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Intimate partner violence and depression (Literature review)

Being from schools with limited resources is worth experience to share.  I used to visit HIV center regularly and it helped me to get the real in-depth idea of mental health aspect of HIV patients.   I appreciated epidemiological facet of longitudinal, retrospective, prospective, case control/ cohort, cross sectionals studies and then interacted with researchers. Presentations by brains such as– Dr.Robert Ramien, Dr.Gulick, Dr.Robert Klitzman, Dr.Robin Rubien, Dr.TsiTsi and Kate (many more) added pages after pages to my knowledge.  But to the heart, I was always eying on real hands-on experience. I always thought to grab some study to learn from any of researcher, and had desire to work with. Since Lehman College was with lack of resources, I tried to compensate it by attending lectures at NYU, Boston and Columbia University. Now coming back to Lehman, since I (we) already had bad experience with instructor (confused, had poor verbal(oral) communication skills * example:pronouncing many words wrong such as multi as moolti*; and  ra**** I felt it*) who taught research method course, I had concerns, I was also worried to pursue capstone course with her; I conveyed my concerns to Professor Levitt and Professor Tsui (internship instructor) many times. Anyway long story short, I desperately wanted to develop research skills. Lehman College was with limited resources and confused choices like former chair of health science  department ; I was super-excited to learn when we had new faculty. Professor Levitt denied me opportunities. On the other hand, unfortunately, we had same instructor for capstone course who took our research method. Few of our seniors described instructor as hard and soft as they did for research method course (on the first day of both courses) .

Truly speaking, we were not interested in hardness and softness; we were students to learn. I wanted to develop good paper out of my internship at Einstein (thanks to my wonderful supervisor and mentor Dr. Moadel). On the basis of weird experience we had with chair as she was confusing, and then many things unfolded, which ultimately pushed me into ****** ****** *******. I ended up spending almost 9 thousand dollars on my capstone; unfortunately, instructor (confused and culturally incompetent) was the wall between my public health passion and me. One of senior alumni  (presently work with Department of health who termed chair as his best professor) made me aware of Chair’s power, resources and contacts. While working at Einstein, I could not get over thought of Chair and her power. It continued for long, my passion for public health was insulted. I am dedicating this article to my best Professor (faculty at Lehman College) to let her know that I was ************* at Lehman College. I urged director Professor Levitt to let me learn any of pieces of  IPV study , or any of studies related to Qualitative research, she denied me every opportunity. My public health passion  was destroyed by both powerful  chair and director.Professor Levitt was nice person overall, however, I wish she would have relieved former chair(then chair)  from instructing capstone course and research method course. Wasn’t it waste of time, money and limited resources?

Intimate partner violence is global public health problem. Prevalence of Intimate partner violence differs geographically and financially. In countries like Peru, Ethiopia and Bangladesh, it was reported to be of 60%, while in Japan, it was 15 percent (Garcia-Moreno et al., 2006). In financial context, it is high in low- middle-income countries (Kabir, Nasreen, & Edhborg, 2014). A review by Tesera Bitew also found intimate partner violence associated with depression (Bitew, 2014). Rural communities were found to have more prevalence than urban communities. (Erulkar, 2013) . After analyzing data from 19 countries, researchers noted the high occurrence of Intimate partner violence during pregnancy (Devries et al., 2010). However, statistics in those countries is under-estimated, as many of women do not report it because of fear from husbands and male-dominant societies. Conflicts and being refugees/immigrant also enhances chances of IPV (Hyder, Noor, & Tsui, 2007) .Women who witnessed conflict violence is more likely to experience IPV than women who didn’t witness conflict (Falb, McCormick, Hemenway, Anfinson, & Silverman, 2013). In India, employed women experienced IPV more than unemployed owing to male dominant society (Chakraborty, Patted, Gan, Islam, & Revankar, 2014).


