’ll just walk you through it quickly. In
the first column are the diagnostic symptoms of PTSD: anxiety, dissociation,
hyper-vigilance, hyper-arousal, nightmares, and flashbacks. In the second column is
something that I call OTSD, ongoing traumatic stress disorder, which has all
of the symptoms of PTSD, the psychological symptoms, but the
physiological symptoms, the physical health symptoms that I elaborated in the
previous slide. And then the right column is something called complex PTSD, which
is basically the maladaptive personality coping strategies that some people use,
basically that have relationship impairments and disturbances of mood
such as outbursts of anger. We’ve long recognized the importance of a bio-psychosocial medical model and even with spiritual dimensions, but in practical
reality these dimensions are usually seen as separate concerns often
addressed by different people. Simply stated, war is bad for your health. Wars often cast as a moral struggle, two
opposing sides, us versus them, good versus evil. In the words of Carl von Clausewitz, the famous Prussian general who gave us perhaps the most accepted
definition of war as the extension of policy by other means. Von Clausewitz
says military action is never directed against material force alone. It is
always aimed simultaneously at the moral forces which give it life, and the two
cannot be separated. Whatever moral forces give rise to conflict, the effect
is disastrous on ordinary people, soldier or citizen, caught in the crossfire, may
also be disastrous for humanitarian workers whatever their moral persuasions
regarding a particular conflict. So we’ll look a little bit more closely at front…
Oh let me comment on these pictures. This is a Baghdad on on a bad day and in the
top there’s a picture that I wanted to capture because it looks like the the
traditional villages of Baghdad in the old days. One could probably get a sense
of what a good day and a bad day in Baghdad might be, this kind of attention
that if one picked up on, so I had a little pocket camera and I wanted this
picture the vehicle where in and is whizzing by and I just grabbed this picture but
we were stopped by the IP, the Iraq police because because of this
suspicious person taking pictures. My bodyguards quickly handled it with my
papers in my passport and explained that I was an American professor and we were
able to go on, but just taking that picture triggered a sense of people who
were on edge to begin with. Later that day we’re giving the lecture
in one of the hotels in Baghdad and a bomb went off a kilometer away, and the
concussive blast from that bomb a kilometer away blew out all of the
windows in the hotel making the – connection making the connection there
were probably a sense that there was tension that we might have expected
something like that to happen. On a good day
the Peruvian security officers might be joking around with people as we went
through the checkpoints. Somali kuma meagle, sort of Hisparabic, combination
of Spanish and Arabic. Things are relaxed and things are easy,
and not every day is like this day was. The definition of trauma is subjective.
The dictionary defines trauma as a deeply distressing or disturbing
experience. More recently trauma has come to be understood as an emotional shock
following a stressful event, which may be associated with the physical shock and
sometimes leads to long-term distress. In medicine trauma may be a physical injury,
so when you see a trauma hospital, for example as we see over instead of
Franklin Road level one trauma center, they’re talking about a physical injury
belying the etymological origin of the word from from Greek originally a wound. So the import of what I’m about to say
that we often think of trauma and PTSD in terms of a particular event, but the
brain responds to experiences not events so it depends on how people experience
the event rather than the event itself. The interrelationship of the physical
and mental aspects of trauma hints at the stigma associated with PTSD and with
any emotional distress, particularly in war situations where heroism is the
expectation and anything less may be associated with some overt or implicit
culpability, an inability or an unwillingness to hide one’s own
vulnerability, or to pretend it doesn’t exist. Current attempts to understand
traumatic brain injury help us appreciate earlier misunderstandings of
shell shock and address the disservice to those who serve. Recently the D in PTSD
has come into question suggesting post-traumatic stress is not a disorder,
but rather an injury, particularly in military circles there has been advocacy for
replacing the D, for disorder, with an I, for injury. The argument being that
soldiers and veterans would be more likely to seek treatment and treatment
would be less stigmatized. While PTSD is enshrined in the Diagnostic and
Statistical Manuals, the abbreviation post-traumatic stress is gaining some
currency over the more controversial acronym PTSD. Indeed calling the response
people have in any disaster, natural or man-made, a disorder is probably a
misnomer. What we’re talking about are normal reactions to abnormal situations,
convenes for pictures. The first is the anniversary rituals of the Indian Ocean
tsunami which occurred on Boxing Day, the day after Christmas 2004, so this is 2005,
one year later, and what’s going on there is planting a palm tree in memory of
each person whose life was lost in the tsunami. Now this also speaks to a spiritual
dimension because my Indian friends, as I told the story, a tree planted in memory
of the person. One man said to me this is my wife, and I had to be reminded that in
India people believe in karma. He wasn’t saying this is a tree that’s the
memory of my wife. He’s saying my wife now lives in this tree, so this is a
spiritual way of coping with loss. The second picture up there is the great
Szechuan earthquake 2008, and this is a team from ETSU, a professor, a psychiatry
resident, a medical student from ETSU, a professor from Bangalore in India, two
professors from Duke, and one professor from the West China Medical Center, and
the program and you can see the English translation of the Chinese disaster
