On Improving the Effectiveness of Foreign Aid

By Dr David Laing Dawson

Canada’s foreign aid spending totaled CAD$ 5.4 billion in 2013  compared to CAD$ 5.66 billion in 2011. This equates to about C$154 per Canadian. Aid spending was 1.9% of total 2013 budget expenditure.

This money is spread around dozens of countries all over the world. The list of receiving countries includes Russia, Pakistan, Syria and Yemen. Undoubtedly each project is worthwhile and based on impeccable humanitarian principles.

We also know that many of these countries improve for a while (education, governance, medical care, nutrition, crime, infrastructure, services) and then collapse again. Sometimes the collapse has a natural cause (tsunami, drought, earthquake), but often the cause is corruption, sectarian strife, poor governance, undeveloped civil service and infrastructure, democratic failure, independently powerful armed forces, gross income disparity, over-population, refugees from neighbouring failing societies, continuing poverty, poor education.

Sometimes the money is wasted. A portion lines the pockets of criminals. Sometimes free money creates a climate of dependency and fosters corruption.

And each of these failed or failing countries is a potential target for exploitation and ultimate takeover by extremist groups, or psychopathic dictators: ISIS, Boko Haram being the current scourges.

It is understandable that some thoughtful, educated and outspoken citizens of these countries are now saying: “Do not give us money.” There is even some evidence that some countries not receiving aid have fared better than those that have received aid.

If the definition of insanity is “doing the same thing over and over again while expecting different results” then our foreign aid policy is insane.

But what else can we do?

Here is an idea:

Canada (and each and every other developed nation) can chose one or two or three or four countries with which to work, and to help exclusively, and, in partnership with the leaders and people of that nation, provide aid (money, expertise, people, equipment) in a planned and evaluated fashion, to create, over time, a foundation of good democratic governance, universal education, universal health and medical care, a functioning police and court system, a self-sustaining economy, a solid infrastructure for commerce, sewage, clean water, goods, services, and information.

Each successful country – successful enough to be resilient to changes of government, extreme weather, the intrusions of corrupt corporations, would-be dictators, and natural disasters –  will be a bulwark against extremism,  terrorism, and a return to the medieval.

We would have to find a way to overcome fears of colonialism, to do this in an entirely altruistic fashion, and it would be a long-term project. We would not get quick returns (images of the maple leaf on bushels of wheat being handed out to starving people, mosquito nets over palette beds in village huts, happy children attending a school in one impoverished village in Nigeria).

But what we, and dozens of other developed countries are doing, is not working. Our band-aids cover up the bleeding but do little (some are saying they do, ultimately, more harm than good) to overcome the illness and create sustainable health.

To Learn From History We Must First Know It.

By Dr David Laing Dawson

PART II

And then there are those who want to make schizophrenia go away, along with psychiatrists and their medications. Some are claiming that it is a misdiagnosis. Most of these folks, they say, are suffering from disorders of entirely psychological cause and explanation, such as DID (Dissociative Identity Disorder, which is the child of Multiple Personality Disorder) or a form of PTSD from childhood trauma, or, on the other hand, simply experiencing just one of the unusual states of mind and perception within the vast normal array of human potential.

Well, I must admit, we psychiatrists continue to struggle with, argue about, investigate, study, re-conceptualize, re-define schizophrenia, while searching for causation and better treatment. In the manner a fever and a rash are not the illness itself, but rather the body’s reaction to a pathogen, many of the symptoms of schizophrenia are the person’s, the brain’s reaction to underlying dysfunction(s). And we are only beginning to understand, at a cellular/pathway/messenger/neuron by neuron level this most complex of organs, the human brain.

There may be as many as six different pathways to this most devastating and misunderstood of illnesses, each with a different genetic vulnerability and epigenetic influence. But we know it happens quite consistently in all cultures and historical times. How we have thought about these people who become so cognitively dysfunctional, so specifically irrational, has varied from culture to culture and age to age. But they have been there and they are there now:  In African villages where they might be tied to trees outside the village for families to feed until the mania passes or the patient dies. Suffering in the streets and jails in Dorothea Dix’s time. Burned as witches. Punished in stockades. Banished from villages in Europe and left to wander the country side. Poets (who undoubtedly never had to live with an insane person) speculating that insanity may be simply a form of creativity, and being someone more in tune with the rhythms of the invisible world than the rest of us. Yes, we’ve been there before.