Intimate partner violence is associated with myriad of health problems. The effect of IPV on mental health is well documented. My brief review focuses on depression, one of the major mental health outcomes. Study indicate that the percentage of women who report having symptoms of depression varies according to their exposure to intimate partner violence(Meekers, Pallin, & Hutchinson, 2013).Women who were abused both in childhood and adulthood were four to seven times more likely to suffer from depression than never-abused women. (Ouellet-Morin et al., 2015). In Chinese study, research categorized in to IT and SCV, and found IT associated more with depression (Tiwari et al., 2015). There have been studies to report association between physical abuse and depression, but a prospective cohort study found emotional abuse as one of the risk factors for post-natal depression. (Ludermir, Lewis, Valongueiro, de Araujo, & Araya, 2010). In this study of 1045 women, of which 270 women reported depression, psychological torture was found to be important cause. According to Yoshihama et al, the role of psychological abuse is understudied(Yoshihama, Horrocks, & Kamano, 2009). Injuries stemming from psychological abuse took more time to heal than physical abuse(Matheson et al., 2015). One Chinese study reported high-level of depression in migrants’ victims of intimate partner violence. Lagdon et al studied mental health outcomes of 58 studies and found depression as the most common outcome. (Lagdon, Armour, & Stringer, 2014). Golding et al estimated prevalance of depression at 48% among women victim of IPV.


Ludermir study make policy makers to focus on even psychological abuse. So while planning for interventions, psychological torture should be taken into account. Interventions targeted at young men have shown positive results in Ethiopia. (Pulerwitz et al., 2015). So education young men of women right values could be positive step.(continued)




Bitew, T. (2014). Prevalence and risk factors of depression in Ethiopia: a review. Ethiop J Health Sci, 24(2), 161-169.

Chakraborty, H., Patted, S., Gan, A., Islam, F., & Revankar, A. (2014). Determinants of Intimate Partner Violence Among HIV-Positive and HIV-Negative Women in India. J Interpers Violence.

Devries, K. M., Kishor, S., Johnson, H., Stockl, H., Bacchus, L. J., Garcia-Moreno, C., & Watts, C. (2010). Intimate partner violence during pregnancy: analysis of prevalence data from 19 countries. Reprod Health Matters, 18(36), 158-170. Erulkar, A. (2013). Early marriage, marital relations and intimate partner violence in Ethiopia. Int Perspect Sex Reprod Health, 39(1), 6-13.

Falb, K. L., McCormick, M. C., Hemenway, D., Anfinson, K., & Silverman, J. G. (2013). Suicide ideation and victimization among refugee women along the Thai-Burma border. J Trauma Stress, 26(5), 631-635.

Garcia-Moreno, C., Jansen, H. A., Ellsberg, M., Heise, L., Watts, C. H., Health, W. H. O. M.-c. S. o. W. s., & Domestic Violence against Women Study, T. (2006). Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet, 368(9543), 1260-1269.

Hyder, A. A., Noor, Z., & Tsui, E. (2007). Intimate partner violence among Afghan women living in refugee camps in Pakistan. Soc Sci Med, 64(7), 1536-1547. doi: 10.1016/j.socscimed.2006.11.029

Kabir, Z. N., Nasreen, H. E., & Edhborg, M. (2014). Intimate partner violence and its association with maternal depressive symptoms 6-8 months after childbirth in rural Bangladesh. Glob Health Action, 7, 24725.

Lagdon, S., Armour, C., & Stringer, M. (2014). Adult experience of mental health outcomes as a result of intimate partner violence victimisation: a systematic review. Eur J Psychotraumatol, 5.

Ludermir, A. B., Lewis, G., Valongueiro, S. A., de Araujo, T. V., & Araya, R. (2010). Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet, 376(9744), 903-910.

Matheson, F. I., Daoud, N., Hamilton-Wright, S., Borenstein, H., Pedersen, C., & O’Campo, P. (2015). Where Did She Go? The Transformation of Self-esteem, Self-Identity, and Mental Well-Being among Women Who Have Experienced Intimate Partner Violence. Womens Health Issues. Meekers, D., Pallin, S. C., & Hutchinson, P. (2013). Intimate partner violence and mental health in Bolivia. BMC Womens Health, 13, 28.

Ouellet-Morin, I., Fisher, H. L., York-Smith, M., Fincham-Campbell, S., Moffitt, T. E., & Arseneault, L. (2015). Intimate partner violence and new-onset depression: a longitudinal study of women’s childhood and adult histories of abuse. Depress Anxiety, 32(5), 316-324.

Pulerwitz, J., Hughes, L., Mehta, M., Kidanu, A., Verani, F., & Tewolde, S. (2015). Changing Gender Norms and Reducing Intimate Partner Violence: Results From a Quasi-Experimental Intervention Study With Young Men in Ethiopia. Am J Public Health, 105(1), 132-137.

