This article has been written as part of the partnership between The Lancet Student and Asian Medical Students’ Association International. The 30th Asian Medical Students’ Conference will be held next week in Taiwan on the theme of ‘Stigmatised Illnesses: To understand, to accept, and to change’. We look forward to hearing about the conference, look out for the conference blog and podcast next week! Alistair Hustig, the Secretary of Academcis – Asian Medical Students’ Association International, has written this fantastic article on the theme.

‘Stamping out Mental Health Stigma’, NHS.

Stigma. This one word often represents the most crucial element effecting people living with a wide range of illnesses. It negatively impacts efforts to treat and prevent disease, and adversely affects individuals’ quality of life. Many illnesses have a high prevalence of stigma including mental illnesses, cancer, leprosy, and sexually transmitted diseases. However, the type of stigma varies with different conditions. This article highlights some causes and differences of stigma associated with mental health and HIV, as well as successful strategies of reducing its impact.

Definitions of stigma encompass social identity (deviance from what is normal), power discrepancies (that allow discrimination), and discrediting attributes that result in devaluation of people living with illnesses, such as those above (1,2,3). This often manifests itself in an external sense as discrimination, hatred, intolerance, rejection, and exclusion. However what is often under-recognised is the internal aspect of stigma. Internal manifestations can include self-loathing, shame, and self-blame, all of which are preyed upon when someone stigmatises (3,4). Stigmatisation can also extend to family, friends, and even to institutions and clinics which themselves perpetuate stigma. As a result anyone associating with patients, or visiting centres, can be dragged into the net of stigma.

People living with Mental Illness
People who have depression, schizophrenia, and other mental illnesses, commonly report stigma from both community and health professionals. Depression is a leading cause of disability effecting 121 million people worldwide (5). Schizophrenia affects millions of people. Of these, only 25% of those with depression, and 50% of those with schizophrenia who are in need of treatment are receiving appropriate therapy (5). These figures suggest that stigma, at least in part, may be having an affect on treatment of mental illness. The perception of depression as a weakness rather than an illness (6); or people with depression are dangerous, and ‘schizophrenics’ are violent (6,7) remains embedded in public opinion. These views are less shared with other common illnesses for example cardiovascular disease. Unlike mental illnesses, cardiovascular disease is less stigmatised at least in part because the aetiology, pathophysiology, and successful treatments are well known. The fear of the unknown may therefore contribute to stigma being ingrained in an illness. As a result people with the illness are afraid of disclosing to family and friends, and do not seek help where it would be of benefit (6). Health practitioners, even those in the field of mental health can also stigmatise through intensive use of language and labelling. Some are more empathic and understanding of the nature of the illnesses, but some practitioners continue to define their patient by their illness. The difference in language is powerful – a ‘schizophrenic’, whose behaviour defines them, versus a ‘person living with schizophrenia’, whose illness causes altered behaviour (7). This labelling may plague the patient as a ‘life sentence’ (7) reducing self-esteem, withdrawing social opportunities, and creating ongoing employment difficulties (8), ultimately ruining any chance of normality.

People living with HIV
It is estimated that around 33 million people worldwide are infected with HIV, with the majority in low- and middle-income countries (9). Of these, only 3 million were receiving appropriate anti-retroviral therapy as at December 2007 (9). Again one of the biggest issues preventing uptake is stigma. However, the stigma signature associated with people living with HIV is different to that explained for mental illness. Bos and colleauges (10) propose a model for stigmatisation of people living with HIV. They describe how perceived contagiousness (everyday contact, not just sex), perceived seriousness (life-threatening), personal responsibility (unsafe sex) and norm-violating behaviour (e.g. male-to-male sex, and intravenous drug use) contribute to increase fear and anger while decreasing pity for people living with the disease. Stigma also surrounds certain groups at increased risk, such as homosexuals, intravenous drug users, and sex-workers. This further stigmatises people living with HIV leading to amplified discrimination and negative social responses. As a result, people living with HIV have a decreased quality of life and are less likely to seek testing, treatment, and counselling, or disclose their status to potential support providers. This can result in advanced presentations with high viral loads, low CD4 counts, and opportunistic infections.