And then in our part of the world between 1880 and 1980 mostly residing in Asylums and Mental Hospitals. And now, of course, as described in previous essays by Marvin Ross  and myself, we find that vast numbers of people so afflicted are being housed in, have been returned to our jails and prisons, and kept away from public view .

(In considering historical and cross-cultural data it is always well to remember that life expectancy for the general population was about 40 years in 1850’s North America, 60 today in India, less than 50 today in Africa, and in all times and places, considerably less for the mentally ill, the poor, and the indigent.)

As Marvin Ross pointed out recently, the doctors who observed and described schizophrenia as a progressive disease with inevitable poor outcome, were doing so at a time when we had no effective treatment. They were not wrong in their observations. Untreated schizophrenia invariably leads to a progressive deterioration of function, early death, and sometimes violence.  Although there are always, as with everything in this world, a few exceptions. A few.

Only 65 years have passed since we discovered the effectiveness of anti-psychotic medication, starting with the famous Chlorpromazine (Largactil, Thorazine) in France. And only 60 years have passed (1954) since this drug was first introduced to North America. And because we were so tentative with these drugs at first, often weaning our patients off them after three months of recovery without relapse (1965), and when that didn’t work, waiting six months, then a year (1970) , then making that two years, then five, then ten, (1975) and with our patients sometimes lost to follow-up, and stopping the medications themselves, some because of side-effects, and relapsing and being readmitted, and then starting over – it really has been only about 20 to 30 years now that we have concluded that most (if not all) people who suffer from schizophrenia will need to take these medications for life in order to remain stable and well. And this has finally allowed us to have, as I have had, the opportunity to see some people take these medications regularly for 30 years, and observe that with very consistent treatment (anti-psychotic medication), a good support system (usually family and some counseling), schizophrenia need not be a progressive illness with a bad outcome.

Historical Ignorance: Anti-wheat, Anti-vaccination, Anti-anti-psychotic medication

By Dr David Laing Dawson

PART I

We humans tend to be near-sighted. We are born in a time and place; we experience youth in a time and place. Until we are adults we don’t really make many observations and consider at length the wide and diverse world around us. Then when we do we do it without history, without perspective. We filter what we see through prisms already formed. We see only what we want to see. We are greatly influenced by what the statisticians call “peak experience”: that singular event, the one time out of 50 or 100 or 2000 that the slot machine paid out a thousand dollars. We are drawn to magic; we love the concept of luck; and we are lazy. I am disappointed to learn that the fitbit bracelet I put on my wrist every morning merely measures my activity. It does not contribute to it.

How wonderful it would be if taking a harmless pill each day could be a substitute for a good diet and exercise.

Until very recently most of us did not live long enough to experience, as adults, any more than 30 years of human change and development.

Hence the anti-wheat craze, the condemnation of wheat that is “not the wheat your grandparents ate.”

We have been selectively breeding our plants and animals since pre-history, and more vigorously and scientifically since the 18^th century. Naturally we have tried to make them more bountiful and more resistant to drought and disease. And we have largely succeeded. Perhaps at the cost of variety of shapes, sizes, and tastes, but our ability to do this is the main reason we now have over 7 billion people on this planet rather than the 2 billion in my grandparents’ time. Our improved wheat may be killing us, but it is killing us because it is allowing us to feed four times as many people on this planet who now clear the land, build cities, eat all the fish, eat all the time, and burn fossil fuels.

The anti-vaxers are similarly near-sighted and ahistoric. They are too young to have memories of polio in the schools, of deaths from measles, mumps, diphtheria, and whooping cough. They are an educated lot, the press tells us, but apparently they have not read any biographies from the 19^th and 18^th century which invariably tell us of our subject having had 7 siblings, with two surviving into adulthood, the others dying as infants, children, and teenagers of the prevalent communicable diseases of the time.

Yes, there does seem to be an increase in autism. But the very concept of autism is new. Child psychiatry, as a sub-specialty of psychiatry, emerged alongside the concept, the studies, the definitions of this particular disorder of childhood, in the mid 1930’s. The war rather preoccupied us until the late 40’s, so any widespread awareness of Autism as a particular disease of childhood, differentiated from other forms of mental disability, could not occur until the 1950’s and 1960’s. And until quite recently those afflicted with a moderate or severe form of this dysfunction would be sent to an undifferentiated institution for retarded or handicapped children. Out of sight and out of mind. Those with mild forms of this dysfunction might be considered simply eccentric, odd, problematic. And those with mild forms of this dysfunction accompanied by exceptional abilities in other forms of cognition, were simply eccentric geniuses, mad scientists, isolated inventors, obsessive hermits. (Alan Turing)

Not that we shouldn’t study it, do the research, but the apparent increase in numbers of those diagnosed with autism can be explained by expanded criteria (autism spectrum disorder), dramatically increased school testing, de-institutionalization, an abundance of psychologists, and a renewed interest in the problem now that we have means of looking at brain function, examining genomes, and videotaping behaviour. And don’t forget, until recently, half these kids would have died from those diseases mentioned above if they (and 90 percent of their peers) had not been vaccinated against them.