mental health community training, so in terms of global mental health,
unlike some areas of Medicine where say an orthopedic surgeon can go to Haiti
and do amputations for two weeks and get in on on an airplane and leave and the
job is done, in the disaster affected villages, the recovery from trauma is
something that may take years, and so what what we do is provide training for
the people that are going to be on the ground in an ongoing way, and one of the
very important aspects of this, people are desperate to tell their stories just
as the people in in Erbil in Iraq were desperate to tell what was going on that
somebody witnesses what their experience is experiencing, the people in these
disaster villages who are listening to the stories and may be vicariously
traumatized by what they’re hearing, it’s important for them to have an
opportunity to process their feelings and validate what what’s going on, so
this has become an important part of the training of global mental health is to
help the people that are helping the people that are most in need. The lower left is the parking lot of the University Hospital in
port-au-prince immediately after the earthquake in 2010.
You see bodies stacked about three feet deep. It might have been the parking lot
of the Ministry of Health in 2005/2006 and Baghdad, so to know this kind of hard
to put into words more than that to say about it, except to be prepared to deal
with with that, and then the picture in the lower right is taken from the 13th
floor of my hotel room in the Al Rashid Hotel in the Green Zone on one morning
when we were doing a training program, and four bombs went off in a period of
about five minutes. Who set them, off what they did, it’s hard to say, but it’s very
disruptive of course and this is very disturbing and unpredictable. This slide represents PTSD as a result
of a single traumatic event, which I’ve suggested PTSD may not be a single
traumatic event it may be an ongoing thing, but in the case of a single
traumatic event, not everyone who experiences events that some people
might consider traumatic gets PTSD, so we pay a lot of attention to what are the
resilience factors, what are the protective factors, and how can one
intervene early in ways that may prevent more long-term consequences and
secondary problems such as substance use disorders, depression, including the risk
of suicide, and other anxiety disorders, and maybe panic attacks. The one month
jumps out and I’ll tell you a story about this. My friend Sallah and Ali,
who were doing a training psychotherapy training program in Baghdad, this is
December 2009, I was usually not allowed out of the hotel, the security people
said no you’ll stay here, but my Iraqi friends, of course, would go out and visit
their families and go out to restaurants and so forth, and Sallah and Ali were
going out and they were going through a checkpoint. There was a woman who held up
a little vial of pills that was empty suggesting that she’d run out of her
medicines, and so they gave her ten dollars. About this point, Ali saw his
uncle whom he hadn’t seen for some time across the street and he ran across the
street to say hello to his uncle. At just that time, the woman detonated. Now
whether this is an active verb or a passive verb, I think as I understand the
situation, it’s more likely that she had no idea that she was fitted with a bomb
and that it would be detonated, but anyway the bomb went off, probably remotely
detonated, probably this was somebody with mental illness who had run out of
medication and so was vulnerable. We often think of suicide bombers as if
this is an act of ideology, when in many instances it’s not an act of ideology at
all. But anyway, whatever happened, three people were killed. My friend Sallah was
knocked unconscious. He was deaf from the concussive blast, and when he woke up
he was covered with blood and guts, which he at first thought were his own. It took
him a long time to recondition himself to eat without the smell and taste of
what he had experienced. Ali, meanwhile, was not there at the time. He had gone
across the street to talk to his uncle, and for one month he did fine, but then
when the memory and the impact of what had happened settled in, he needed to get
psychiatric treatment and get on antidepressants. Stress and trauma are
related concepts. It’s worth remembering that stress was originally an
engineering term applied to materials. Stress involves the complex interactions
of mind and body mediated through the endocrine and immune systems. Trauma also
has physical roots, damage to materials, but understood psychologically, trauma
refers to experiences which are overwhelming. So just those of you that
are physicians remember your biology. Some stressful event, whatever it might
be, impacts the perceptions of the brain, which then sends signals to the
hypothalamus to the anti-anterior- pituitary to the adrenal cortex, which
secretes cortisol, which is protective in the short run, and where the red arrows
are turns off the signals to the adrenal cortex. The cort- the adrenal gland also
secretes norepinephrine, which is part of the fight-or-flight reaction, so that’s
what happens in acute stress. In an evolutionary sense, the body has
adapted mechanisms to survive stressful experiences. The fight-or-flight
mechanism of the autonomic nervous system has enabled our ancestors to
survive encounters with saber-tooth tigers, such things as increased heart
rate, increased blood pressure, conversion of stored glycogen in the liver to ready
energy glucose. This is adaptive in the short-term and keeps you alive long
enough to pass your genes on to another generation, but repeated stress with the
exaggerated cortisol response leads to adverse health outcomes: hypertension,
diabetes, high cholesterol, leading to heart damage, asthma, decreased immune
function, increased infections, depression, attempts to solve these imbalances with
drugs, and the possibility of neoplasms and early death. The sympathetic nervous
system pictured on the right is the fight-or-flight mechanism. The
parasympathetic nervous system on the left is the rest and relaxation response.