Strategies for Reducing Stigma
The need to address stigma is paramount in order to reduce prevalence and thus burden of illness (e.g. curbing the HIV epidemic), and increase treatment uptake. For mental illnesses, in particular depression, Barney and colleagues (6) suggest that blaming, avoiding, and labelling people living with mental illnesses must be addressed. Accurate knowledge and portrayals of survival and recovery, as well as the true risk to the community for these health conditions needs to be expressed by all means possible, especially the media.

Public disclosure of HIV status has been shown to have a beneficial impact to both the individual and the surrounding community (11). Individuals are often very scared and describe this as the most difficult and dangerous thing to do. Post-disclosure they feel empowered, released from a heavy secret, and less isolated and withdrawn, taking back control of their lives (11). To help facilitate this appropriate training and support needs to be given before disclosing to prepare for potential negative reactions from community members. However, public speaking regarding one’s positive living helps to make the community more aware and dispel myths around HIV, thus reducing stigma. This is echoed by studies involving public speaking by people living with HIV (11) and mental illness (12), which have shown improved attitudes among high school students to those living with the illness. Uniting all people with stigmatised illness would provide a voice that would be far too loud to ignore.

Access to relevant treatment that communities understand is effective and essential in any stigma reduction programme. The case of universal access to HIV therapy in Botswana (which has the 2nd highest prevalence), implemented in 2002, provides clear evidence of reducing stigma (13). Wolfe and colleagues (13) demonstrated pre- and post-implementation that only 31% of people had disclosed positive HIV status to family, and 5% to friends in 2001, compared with 90% and 55% respectively in 2004. Other examples of reduced stigmatising attitudes include an increase in the number of people that would care for a person living with HIV, accept them as a teacher and buy food from a shopkeeper with HIV.

Conclusion
Stigma and its consequences affect the course of illness for many millions of people worldwide. It provides an enormous barrier to all attempts to help people living with stigmatised illnesses. Stigma affects all, it endures, and it compromises survival and recovery of those most in need. We must strive to find new ways to abolish stigma, and thereby allow access to treatment and empowering positive living.

Alistair Hustig, hust0007@flinders.edu.au
Secretary of Academics – Asian Medical Students’ Association International
Australian Medical Students’ Association Councillor
Graduate Entry Medical Programme Year II – Flinders University, Adelaide, South Australia
Bachelor of Medical Science – Flinders University, Adelaide, South Australia

References
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes. [Online]. 2007 [accessed 20 June 2009]. http://data.unaids.org/pub/Report/2008/JC1521_stigmatisation_en.pdf.

2. Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: stigma, social value and social exclusion. Sociology of Health & Illness 2005; 27(4): pp. 468-489.

3. Courwright AM. Justice, Stigma, and the New Epidemiology of Health Disparities. Bioethics 2009; 23(2): pp. 90–96.

4. Cameron E. Witness to AIDS. Cape Town: Tafelberg Publishers Limited; 2005.

5. World Health Organization. Mental Health: Disorders Management. [Online]. 2009 [accessed: 21 June 2009]. www.who.int/mental_health/management/en/.

6. Barney LJ, Griffiths KM, Christensen H, Jorm AF. Exploring the nature of stigmatising beliefs about depression and help-seeking: Implications for reducing stigma. BMC Public Health 2009; 9(61).

7. Flanagan EH, Miller R, Davidson L. ‘‘Unfortunately, We Treat the Chart:’’ Sources of Stigma in Mental Health Settings. The Psychiatric Quarterly 2009; 80: pp. 55-64.

8. Corrigan P. How Stigma Interferes with Mental Health Care. American Psychologist 2004; 59(7): pp. 614-625.

9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic. [Online]. 2008 [accessed 20 June 2009]. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp

10. Bos AER, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: The importance of theory- and evidence-based interventions. Psychology, Health & Medicine 2008; 13(4): pp. 450-460.