Schizophrenia and the Family

By Marvin Ross

In one of my earlier blogs, I talked about the stress that families with children with serious mental illnesses experience. Of course, parents who have a child with any serious chronic illness all have stress. But, when that illness is a serious mental illness, then the stress is even more horrendous for two reasons.

The first is that an illness that involves the brain results in significant changes. A happy, bright, funny person may become angry, violent, and unable to think rationally when in the throes of a psychotic state. Reasoning becomes impossible with someone who is delusional and who may very often deny or fail to understand that something is wrong. How do you cope and get that person the treatment  they need? It is difficult and can tear families apart.

We can read the above words or my previous blog on the suffering of families and think that we understand but to truly understand, we need to see it. And my fellow blogger, David Laing Dawson, managed to do that in this scene from his film, Cutting For Stone about a young man developing schizophrenia. Dominic Zamprogna who is best known for his roles in Edgemont and General Hospital, plays the young man Philip and, in this scene, confronts his parents after an escape from the hospital. While fictitious, the scene that is portrayed reflects the reality of many families and, having been there when this scene was shot, the emotion effected all of the crew.

After Vince Li, a man with untreated schizophrenia, murdered a fellow passenger on a Greyhound Bus in Manitoba, David filmed this interview with Philip’s mother in a short called “10 Years Later”.  And this is the second problem faced by families, the stigma of the illness and the horrific things that those who are untreated do. And, before seeing this clip, I should point out that Vince Li was released from a Toronto hospital while still psychotic with no follow up. Since being in a forensic unit receiving treatment, he has improved considerably, His psychiatrist told the review board that he is at low risk to re-offend. Risk assessments done by several other doctors came to the same conclusion.

The above is fiction based upon David’s many years treating patients and so is as realistic as it can be. However, Katherine Flannery Dering who wrote about her brother with treatment resistant schizophrenia provides an actual description of how mental illness impacts the entire family. This is an interview that Katherine did with journalist, Ardina Seward, in a diner in Westchester, NY.

Has Mad in America Changed its View of Medication for Schizophrenia?

By Marvin Ross

For those of you not familiar with Mad in America (MIA), it is a US organization begun by journalist Robert Whitaker. He is the author of books that are highly critical of modern psychiatry and its reliance on medication particularly for schizophrenia. As they say on their website they “investigate the problems and deficiencies with the current drug-based paradigm of care.”

I happened to come across this announcement on their site: “In World Psychiatry, two Canadian psychiatrists argue that the body of scientific evidence about schizophrenia shows that it is not a progressive illness and therefore we should have much higher expectations of full recoveries than we do.” I was intrigued because one of the authors of this study is Dr Robert Zipurski of McMaster University in Hamilton, Ontario.

Once before, MIA cited a study by him that used quotes selectively. They implied that Dr Zipurski provided proof of the evils of antipsychotic medication. Their website stated “decreases in brain tissue volumes are attributable to antipsychotic medication, substance abuse, and other secondary factors.” But, a careful reading of that paper found that when people discontinue medication early, the relapse rate is up to 78 per cent compared to 0-12 per cent for those who remain on medication.

MIA did not provide its own interpretation of this current paper which Dr Zipurski wrote with Dr Ofer Agid of the Centre for Addiction and Mental Health in Toronto. The two authors continue from the previous paper mentioned above and point out that:

Relapse of psychotic symptoms following a remission from a first episode of schizophrenia is also observed to occur in over 80% of individuals when studied naturalistically. This is largely attributable to discontinuation of antipsychotic medication rather than to the effects of an unrelenting disease process. The risk of symptom recurrence in remitted first episode patients receiving maintenance antipsychotic treatment is estimated to be in the range 0-5% in the first year of follow-up, compared to 78% in the first year off medication and close to 100% after three years off medication.