All of these physiological changes are automatic and out of our direct
conscious control except for one, breathing, and the ancient
traditions have long recognized that we can calm our nerves by deep slow
breathing, which provides oxygen to the lungs, heart, and brain, and restores
equilibrium. So thus it becomes very important with anxious people and in
Washington there are a lot of anxious people, there have been right along this
is nothing new, and yogic practices, exercise, breathing techniques, are all
important aspect of dealing with stress. We have the concept of the sabbatical.
We have the concept of the Sabbath that every seven days or every seven years
you have to, you’re encouraged, the Bible encourages us to take a period for rest.
I’ve actually modified that from my Washington patients, and I suggest that
every 7 hours you should take an hour for yourself, and that every 7 minutes
you should remind yourself to take a deep breath and make sure that
you’re not stressing out too much, and certainly to get up from the computer
screen and not be sitting at the computer screen hour after hour. Okay
this is probably the most important slide that I’m going to show you tonight,
and and there’s a lot of information on here but I’ll walk you through it. This
is an important correlative study, corollary between adverse childhood
experiences in the left column, the impact of trauma, and health risk
behaviors to ease the pain of the trauma in the second column, and the long-term
consequences of unaddressed trauma in the third column.
So you’ll sometimes hear this referred to as the ACE study or the adverse
childhood experiences study. It’s a large- end study, 17,000 people through the
Kaiser Permanente system were studied by Vince Valetti and his colleagues at the
CDC, the Centers for Disease Control, and this is well-validated. So the thing that
you’re concerned about, the correlations, are between emotional abuse, physical
abuse, or contact sexual abuse in people under age 18, neglect of the child,
physical or emotional neglect, and these traumatic events in the child’s house
rural environment, alcohol or drug user, someone who’s chronically depressed,
emotionally disturbed, or suicidal in the family, witnessing the mother treated
violentl,y someone imprisoned in the household environment, someone that’s a
member of the family being imprisoned, and not being raised by both biological
parents, loss of the parent by death, and less suicide worse by abandonment.