11. Paxton S. The paradox of public HIV disclosure. AIDS Care 2002; 14(4): pp. 559-567.

12. Spagnolo AB, Murphy AA, Librera LA. Reducing Stigma by Meeting and Learning from People with Mental Illness. Psychiatric Rehabilitation Journal 2008; 31(3): pp. 186-193.

13. Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, Iacopino V, Heisler M. The Impact of Universal Access to Antiretroviral Therapy on HIV Stigma in Botswana. American Journal of Public Health, 2008; 98(10): pp. 1865-71.

Bibek Aryal and Suman Raj Adhikari introduce the Nepal Medical College Red Cross Youth Circle and the hard work it is doing to promote healthcare in Nepal.

Nepal Medical College Red Cross Youth Circle (NMCRCYC) is an autonomous medical student body, located in Nepal Medical College (NMC), in the outskirts of the Kathmandu city in Nepal and established in 2006. The Nepal Red Cross Society, whose principles the circle abides by, is the umbrella organization of all similar Red Cross Youth Circles in Nepal. The slogan of NMCRCYC is “I Serve.” It is a non-profit, non- political and a purely social, philanthropic organ of Nepal Medical College and it has been able to provide a platform for selfless volunteer service to the students of NMC. By running various programs like blood donation, flood-relief service, and health camps, to name a few, it has been able to carve a niche for itself among the Red Cross Youth Circles of Nepal. Its efforts have been instrumental in increasing health awareness and activities in communities located in the vicinity of NMC and beyond.

NMCRCYC came into action with the universal slogan of youth red cross, “I serve”. NMCRCYC is now an effective and fully functional organization with over 300 members all of whom are medical students in the college.

The college principal inaugurating the NMCRCYC board

NMCRCYC, being an organization composed of medical students is primarily concerned with health-related activities. The objectives and goals of the organization are as follows:

1. Run blood donation programmes and incorporating them directly into the national blood drive programme.

2. Emergency Blood On Demand (EBOD) programme (which has been further elaborated below).

3. Run free health camps as a means to provide access to health care to the needy.

4. School speaking program: A public speaking programs in schools of rural areas. About a week before the program, students are given a pool of topics to prepare on and some observer and judges including the members of NMCRCYC are present to evaluate the students’ speech. At the end of the program, the facts and views presented by the students are corrected, suggested and commended by the observers. Awards are also given away to encourage the students. During these programs, the parents and other people from the locality gather in the school premises to attend. Thus, this program acts as a awareness campaigns in rural areas.

5. Disaster preparedness and relief programmes.

6. Poor-patient fund collection in order to provide them with free treatment for those who cannot afford the hospital charges.

7. Exploring training opportunities like first aid training.

8. Set up links with non-government organizations (NGOs) and International NGOs (INGOs) , and work in partnership with them in national health programmes.

Emergency Blood On Demand

“Your blood is replaceable, life is not” was the slogan used for 1st first blood donation programme organized by NMCRCYC. The 100 pints of blood collected during the program was handed over to the Red Cross Blood Bank, Kathmandu (daily requirement of the blood bank is 600 pints). At the same time, NMCRCYC has set up an Emergency Blood On Demand programme (EBOD) in which the relevant data of active members of RCYC who are willing to donate blood in case of an emergency has been recorded. In the event of an emergency and in some unlikely conditions – such as when compatible blood is not available in the bank – the pathology department do contact NMCRCYC, and the matching person is called to the spot to donate the blood. This was proved very effective to the hospital in running routine surgeries despite of the blood shortage in the bank and thus the program has been highly appreciated by the pathology department of Nepal medical college and teaching hospital (NMCTH).

At the same time, as per need, volunteers of NMCRCYC have donated blood for hospitals other than NMCTH in the Kathmandu city. The Red Cross Society itself praised the blood drive and the EBOD programme. We are now extending the EBOD programme and are also including the staff of NMCTH, who are interested in donating blood together. We expect to widen our EBOD programme to more than 400 emergency blood donor members by the end of 2009.

