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NICARAGUA: WAR AND MENTAL HEALTH
914
**This letter has been shown follows.-ED. L.
to
Professor
Lahaye, whose reply
SiR,—Dr Birch emphasises a point that we discussed thoroughly before publication of our paper. In 1980, when vaccination was started experimentally, it was provided free of charge to employees. This situation lasted until 1982, when the first vaccine went on sale in Belgium. There is no information about the number and cost of vaccinations during the experimental phase. The number of vaccinations paid for employees, however, must have been negligible: the cost of the vaccine was prohibitive and hospital personnel were not at that time well informed about the safety of the new vaccine and how to get it. The reduction in the number of compensation claims for hepatitis B infection must be attributed to free-of-charge vaccinations. Comparison should therefore be made between the situation before 1980 and that at the end of 1986. Once the experimental phase was over the insurance system took over the financial burden. What would have happened without insurance coverage must remain speculative. An increase in cases after 1982 (as happened in England and Wales’) is as good a possibility as the decrease proposed by Birch. The hyperbolic extrapolation seems the most likely one. However, even if a decrease in the number of cases is assumed, refunding via insurance remains profitable, though perhaps in the longer term. Comparison between countries over the period 1983-86 is difficult because of the lack of comparable epidemiological data, but we intend to try to examine differences in compensation and in responses to vaccination between north and south Belgium. In the Belgium system refunding of vaccine costs has proved profitable, a result partly of collaboration with occupational physicians. Vaccination is expensive but it has to be refunded only once, whereas the costs to the insurance system of compensation are very high and when there is permanent disability, cumulative. Our estimates are only valid for the situation in Belgium. The main idea in our paper is that insurance funds should invest in prevention rather than in damage compensation. Insurance funds should examine this alternative within their own legal obligations in respect of compensation of a disease. A more prevention-oriented policy can be beneficial, not only for the insured but also for the insurance fund itself. I agree that a vaccine programme should not be solely dependent on payments from insurance funds but the influence of such refunding is undeniable. Fonds des Maladies Professionelles, Avenue de l’Astronomie 1, 1030 Brussels, Belgium 1. Finch RG. Time for action on hepatitis B immunisation. Br Med
D. LAHAYE J 1987; 294
197-98.
NICARAGUA: WAR AND MENTAL HEALTH
1979 and the consequences-for example, the return of malaria, the widespread food shortages, and malnutrition. Health workers are specific targets, and more than 100 have been murdered. They now have to take down the signs which designate health posts or anti-malaria stations, hide their equipment, and make calls without the advance publicity that is so important to primary health work. "Hit lists" broadcast by the Contra radio station in Honduras frequently include health workers. To know oneself to be marked down for assassination and torture and to have to work in remote like a fugitive is to live under enormous stress, and health workers are prone to psychological breakdown. In the Ciudad Sandino neighbourhood of Managua 25 % of all patients seen for psychological problems had depression following a war-related event such as the loss of a family member.4 (In neighbouring El Salvador psychiatric visits rose from eighth to third on the list of common reasons for seeking medical care during the height of the civil war in that country.s) In many women the impact of war manifests as psychosomatic ailments (headaches, . general pains, palpitations, malaise) and child abuse and alcoholism seem to be on the increase. In the soldiers themselves psychotic states, often have been schizophreniform, triggered by the stress of call-up and combat. Group therapy has been used for soldiers with shell-shock; 80% of whom recover during the twelve weekly sessions but the more severely affected do not return to active service. Combatants seem unlikely to sustain the psychological damage seen in US Vietnam veterans. Fighting in defence of home soil does not seem to generate the long-term anomie, dislocation, and high suicide rate to which those survivors of a disowned war on an alien continent have been prone. The grief, fear, and disorientation of war in Nicaragua is scarcely new. This small nation has known little peace this century. One can but speculate about the longer term psychological impact. What happens to ordinary people when fear and anxiety are everyday states of mind, when the half-expectation of violent death or family rupture is woven into a culture? Nicaragua’s social services and health ministries give priority to those most affected by the war, and neighbourhood committees provide practical and moral support to vulnerable individuals and families. In post-Somosa Nicaragua there is now a belief that all things Nicaraguan need not be second rate. Such resurgence in a sense of self plays its own part in buttressing the mental health of the community against threats to what has been won in health, education, human rights, and land reform. areas
Department of Psychiatry, Epsom District Hospital, Epsom, Surrey KT19 7EG
DEREK SUMMERFIELD
1. Garfield R. Health consequences of war in Nicaragua Lancet 1985; ii 392. 2. Williams G. Immunisation in Nicaragua. Lancet 1985, ii: 780.