So you ask, in terms of developmental history, these 10 questions and you give
the person a score based on how many of those they have. What you find is that if
there were more than four aces, the person is seven times more likely to
have problems with alcohol, twice as likely to have sex before age fifteen,
twice as likely to have cancer, four times as likely to have emphysema, and if
they’re more than six cases, the person is more than thirty times likely to make
a suicide attempt. Now, if we look at any of these situations by themselves, let’s
just say cancer, it’s the job of the oncologist to treat the cancer. If we
look at skeletal fractures, that’s an issue that’s an orthopedic problem. We
don’t usually take a developmental history of somebody who breaks an arm,
but in any of these situations and it’s rarely done, there’s really time to do it
in the physician’s office, but if you look at the correlations, you’ll see that if
there are more than four of these events that’s more likely to be maladaptive
health behaviors that may lead to long-term health consequences. And I just
showed this picture to take it back to Iraq. This is an Iraqi soldier kissing
his mother on the forehead before going off to fight the battle for the for
Tikrit last year, and so you see the forehead in Islam is very very sacred
part of the body and so this is a very emotional picture for that reason, but
where I’m going to call attention to is the ubiquitous cigarette, so almost
everyone in Iraq smokes to cope with the stress and even smoking as a single risk
factor in itself leads to the long-term health consequences that we know that
are so well established for smoking. The World Health Organization has
developed a international scale. It’s called the ACE IQ, ACE international
questionnaire, and I think there are shortcomings of it, but it does suggests
that there are aspects of trauma that aren’t captured just by the child’s
adverse experiences. I’m sorry, trying to juggle too many things here. Okay,
back to that. The questions cover family dysfunction, physical and sexual
emotional emotional abuse, and neglect by parents and caregivers, peer violence,
witnessing community violence, and exposure to collective violence. The ACE
IQ is currently being validated through trial implementations as part of broader
health surveys. The World Health Organization Iraq Mental Health Survey
conducted in 2008, indicates the type of violence experienced by Iraqis at the
height of the war. So notice some of the following things that we found in the
South Center, which would be the Baghdad region: internal displacement, exposure to
bomb blasts, which happened to me a couple of times, capture, public
humiliation, accused of collaboration, my friends that I mentioned because they
spoke English were accused of collaboration, beaten by parents as a
child, beaten by someone else, sexual assault, causing accidental harm
to others, witness killing, death of a dear one, family member kidnapped, not
uncommon in Iraq, any war related trauma, any trauma, or other In the Kurdistan
Region, it shows higher values for the categories of life-threatening illness,
and this is what I was observing that people were commenting and I observed
life-threatening illnesses and people who are living in the Kurdistan region
or people who had been internally displaced from other parts of Iraq to
the Kurdistan Region when Kurdistan was safe, and of course now there are mammoth
refugee camps from people being displaced to Kurdistan from
Syria and other parts of Iraq that are now even more difficult. Resilience is
the positive capacity of people to cope with stress and catastrophe. We can talk
about cumulative protective factors used in opposition to the, what we sometimes talk about as, the risk factors. You’ll recognize the Washington Monument there. Medicins Sans Frontieres, Doctors Without Borders recently did an exhibit, which is
traveling from country to country, from city to city. It was in San Francisco,
then in Washington, Philadelphia, Boston, New York, maybe, forth from home, and it’s
talking about the the refugee crisis worldwide. It mentions the Syrian
refugees significantly but it also mentions Honduran refugees trying to get
to Mexico to escape organized crime with its brutal murders, and and of course
many of those are trying to get to Mexico and then trying to get to the
United States. And also notably, the Burundian crisis, where 175,000
Burundians have fled to nearby Tanzania and are living in refugee camps or are
basically camping out in the forest in in Tanzania and also many to Rwanda, so I
put up the map of Burundi, which is an East African, South Central East African,
country immediately adjacent to Rwanda, and the stories are intertwined in ways
that are important but aren’t often recognized. Prior to the Rwandan genocide
in 1994, there was a migration of Tutsies from Burundi to escape the
civil war that’s been going on there for three decades, now four decades actually,
to Rwanda, so when the Hutu tribe declared it’s time to eliminate,
time to eliminate the cockroaches was the way the original signal went out
over over the Rwandan radio. These were not the Tutsis that they had been living
with since colonial times or throughout history. These were the migrants that had
moved from Rwanda to escape the conflict there, so currently, and the situation is
politically very complicated, I was scheduled to go to University of Ngozi,
which isn’t on the map but is right about there, last January and the State
Department canceled the trip because the situation is so politically violent. It
was rescheduled for this upcoming January, January 2017, and again it has
been canceled again, so Burundi is a powder keg. It’s, it’s a very volatile
situation for long-standing ethnic conflict. Now one of the things, and I hope I