Free Health Camps

A total of 300 patients were provided with free health care with 90 cases referred for free treatment to Nepal Medical College Teaching Hospital. Two hundred children from the local area were wormed during the Free Health Camp organized at Chapagaon, a remote village devoid of modern healthcare facilities. The Health Camp was influential in exposing the students to real life conditions of Nepalese villages. General Medicine, Gynaecology and Obstetrics, E.N.T, Paediatrics and Ophthalmology OPD clinic were carried out with intern doctors, house officers and Dr. Muni Raj Chhetri (Chief Advisor of NMCRCYC).

After the health camp, more than 80 referred cases were attended by the NMCTH itself. During the health camp, general education and awareness programs on issues related to topics such as nutrition, family planning, personal hygiene, and primary health care and such like were conducted at a local school. Educational material and first aid medications were also distributed during the program. The program was very successful in that it catered to the pressing health problems of many people in the community. Additionally, the program encouraged the students to be involved in community health projects. As a consequence, many students actively participated in similar camps organized by other non-profit organisations in various places.

Patients in the free health camp

Poor Patients’ Fund

Many people in Nepal are too impoverished to afford basic health care facilities. The majority live in remote hilly villages where there is limited or no access to health services. A large number of people are unable to seek expert advice and service due to economic and social difficulties. Uterine prolapse is an urgent example of many women having to suffer from medical complications arising from the inability to afford health services. At present, according to the WHO, UNFPA and TU Teaching Hospital, 600,000 women are affected by the disease in Nepal and among them, 200,000 require immediate treatment. To address these kinds of issues, NMCRCYC started a Poor Patients’ Fund in April 2007. Many OPD cases as well as in-patient cases have been referred for free service including, but not limited to, surgery, investigations, and bed charges since the establishment of this fund. As a direct result, many patients unable to afford such services were able to receive care thanks to this fund.

The fund, however is not a proper fund per se. NMCRCYC hasn’t found any source of funding so far, so an arrangement has been made with NMC Teaching Hospital administrative body to provide free services to the patients referred by NMCRCYC. To provide for the expenses of the medications, NMCRCYC has organized some charity movie shows in at the college premises. The fund collected from one of these shows was donated towards the treatment of a leukaemia patient.

Disaster Relief Program

Many parts of Nepal are affected by several natural disasters each year. The eastern and western plains (also called Terai) are often hit by catastrophic floods. For the last three years, NMCRCYC has actively participated in collecting and providing relief material to the people affected by such floods. NMCRCYC coordinates the voluntary donation of cash and relief material in cash and in kind (clothes, food material, money, etc) from the students and staffs of NMC. The donations are then delivered and handed over to the people of disaster affected areas by the Red Cross District Chapter of Kathmandu.

Flood victim relief material being handed over to secretary of the Red Cross Kathmandu Chapter

Collaboration with Other Organizations

In order to coordinate health services to a larger population, we thought it necessary to work in partnership with several NGOs and INGOs doing similar works in Nepal. We at NMCRCYC have formed an outreach committee to facilitate the communication and partnerships with such organizations. So far, we have reached an understanding with “World Friendship Nepal” (WFN), an organization working for women’s health issues. We have jointly organized a “One-day Free Health Camp” during Shivaratri, an important Hindu festival attended by devotees from all of South Asia. The outreach committee is also working to co-ordinate with groups working on child health matters.

We are also co-ordinating with other Red Cross groups to undertake various works projects. In the coming year, NMCRCYC is planning to organize training programs on “Advanced First Aid” for the students of the college. This program will be supported by Nepal Red Cross Society, Kathmandu District Chapter. The Chapter will provide experts for the training.

Throughout its history, a significant amount of Red Cross activities in Nepal have been carried out by students and youth volunteers (Junior and Youth Red Cross Circles organized at schools, campuses and communities). Today, the participation of the youths with in the Red Cross has become more important than ever and this fact which has lately been acknowledged by the Red Cross Society itself. NMCRCYC is always working with the principals of the Red Cross as its guiding motto. We believe that the noble spirit of service and volunteering needs to be preserved and promoted especially among the students and youths at every level. The feeling of responsibility and benevolence towards people less privileged than oneself needs to be inculcated among the future experts, policy makers and leaders of the country. While being indispensable for the progress of third world, this culture of social service can be a very important means of using the technical and academic expertise for the benefit of fellow citizens, especially in developing countries like ours. In the long term, such works can contribute towards the creation of just, fair and prosperous societies.