Tiwari, A., Chan, K. L., Cheung, D. S., Fong, D. Y., Yan, E. C., & Tang, D. H. (2015). The differential effects of intimate terrorism and situational couple violence on mental health outcomes among abused Chinese women: a mixed-method study. BMC Public Health, 15, 314.

Yoshihama, M., Horrocks, J., & Kamano, S. (2009). The role of emotional abuse in intimate partner violence and health among women in Yokohama, Japan. Am J Public Health, 99(4), 647-653.




Recent judgment by Supreme Court to allow same sex marriages all over the country is one of the major landmarks in light of public health. There are numerous examples when policy changes have resulted in improved health such as tobacco policy, anti soda law to curb obesity, affordable care act, and civil right movements. This judgment is also not exceptional, and it has potential to reduce health disparities among LGB groups. In 1973, American Psychiatrist Association removed homosexuality from DSM. Being LGBT has nothing to do with mental health illness; it is our (heterosexuals) conservative nature makes them feel/experience mental health problems. To appreciate Supreme Court decision, this is my brief literature review on mental health aspect of LGBT groups. And I hope this revolutionary step would also motivate other part of the world to follow the same step.

According to various different rsources, we can estimate that United States is home to three to four percent LGBT population. Because of social, cultural, religious and political fabrics and taboos, real and clear number is not available globally. Health disparities among LGBT groups in United States are well known. Building on it, my paper focus on mental health disparities in LGBT population. Compared to heterosexuals, sexual minorities that comprise lesbians, gay men, bisexual individuals and trans genders are at an increased risk for mental health illness and psychiatric morbidities. According to Meyer’s conceptual framework in from of stress theory, stressors can elucidate disproportionate prevalance of mental health illness in sexual minority groups. When coupled with other minority statuses, additive effect increases probability of experiencing homophobia, discrimination and rejection (Meyer, 2003) . People living in a state with policies that did not provide safeguards to lesbian, gay, and bisexual individuals were four times likely to suffer a comorbid psychiatric condition compared to individuals living in a state with positive policies (Hatzenbuehler, Keyes, & Hasin, 2009). They are more prone to experience depression, anxiety, high distress, substance abuse, suicidal tendency, hopelessness, and disability.

Support from family is very crucial for LGB group; even support from sexual minority group can make a big difference in light of mental health. Ryan et al study proposed that family acceptance could help in reducing the stressors in this group. (Ryan, Russell, Huebner, Diaz, & Sanchez, 2010). Even few studies have reported that friends and family support helps in cessation of substance abuse. A longitudinal cohort study established inverse relationship between family support and smoking rated among sexual minority groups. (Newcomb, Heinz, Birkett, & Mustanski, 2014). Another longitudinal study concluded negative association between alcohols uses and perceived family support (Newcomb, Heinz, & Mustanski, 2012). While distinguishing between family support and non-kin support, Almeida et al study found family support is more useful for mental health compared to non-kin support (Almeida, Subramanian, Kawachi, & Molnar, 2011).

Discrimination stemming from racism also adds up already high anxiety level. According to Myer minority theory, many minority statuses augment experience of feeling homophobia and stress, which further aggravate outcome. Social stress is contributing factor for anxiety. A recent study reported two times anxiety and mood disorders among LGBT groups compared to heterosexuals. Previous studies have found differences in distress level of LGB and heterosexuals. Research implies relationship between emotional distress and perceived discrimination in sexual minority groups (Almeida, Johnson, Corliss, Molnar, & Azrael, 2009).

Several studies found higher chances of depression in LGB groups. Patel et al study determines that clinical depression is more widespread in sexual minority because of social rejection and stigma. (Patel, Mayer, & Makadon, 2012). According to research at UCLA Center for Health Policy Research, despite no differences in access to health care, older gays are reportedly to have higher rates of depression than heterosexual counterparts (Wallace, Cochran, Durazo, & Ford, 2011). Long time distress stemming from social environment can force patients to clinical depression (Safren & Heimberg, 1999). Stigma in union with stress put MSM to higher risk of Psychiatric morbidity in form of depression (Sandfort, Bos, Knox, & Reddy, 2015). Research conducted in Estonia, Northern European country, also reported high prevalance of anxiety and depression in sexual minority groups (Parker, Lohmus, Valk, Mangine, & Ruutel, 2015). A cross sectional study, using respondent driving sampling, conducted in Sub-Saharan Africa also reported high prevalance of depression among MSM attributed to social stigma (Stahlman et al., 2015). A longitudinal study exclusively conducted in sexual minority women found this sample had higher unadjusted odds of depressive symptoms compared to heterosexual women (Pyra et al., 2014). Lytle et al found this result consistent in across all racial groups in the United States (Lytle, De Luca, & Blosnich, 2014). Emails were sent to invite students from 30 osteopathic medical schools for cross-sectional questionnaire-based study , of which, only 6 schools responded. Results are in accordance with established association of sexual orientation and depression (Lapinski & Sexton, 2014). While evaluating distress among 9th-12th LGBT grad students, researchers found higher rates of depression among students who percieved discrimination (Almeida et al., 2009).