have a slide inserted here about this, one of the things that Rwanda did that
was very impressive after its genocide, it established a Truth and
Reconciliation Commission, and so that not all of the people that were involved
in the genocide were punished through the judicial system. They were given an
opportunity to appeal for forgiveness through the Gacaca courts, which Gacaca means a hundred people on a lawn, so the communities were asked to
see if the person that was asking for forgiveness could be reintegrated into
the community, and on the whole, the situation has been very successful. The
president of of Rwanda has proclaimed that we are no longer Tutsis and Hutus,
we’re all Rwandan, so in a sense tribalism has been replaced with
nationalism, and there’s been a tremendous economic development. The
situation in Burundi is a very difficult situation. The government is divided by
quotas and the tension still exists and obviously it’s a very vulnerable
situation. In November this past year I was asked
to put on a mental health response to the Syrian refugee crisis in Greece. I
wasn’t able to go myself, but sent a team and this is a photograph that one of
them took of the life rafts coming across from Turkey to Greece. One
of the things I want to call attention to here is that some of the workers are
wearing the Red Cross, the Red Cross and the Red Crescent, and the Red Cross has
traditionally been a symbol for humanitarian workers and even in wars
the ambulances with the Red Cross could go in and take the wounded off the
battlefield. The situation has changed in recent years and often the humanitarian
workers are the targets, that humanitarian workers have become one of
the one of the techniques of warfare, so Medicins Sans Frontieres, which I
identified earlier, for example, it’s hospitals in Syria have been hit
repeatedly, including by American airstrikes and Russian and Syrian and it isn’t clear exactly who, but four, four MSF hospitals have been hit, targeted. They
have lights on. It’s obvious who has electricity, who has generators, and the
hospitals have been targeted, so it’s a very serious situation and MSF is not
currently operating in Syrian as as you probably know in Aleppo, it’s impossible
even to get food into the people who city has largely been destroyed. Say word about the George Washington
University global mental health program. We’re an innovator in global health and
mental health, health program is recognized internationally for preparing
students, residents, and faculty, to respond to global crises and complex
emergency situations. GWU has touched the lives of vulnerable populations
worldwide through programs that foster community support and healing. The GWU
community approach builds medical infrastructure through education and
consultation and strengthening civil society institutions, and this is a
webpage, which you’re welcome to go to, which is the program building resilience
and humanitarian workers, which we did for the US Embassy in Athens with the
support of the Greek NGO Metadrasi. The website is at the top. You can see
sites.google.com slash sites slash gw resilience workshop, but in fact you can
just google GW resilience workshop, and all of our powerpoints are there. The
schedule is there. All of the resources for complete course and global mental
health are on this website, so I invite you to go there, and then in the lower
side you see the map. It actually doesn’t show up very well, you see the red arrows
which are going from Turkey to the various Greek islands. It
might be worth making a comment about Lesbos, which is where most of the
most of the refugees have gone. It’s the closest to Turkey and then the stopover
point for moving on to Greece, Greece mainland and then overland to northern
Europe until the borders were closed with the the Accord in March of 2016.
Lesbos, some of you may remember, you know the term lesbian, the term lesbian comes
from the island of lesbos, and there was a famous play by, I believe it was
Aristophanes, called Lysistrata, and the situation was that
the women refused to have sex with men. What did the men do that made the women
refuse to have sex with them? Ah, they were always going to war, and the women said
enough of this. The only power we have is to refuse to have sex with you, so that’s
the play Lysistrata, and hence the term lesbian, so just that little historical
reference. It’s applicable. For me one of the most poignant things in in
the refugee camps, perhaps the Moria camp was pointed in
the sense. It’s a it’s a concentration camp. It’s barbed wire. People can’t go in
and can’t go out. This is a camp for unattached minors. These are people who
have either been orphaned or whose parents have sent them abroad hoping
that they can find their way in Europe somehow, sixteen, seventeen year old boys,
some of them not even yet shaving and they’re on their own, and this is the
camp that MSF had set up. I’m going to, I’ll just make a comment about physical
unless some of you that have known me for a long time know that I was
diagnosed with cancer in 1998 when I was here, a bone marrow transplant. The
technology was very helpful in helping me get through it, and stress causes
illness, illness causes stress. Meditation was an important part of coping with the
illness, the things that I told you about breathing, about yoga, about mindfulness,
and so this is the view of the mountains that I tried to use as a meditation, but
every time I tried to look out the window at these mountains, the branches of two of the trees would come together like the the grin of a Cheshire Cat as
if to say, “you can’t relax. you have cancer,” and so my task in terms of
mindfulness meditation was to get beyond the Cheshire grin to the mountains of
Tennessee to relax. This is a book I wrote about the cancer experience, “One
More Mountain to Climb: What My Illness Taught Me About Health.”