Bibek Aryal and Suman Raj Adhikari are the President and Vice-President of the NMCRCYC

coolbibek@hotmail.com

By Request of the Authors: Any anyone wanting to join or assist the organisation would be most welcome. Volunteers should contact the above e-mail address. Thank you.

This is Bith Soktepy, the new Cambodian RC. This was my first time joining the EAMSC in Malaysia. This was such an unforgettable experience I’ve obtained. Cambodian delegates including I, were so proud to be the group moderator during this conference. We were being trained a lot by Malaysian organizing committee. Honestly, the conference was well organized as well as the program worked smoothly without obstacles. It was admirable.

I’ve learnt a lot about this conference and I hope to grasp this experience and conduct an EAMSC in Cambodia some time in the future. Without AMSA, I wouldn’t have learnt much or had such a precious opportunity to join this amazing conference.

Bith Soktepy (Tepy), Cambodia 

You might or might not remember who I am. Some of you might remember me as “The Bus Guy”, some as “The guy at the airport”, some as “My Group Moderator”, some as “The guy who played ‘Blow wind Blow’ with us”, or maybe even “that guy from group 10”.

Introduction aside, I’m Matt Liew, Kong Weng, EAMSC 2009 Head of Transportation and proud co-GM of Group 10. I’m just going to share with you the part of the conference that touched me the most.

The most heart-wrenching part of the entire conference for me was the day after, when all the delegates were leaving. It killed me to think that I might probably never see any of these people ever again in my life, yet at the same time I was completely inspired by the fact that I was among the future leaders of the medical community.

You had to be there to know the feeling. Between 10am and 12pm, energy in the hotel lobby was high, with lots of people waiting for their departure transfers. I didn’t even realize that people were leaving, because every last one of you were just as energetic and lively on that day as you were throughout the conference. There was not even an inkling of sadness that we were returning to old familiar faces, while leaving our newfound friends who each left a mark on our lives.

As time went on, and as I sent off more people into taxis, vans and buses, the energy levels started dropping. The sense of pride that was initially there due to having been among such  a truly inspirational group of people was rapidly consumed by a feeling of sadness. A realization that every single face that I had seen off I might never see again was crushing. I had to block out all emotion to stop myself from breaking down.

Those of you who know me know that I would never shed a tear in public, and I kept to it. It was tearing me apart inside as I watched the delegates board their designated transportation one by one, but I kept the smile, the firm handshake, and the “I hoped you enjoyed your stay. Have a safe trip, hope to see you next conference.” By the second-last batch I sent off at 3pm, I was so emotionally drained that I had to go to my room and just collapse. I needed the breather before I saw off the last group at 8pm. It may sound over-dramatized, but you had to be there to know how it felt.

The one thing I will note is that although this was the most depressing job in the entire conference, it was also the most fulfilling job I’ve ever done in my life, and thanks in no small part to the smiles on your faces as you left. Had it not been for the smiles on your faces, the cheerful voices, I don’t think I could have done it.

Thank you all for such a fulfilling conference, and thank you all for the memories. Each one of you has left a mark in my life.

Matt Liew, Kong Weng, Malaysia

Director of Transportation, EAMSC 2009

Sensational. From start to finish EAMSC Malaysia 2009 had non-stop amazing times. From Cultural appreciation, to Academic knowledge that you can’t get from a textbook, it had it all. 

On Culture Night, the diversity of the 17 countries in attendance was brilliant, colourful, and oh so talented. Indonesia’s instrumentation, Korea’s drumming, Japanese playfulness, the Aussie chooky, and more made cultural night a smash. It was entertainment that you can’t pay to see.