A number of population based studies revealed higher rates of suicidal ideations in sexual minority groups. Prevalance of suicidal tendencies among trans-genders is more than general population. According to randomized trial study, people who experienced forced anal intercourse debut are more likely to have suicidal ideation (Defechereux et al., 2015). Adolescent group is the most vulnerable group for suicide attempts in MSM population. This is because gender awareness is developed in this period (Russell & Toomey, 2012).   Another study established association between parental rejection because of sexual orientation and suicidal tendency of gays (D’Augelli et al., 2005). A study designed in Denmark to investigate the suicide risk by sex and relationship status found that MSM have eight times more risk of suicide attempts compared to histories of heterosexual marriages (Mathy, Cochran, Olsen, & Mays, 2011).

Discrimination and stigma act as barrier to access to health services. Professional can also compound the problem for not having enough knowledge about community. Because of barrier and stigma, gay men in Spain are more likely to diagnose for HIV at advanced stage compared to heterosexuals (Hoyos et al., 2013). According to Hyoes et al, main barrier to HIV testing among MSMs includes: fear of HIV, legal implications of positive test and stigma/discrimination. In India, largely due to stigmatization by Indian medical community, MSM avoid routine health care (Patel et al., 2012). Sexual prejudice against MSM and transgender women is recognized as one of the impediments for access to anti retroviral therapy (Chakrapani, Newman, Shunmugam, & Dubrow, 2011). Chakrapani et al study implies barrier at three levels: family/social, health care system and at individual level. One Canadian study recommends that psychiatrists need to understand LGBT issue better.

Ryan et al study reported higher rates of smoking among sexual minorities. Bisexuals are more like to get indulged in Bing drinking and smoking. Stress resulting from stigma and discrimination contribute to higher risk of indulging in substance abuse. American College of Physicians documents the higher rates of smoking among MSMs than general population (Makadon). Alcohol misuse, a major health concern in lesbian and bisexual veterans, could be credited to higher prevalance of mental health symptoms (Lehavot, Browne, & Simpson, 2014). Revealed that gays rejected by family are more likely to indulge in alcohol and substance abuse. Gay neighborhood is not defined by more concentration of homosexuals in the neighborhood, but it is defined by higher concentration of gay bars, which highlight the magnitude and reflection of alcohol problem in sexual minorities (Midanik, Drabble, Trocki, & Sell, 2007). Lesbian bars were identified by several qualitative studies as a gathering place for lesbian women(Gruskin, Byrne, Kools, & Altschuler, 2006; Hequembourg & Brallier, 2009).

In nutshell, mental health of sexual minorities is preventable if certain policies are enacted which could help in reducing stigma and discrimination against them. Supreme court judgment is a big step in that direction and hopefully other countries in the world will follow the same suit.






Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional distress among LGBT youth: the influence of perceived discrimination based on sexual orientation. J Youth Adolesc, 38(7), 1001-1014.


Almeida, J., Subramanian, S. V., Kawachi, I., & Molnar, B. E. (2011). Is blood thicker than water? Social support, depression and the modifying role of ethnicity/nativity status. J Epidemiol Community Health, 65(1), 51-56.


Bayer, Ronald. Bayer R. Homosexuality and American psychiatry: the politics of diagnosis. . New York, 1981.


Chakrapani, V., Newman, P. A., Shunmugam, M., & Dubrow, R. (2011). Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India. AIDS Care, 23(12), 1687-1694.