Cheshire Cat, sunrise in Tennessee. The cartoon says, “Milt, I’m beginning to think
your illness is a disharmony of life energy,” that sums up everything I’ve been
trying to say. This is Abraham Dahl Joffrey who was the prime minister of
Iraq from 2005 to 2006. I was privileged to have dinner with him one evening and
this is a picture I took of him in his library, and in the book that he had
written about his experience of government, he inscribed it in Arabic. My
Arabic friend says he is saying, “Sometimes things get so bad it takes a
psychiatrist to sort them out.” I’m actually not going to have time this
evening to tell you all the things that a psychiatrist might do to sort out the
problems of a country, but I’ll just hint at these and go through this fairly
quickly. Factors affecting coping: “barking
sometimes helps me relax, but it drives the neighbors crazy,” and actually many of
the things that we do, in terms of decreasing our own anxiety levels like
beeping the horn, swearing, behaving aggressively,
retaliating, make us feel better, but make the neighbors crazy, increase the anxiety
level of those around us, so we have to be diplomats in our interactions and one
of the important things is what’s called two-track to diplomacy. It’s diplomacy
beyond the professional diplomat diplomacy. It’s the citizen to citizen
relationships, which increasingly I found to be very important. I think, hopefully,
all the things I’ve done in Iraq have been academically important, but the fact
that I’ve been willing to go, I think, says as much as anything academically
that I’ve been able to say. And here’s a project that we have, the Palestine
Medical Education Initiative. This is my team at JUST, the Jordan University of
Science and Technology, and you may not, it may not be obvious because Mitel isn’t
wearing his yarmulke, but it’s a Jewish Christian Muslim
interdisciplinary team and the goal is, it shows that the partnerships that
are formed in this work across ethnic, religious, and national divides, not only
enable the implementation of programs that improve health,
but these collegial relationships are also a microcosm of the world that we
hope to see. The maps are succession of maps of Palestine from 1948 to 2015, I
guess or the current time. Okay, now we will take a couple of minutes here to do our
little quiz, so those of you that have logged on to this app get to vote, again,
but on a different question. The United States foreign policy is a combination
of what is called smart power. It’s a combination of defense, diplomacy, and
development, and so the question that you’re asked, and it’s a trick question
and I’ll tell you what the trick is, you’re asked to vote on how much do you
think the U.S. spends on foreign aid. What percentage of the United States
annual budget do you think the U.S. spends on foreign aid? Why I
say it’s a trick question is because this could be seen as a question of
opinion or a question of fact. There is a factual answer, but the question asks you
for your opinion, so if you happen to know what the answer is, which you soon
will, that’s a different question from what your opinion is. Each year the
Kaiser Family Foundation does this survey and publishes the data, and I’ll
share with you what the data is. There’s also a second question, which I will ask
before I give you this data, which is what do you think the the US should
spend on foreign aid, and that’s the question of value, so we have a question
of opinion, which is what the first slide is, a
question of fact, which is what the answer is, and the question of value,
which is simply your opinion, and there’s no wrong answer to that, whatever your
opinion is is what your opinion is. How much do you think, what is your opinion,
that the UN, US spends on foreign aid? 38% of you said 1%, 5% said 2.23 percent,
10 percent said 23 percent, and 14 percent of you said 20 percent. What the
Kaiser Family Foundation, this is a more sophisticated audience obviously than
the Kaiser Family Foundation surveys, that most people say 25 percent of the
U.S. budget goes to foreign aid. The answer is less than 1 percent. Now this
next question will do this, you’ve already yeah, question 2,
thank you, and now that you know the answer, the next question is what you
thought before you knew the answer, based on what you said the first time. What do
you think, how much the US should spend on foreign aid? Actually, if you thought
1% and you think it’s a larger number, that’s what you would answer. If you
thought 20% and there’s a smaller number, that would be would you’d answer, but
what did you think before you knew the answer and then we press is it. Has everyone voted that wants to vote? Does anyone want to change as well, change their vote? We can say that now, change
their vote. Okay, and now we’ll tell you how you voted, and
so 43 percent of you said it should be 10%, for those that work in USAID in
development, the idea of getting 10% would be wonderful, that would be more
than 10 percent, more than 10 times as much as actually spent, and I have the
real numbers, which I will share with you, this is if I can do this. Go back to that…
…Then the United State spends in terms of its foreign aid budget about 0.8 percent of
the of the 40 of the 4 trillion dollars that’s the annual budget budget, it
spends about 38 billion dollars on foreign aid, which is less than 1%. It
spends about 500 billion, which is a little more than 10 percent on defense,
and I’m trying to remember what I said here, and the State Department’s budget
is about 50 billion dollars a year, which is a little more than 1%, and just by
contrast, the European numbers differed in particular the acronym of which I
can’t remember and Oxfam in the various European agencies spend a little over 1
percent so they spend a larger percentage of their their budget on
foreign aid and development than we do. So while while we’re doing this, we can
stop and take questions and I’ll bring the picture back when we finally get it
up, that’s fine, so thank you very much, and would anyone like to make comments
or questions? Would you repeat the question? Okay,
so the question is, do I think there will be an effect on foreign aid as a result
of the recent election, and the answer is yes, but one of the things that I will
say is that, for all that any number of the candidates have said they would wipe
out whole sections of the government if they were elected, it’s not so easy to do.