J, Stover E, Nightingale E, eds. The breaking of bodies and minds: Torture, psychiatric abuse and the health professions. New York: WH Freeman,
3. Timerman
SIR,-Previous correspondents1.2 have described both the remarkable advances in primary health in Nicaragua achieved since the overthrow of the Somosa regime in 1979 and-the threat the Contras pose to those hard-won improvements. On a recent trip to Nicaragua I paid special attention to the impact of the war upon mental health. Bereavement has been experienced first hand by virtually every adult and child in Nicaragua. The thousands abducted to Honduras have left parents and spouses in anguished uncertainty: most have not returned. There are 8000 war orphans and many are emotionally disturbed. Some are mute, some fail to grow, some have regressed into baby-like behaviour, and some are delinquent; others seem in a state of constant fear, refuse to go outside, or show panic reactions to noises like cars passing. These disturbances can persist for years. Many of these children have witnessed the murder and mutilation of those closest to them. Jacobo Timerman, witnessing similar events in Argentina, has described the devastating effects of torture when carried out in front of family members in a culture based on familial love, devotion, and a capacity for mutual sacrificed3 Others have described the Contras’ attempts to destroy the health, educational, and agricultural programmes introduced since
1985: 53. 4. Garfield R. Health and the war against Nicaragua,
1981-84. J Publ Health Policy 1985 (March): 116-31. 5. Garfield R, Rodriguez P. Health and health services in Central America. JAMA 1985; 254: 936-42.
CHILE’S ACADEMICS UNDER THREAT
SIR,—The Chilean political situation has worsened during the past month because of renewed military intervention in the state-owned national University of Chile. The scientific and medical academic community is being disbanded. If the military regime is to ensure its perpetuation beyond 1988 the intelligentsia must be destroyed. We are asking colleagues to show international solidarity and save us. Genetics Unit, Hospital J. J. Aguirre, University of Chile, Santiago, Chile
RICARDO CRUZ-COKE
*** Another correspondent has told us the background to this appeal. military coup that overthrew the democratically elected
After the
**This letter has been shown follows.-ED. L.
to
Professor
Lahaye, whose reply
SiR,—Dr Birch emphasises a point that we discussed thoroughly before publication of our paper. In 1980, when vaccination was started experimentally, it was provided free of charge to employees. This situation lasted until 1982, when the first vaccine went on sale in Belgium. There is no information about the number and cost of vaccinations during the experimental phase. The number of vaccinations paid for employees, however, must have been negligible: the cost of the vaccine was prohibitive and hospital personnel were not at that time well informed about the safety of the new vaccine and how to get it. The reduction in the number of compensation claims for hepatitis B infection must be attributed to free-of-charge vaccinations. Comparison should therefore be made between the situation before 1980 and that at the end of 1986. Once the experimental phase was over the insurance system took over the financial burden. What would have happened without insurance coverage must remain speculative. An increase in cases after 1982 (as happened in England and Wales’) is as good a possibility as the decrease proposed by Birch. The hyperbolic extrapolation seems the most likely one. However, even if a decrease in the number of cases is assumed, refunding via insurance remains profitable, though perhaps in the longer term. Comparison between countries over the period 1983-86 is difficult because of the lack of comparable epidemiological data, but we intend to try to examine differences in compensation and in responses to vaccination between north and south Belgium. In the Belgium system refunding of vaccine costs has proved profitable, a result partly of collaboration with occupational physicians. Vaccination is expensive but it has to be refunded only once, whereas the costs to the insurance system of compensation are very high and when there is permanent disability, cumulative. Our estimates are only valid for the situation in Belgium. The main idea in our paper is that insurance funds should invest in prevention rather than in damage compensation. Insurance funds should examine this alternative within their own legal obligations in respect of compensation of a disease. A more prevention-oriented policy can be beneficial, not only for the insured but also for the insurance fund itself. I agree that a vaccine programme should not be solely dependent on payments from insurance funds but the influence of such refunding is undeniable. Fonds des Maladies Professionelles, Avenue de l’Astronomie 1, 1030 Brussels, Belgium 1. Finch RG. Time for action on hepatitis B immunisation. Br Med
D. LAHAYE J 1987; 294
197-98.