The authors then go on to wonder why outcomes are so poor if people have the ability to remain in remission. The reasons, they say, are numerous including the lack of services for these people or that they refuse treatment. Then, of those who are treated, about 20-30% are treatment resistant to the available antipsychotic medications. Others are non compliant with medication and so have relapses and re-hospitalizations. For others, their concurrent problems with alcohol, drugs, and other mental illnesses mitigate against retained recovery.

They conclude that while “there is room for debate about how recovery should be defined, it should be clear that most individuals with schizophrenia have the potential to achieve a stable remission of symptoms and substantial levels of satisfaction and happiness.”

That stability, they say, can be achieved with antipsychotic medication. Physicians/scientists/psychiatrists who observed that this dementia praecox or group of schizophrenias appeared to be a progressive disease were observing people with this illness pre 1960 before anti-psychotics were available – they were not wrong or overly pessimistic as there were no effective treatments at the time.

And it does take time for science to recognize that if someone begins antipsychotics at about age 19 and remains on them along with good medical care, that they can get to old age and remain stable or even improve.

It is encouraging to see MIA recognizing the importance of drug treatment by their promotion of this paper.

Jihadi John and The Radicalization of Youth Part II

By Dr David Laing Dawson

Recent events have brought about much hand wringing and soul searching. Six teenagers from Quebec fly to Turkey on route to Syria. Jihadi John is identified as a British Citizen who has been described as gentle and kind before radicalization. Someone hints that harassment by MI5 pushed him into adopting this murderous personae. Someone else suggests that these youths are “alienated” by their western societies, meaning England and Canada in these cases.

How can this happen? How can a young person transform or be transformed in a matter of weeks or months from a fun loving, music loving, facebooking, photo sharing, academically successful teenager into a Jihadi fanatic?

How much of this is our fault? How real are their grievances? Do these grievances explain anything?

Well, these are not adults making a decision about their life trajectories. They are adolescents. And in the evolving socialization and developing brain of every human adolescent there comes a moment (a moment that can last a few months or a year or two) when the pathways of teenage idealism and teenage opposition intersect. This can be a moment of creativity, a moment when a teenager sets off on a good path, determined to do better than her parents, maybe save the environment, stamp out racism, help the poor, invent the personal computer or a new form of music. But it can also be a dangerous and vulnerable moment. And a moment that can be exploited by an unscrupulous adult – a cult leader, a criminal gang, the propaganda of Madison Avenue or slick videos from ISIS.

Reflexive opposition to parents is a natural phase of individuation, of becoming separate, of developing independence. “She argues with me about everything,” a parent will say. Or, as my son-in-law said to me recently, regarding my 15 year old grandson, “He never listens to me; how come he listens to you?”

And then we have idealism. CBC has an annoying habit of interviewing 10 year olds about a progressive program in the school system. I watch these kids on TV, microphone before them, struggling to remember and then repeat the platitudes they have been fed by the adults in charge. All well and good. But there will come a time in their adolescence when these kids notice that the adults around them, especially their parents, don’t really live up to those platitudes. Not completely anyway. In the Christian home the teen will shout at her parents, “How can you call yourself a Christian? You only go to church on Easter Sunday.” “How can you eat meat when you know how badly these animals are treated?”

I don’t know first-hand the equivalent in a Moderate Moslem home but I am sure it happens.

Add some confusion, some anxiety about the future, to this teen who is now able to discern the wide gap between the platitudes, the instructions and admonitions and recipes for life spelled out in our holy books and the actual lives of her parents and other adults, perhaps living Moslem-lite, perhaps drinking some alcohol, perhaps not fasting religiously. This child will prove fertile ground for the propaganda of ISIS: Playing to the teenager’s natural opposition to her parents; playing to her idealism; promising to staunch the confusion, to alleviate the anxiety; offering a role, a defined role and purpose, a part in a bigger play. To say nothing of everlasting life, joy and fulfillment, and, for some, a righteous excuse to wreak havoc and revenge.

So parents, brothers and sisters, community and religious leaders, family doctors, teachers and counselors, be aware of this vulnerability in all teens. Monitor. Watch for the signs of undue influence by cult leaders, drug dealers, middle aged men in another city, and this new horror in our town: ISIS.

Editor’s Note – For Part I see Rat Brains, Youth, and Jihadists. Dr Dawson is a child and adolescent psychiatrist and the author of The Adolescent Owner’s Manual. Library Journal said of his book “Dawson’s understated sense of humor translates well to text. While there are a plethora of books available on parenting teens, his to-the-pointness recommends this for busy readers.” For a video book trailer see https://www.youtube.com/watch?v=9VCrKf1lV2o