The president doesn’t have the sole power to do that. There are congressional
aspects, and then there are many things that are built into the budget, so there
might be some small changes, but I don’t think there’s going to be a drastic
change in terms of this, and and the question beyond that in terms of policy,
and I think one of the things to say about policy is that policy is a matter
getting back to von Clausewitz’s definition of war, an extension of
policy by other means. If you turn that question around, what are the other means
by which international conflicts might be solved other than military? So that
gets us back to smart power: defense, diplomacy, and development, and what the
military will tell you, and this will be a potent force in any government that we
have whether it’s a public administration or a democratic government,
is that it’s a lot better to do whatever you can do with defense and diploma-
with development and diplomacy because the military least of all wants to risk
soldiers lives for something that doesn’t have clear objectives or that
may be difficult to achieve, so all three branches of government, or all three of
these branches in terms of the smart power, are very much in sync about the
importance of they’re all working together, so for those reasons, I don’t
think things are going to change drastically in terms of foreign aid and
development approaches. Yeah, so in Yep, yep, so that’s that’s that’s an
important question, and thank you very much for asking that, that gives me the
opportunity to elaborate a little bit more what’s what’s on the website, so the
approach is dealing building resilience in humanitarian workers, and the first
part of the workshop was focused on self care and self well-being and then the
second part was caring for self and caring for others, so we’re teaching
basic skills in psychological first aid: mindful meditation, hope modules, and
dealing with the yoga and physical aspects that I mentioned, but also
dealing with the cognitive aspects of how are you processing the experiences
that you’re dealing with. Remember that PTSD, the brain responds
not to an event but to an experience, and so to reframe cognitively the experience
in terms of what are the coping styles that you as an individual have that then
you can use to help people who are facing a new location, uncertainties in
their future, and and and dealing with with both fear and hope and the balance
of fear and hope in terms of what choices they have and and what the next
steps will be in terms of the of life’s journey, which in the case of the
immigrants is going to be a journey from place to place, but for all of us is a
journey from place to place in terms of where we were and where we are and where
we’re going. Oh good good thank you,
so they’re the budgetary figures for the smart power. The United States will spend
38 million on foreign aid in 2016 and this is less than 1% of the 4 trillion
dollar budget. The Department of Defense spends 500 billion, which is half a
trillion, and the Department of State spends 50 billion, which is about 1% or a
little more than 1% of the 4 trillion dollar budget, and let’s skip over I’ll
skip over these but share this last slide with you. This is a group of
medical students at the University of Babylon. University of Babylon had a
medical education conference last year. It and some of the other medical schools
are revising their curriculum along the style that we’ve revised our curriculum
here at ETSU, and we and GW have revised to be more student-centered, more active
learning and less passive learning, and so this is a group of medical students
that has founded their own NGO called We Are The Change, and here they are
delivering blankets and food to internally displaced persons on the
Euphrates River. So I posted this and for me was very inspiring. I want everyone to
see this, a view of Iraq that doesn’t make the news we usually see. This is a
group of medical students delivering food and blankets to displaced persons. Very sophisticated, very humanitarian, very progressive. We Are The Change
echoing Gandhi’s admonition to be the change in the world that you want to see.
This is the new face of Iraq. This is the hope that we have been hoping for, and
Mohammad Falah posted in Arabic and I put the Arabic there if any of you read
Arabic, we’ll see if they the translation works and this is a Bing translation,
which usually a Bing translation or Google translation is not very close to
what was really said, but I think this this covers part of the phrase that I
like so much. He says that I understood that we have a
new Iraqi society, which seeks to develop and grow and help each other, and that we
see the role of youth and the estimated change for the better. Thank you very
much for this Allen Dyer and thank you all very much.