For the theme Engaging Asia-Pacific Youth in the Fight against HIV & AIDS there were plenty of academic highlights that should not be missed. Alischa Ross, founder of ‘YEAH’ (Youth Empowerment Against HIV/AIDS) provided some profound personal insights. Together with Professor Adeeba, they made us aware that no one thinks they will get HIV, and as doctors we need to put aside our moral judgements. I was privileged to visit the Ikhlas Drop-In Centre, where drug addicts may go to exchange needles, and eventual support and referrals for ‘clients’ to seek help with their addiction and possible associated illnesses like HIV.

Both the Paper and Poster competitions were fantastic, with outstanding publications produced by each team. These highlighted the differences that each country faces at the moment with dealing with and treating HIV. The work behind each showed through with outstanding results. My congratulations to each and every team.

Everyone was asked to write a pledge that they would strive to complete upon returning home. For me, I seek to promote the normalisation of HIV, as a disease that is not a death sentence, but an illness that one can live with. This is my step to reducing stigma around HIV.

I wish to thank the organising committee and AMSA International for the chance to go to this conference. It was truly owe-inspiring. To the many friends I met and gained, I thank you for making it such an excellent experience. 

AMSC Taiwan 2009 – see you there!

Alistair Hustig, Australia, Flinders University

Secretary of Academics – AMSA International

I am ultra grateful as I have this golden opportunity to attend EAMSC as it was indeed a blast. I’ve learnt so much on HIV/AIDS and most of all have a brand new attitude on fighting against current situation of HIV/AIDS. I’ve come to learn that as a youth, I can do something to combat HIV/AIDS. During the skills building workshop, delegates have had the chance to practice correct ways of using condom on a cucumber and pin condom on the penis which were truly memorable. I have such a fantastic time with my group members (Group 6) and get to build friendship within the Asia-Pacific region. In a nutshell, I love every bits and pieces of this conference and I will surely attend another one if I have the chance. 

Stop AIDS, I promise. 

With Love,

Michelle Ngu, International Medical University, Malaysia.

Coming to EAMSC has been a fabulous experience because I not only get to discuss about HIV/AIDS with people all around the Asia-Pacific region & understand better the situation in each respective country, but I also managed to gain friendships with people of different nationalities and cultures. Preparation for EAMSC had been hectic and busy but seeing it being so successful at this point in time makes it worthwhile. I certainly hope more people can participate in conferences like this in the future. This conference has certainly added more valuable and enriching experiences to my life.

Allison, Malaysia

After a wildly entertaining game of Pin the Condom on the Penis, we began the important business of Demystifying the Condom.

Arranging the steps of how to use a condom was followed by a student’s excellent demonstration of How to Put a Condom on a Cucumber, which the rest of us were very diligent in practising. 

Once we were all competent, our next challenge was to create a badge using colourful paper, scraps of material and, of course, condoms!

Whilst this was a fun & creative session, the importance of correct usage of a condom certainly sank in, and all the questions & mystery surrounding the condom were cleared up.

This is a fun and practical way of reaching out to people through humour and creativity which many will be able to use in projects in their own countries.

Reflections by Group 2!

EAMSC offers an amazing opportunity for like-minded young people to get together to discuss issues, form friendships, and develop skills. This year’s theme of HIV/AIDS knows no national, racial, or religious boundaries and so I see it as fitting that we unite as future doctors from 17 countries to tackle this massive epidemic together.

CEO/Founder of the Australian organisation ‘YEAH’ (Youth Empowerment Against HIV/AIDS), Alischa Ross yesterday addressed delegates with a particular focus on youth and what we can do as both young people and future doctors. She inspired delegates to inform ourselves, take up leadership roles in our communities, and really engage in the fight against HIV/AIDS.

She also reminded delegates that while targeting particular high-risk groups is important, we must remember the stories and faces of HIV/AIDS which can be so easily forgotten amid statistics and numbers. In my view, this is a particularly key point to remember.

Perhaps the most important thing we can do is to reduce stigma and promote understanding in our own communities and day to day lives. As future leaders and professionals we are in the privileged position of being able to influence and shape the communities. Let’s join together and commit to dispelling myths and reducing discrimination against people living with HIV.

A wonderful experience from start to finish! My hat goes off the organising committee. I’ve made great friends and these friendships will last forever.

Ali Mohamed, Malaysia