NICARAGUA: WAR AND MENTAL HEALTH
1979 and the consequences-for example, the return of malaria, the widespread food shortages, and malnutrition. Health workers are specific targets, and more than 100 have been murdered. They now have to take down the signs which designate health posts or anti-malaria stations, hide their equipment, and make calls without the advance publicity that is so important to primary health work. "Hit lists" broadcast by the Contra radio station in Honduras frequently include health workers. To know oneself to be marked down for assassination and torture and to have to work in remote like a fugitive is to live under enormous stress, and health workers are prone to psychological breakdown. In the Ciudad Sandino neighbourhood of Managua 25 % of all patients seen for psychological problems had depression following a war-related event such as the loss of a family member.4 (In neighbouring El Salvador psychiatric visits rose from eighth to third on the list of common reasons for seeking medical care during the height of the civil war in that country.s) In many women the impact of war manifests as psychosomatic ailments (headaches, . general pains, palpitations, malaise) and child abuse and alcoholism seem to be on the increase. In the soldiers themselves psychotic states, often have been schizophreniform, triggered by the stress of call-up and combat. Group therapy has been used for soldiers with shell-shock; 80% of whom recover during the twelve weekly sessions but the more severely affected do not return to active service. Combatants seem unlikely to sustain the psychological damage seen in US Vietnam veterans. Fighting in defence of home soil does not seem to generate the long-term anomie, dislocation, and high suicide rate to which those survivors of a disowned war on an alien continent have been prone. The grief, fear, and disorientation of war in Nicaragua is scarcely new. This small nation has known little peace this century. One can but speculate about the longer term psychological impact. What happens to ordinary people when fear and anxiety are everyday states of mind, when the half-expectation of violent death or family rupture is woven into a culture? Nicaragua’s social services and health ministries give priority to those most affected by the war, and neighbourhood committees provide practical and moral support to vulnerable individuals and families. In post-Somosa Nicaragua there is now a belief that all things Nicaraguan need not be second rate. Such resurgence in a sense of self plays its own part in buttressing the mental health of the community against threats to what has been won in health, education, human rights, and land reform. areas
Department of Psychiatry, Epsom District Hospital, Epsom, Surrey KT19 7EG
DEREK SUMMERFIELD
1. Garfield R. Health consequences of war in Nicaragua Lancet 1985; ii 392. 2. Williams G. Immunisation in Nicaragua. Lancet 1985, ii: 780.
J, Stover E, Nightingale E, eds. The breaking of bodies and minds: Torture, psychiatric abuse and the health professions. New York: WH Freeman,
3. Timerman
SIR,-Previous correspondents1.2 have described both the remarkable advances in primary health in Nicaragua achieved since the overthrow of the Somosa regime in 1979 and-the threat the Contras pose to those hard-won improvements. On a recent trip to Nicaragua I paid special attention to the impact of the war upon mental health. Bereavement has been experienced first hand by virtually every adult and child in Nicaragua. The thousands abducted to Honduras have left parents and spouses in anguished uncertainty: most have not returned. There are 8000 war orphans and many are emotionally disturbed. Some are mute, some fail to grow, some have regressed into baby-like behaviour, and some are delinquent; others seem in a state of constant fear, refuse to go outside, or show panic reactions to noises like cars passing. These disturbances can persist for years. Many of these children have witnessed the murder and mutilation of those closest to them. Jacobo Timerman, witnessing similar events in Argentina, has described the devastating effects of torture when carried out in front of family members in a culture based on familial love, devotion, and a capacity for mutual sacrificed3 Others have described the Contras’ attempts to destroy the health, educational, and agricultural programmes introduced since
1985: 53. 4. Garfield R. Health and the war against Nicaragua,
1981-84. J Publ Health Policy 1985 (March): 116-31. 5. Garfield R, Rodriguez P. Health and health services in Central America. JAMA 1985; 254: 936-42.
CHILE’S ACADEMICS UNDER THREAT
SIR,—The Chilean political situation has worsened during the past month because of renewed military intervention in the state-owned national University of Chile. The scientific and medical academic community is being disbanded. If the military regime is to ensure its perpetuation beyond 1988 the intelligentsia must be destroyed. We are asking colleagues to show international solidarity and save us. Genetics Unit, Hospital J. J. Aguirre, University of Chile, Santiago, Chile
RICARDO CRUZ-COKE
*** Another correspondent has told us the background to this appeal. military coup that overthrew the democratically elected
After the