D’Augelli, A. R., Grossman, A. H., Salter, N. P., Vasey, J. J., Starks, M. T., & Sinclair, K. O. (2005). Predicting the suicide attempts of lesbian, gay, and bisexual youth. Suicide Life Threat Behav, 35(6), 646-660.

Defechereux, P. A., Mehrotra, M., Liu, A. Y., McMahan, V. M., Glidden, D. V., Mayer, K. H., . . . Grant, R. M. (2015). Depression and Oral FTC/TDF Pre-exposure Prophylaxis (PrEP) Among Men and Transgender Women Who Have Sex With Men (MSM/TGW). AIDS Behav.

Gruskin, E., Byrne, K., Kools, S., & Altschuler, A. (2006). Consequences of frequenting the lesbian bar. Women Health, 44(2), 103-120.

Hatzenbuehler, M. L., Keyes, K. M., & Hasin, D. S. (2009). State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. Am J Public Health, 99(12), 2275-2281.

Hequembourg, A. L., & Brallier, S. A. (2009). An exploration of sexual minority stress across the lines of gender and sexual identity. J Homosex, 56(3), 273-298.

Hoyos, J., Fernandez-Balbuena, S., de la Fuente, L., Sordo, L., Ruiz, M., Barrio, G., & Belza, M. J. (2013). Never tested for HIV in Latin-American migrants and Spaniards: prevalence and perceived barriers. J Int AIDS Soc, 16, 18560.

Lapinski, J., & Sexton, P. (2014). Still in the closet: the invisible minority in medical education. BMC Med Educ, 14, 171.

Lehavot, K., Browne, K. C., & Simpson, T. L. (2014). Examining sexual orientation disparities in alcohol misuse among women veterans. Am J Prev Med, 47(5), 554-562.

Lytle, M. C., De Luca, S. M., & Blosnich, J. R. (2014). The influence of intersecting identities on self-harm, suicidal behaviors, and depression among lesbian, gay, and bisexual individuals. Suicide Life Threat Behav, 44(4), 384-391.

Mathy, R. M., Cochran, S. D., Olsen, J., & Mays, V. M. (2011). The association between relationship markers of sexual orientation and suicide: Denmark, 1990-2001. Soc Psychiatry Psychiatr Epidemiol, 46(2), 111-117.

Makadon, H j. he Fenway guide to lesbian, gay, bisexual, and transgender health.

Second. Philadelphia: merican College of Physicians, 2008.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull, 129(5), 674-697.

Midanik, L. T., Drabble, L., Trocki, K., & Sell, R. L. (2007). Sexual orientation and alcohol use: identity versus behavior measures. J LGBT Health Res, 3(1), 25-35.

Newcomb, M. E., Heinz, A. J., Birkett, M., & Mustanski, B. (2014). A longitudinal examination of risk and protective factors for cigarette smoking among lesbian, gay, bisexual, and transgender youth. J Adolesc Health, 54(5), 558-564.

Newcomb, M. E., Heinz, A. J., & Mustanski, B. (2012). Examining risk and protective factors for alcohol use in lesbian, gay, bisexual, and transgender youth: a longitudinal multilevel analysis. J Stud Alcohol Drugs, 73(5), 783-793.

Parker, R. D., Lohmus, L., Valk, A., Mangine, C., & Ruutel, K. (2015). Outcomes associated with anxiety and depression among men who have sex with men in Estonia. J Affect Disord, 183, 205-209. d

Patel, V. V., Mayer, K. H., & Makadon, H. J. (2012). Men who have sex with men in India: a diverse population in need of medical attention. Indian J Med Res, 136(4), 563-570.

Pyra, M., Weber, K. M., Wilson, T. E., Cohen, J., Murchison, L., Goparaju, L., . . . Cohen, M. H. (2014). Sexual minority women and depressive symptoms throughout adulthood. Am J Public Health, 104(12), e83-90.

Russell, S. T., & Toomey, R. B. (2012). Men’s sexual orientation and suicide: evidence for U.S. adolescent-specific risk. Soc Sci Med, 74(4), 523-529.

Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs, 23(4), 205-213.

Safren, S. A., & Heimberg, R. G. (1999). Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol, 67(6), 859-866.

Sandfort, T., Bos, H., Knox, J., & Reddy, V. (2015). Gender Nonconformity, Discrimination, and Mental Health Among Black South African Men Who Have Sex with Men: A Further Exploration of Unexpected Findings. Arch Sex Behav.

Stahlman, S., Grosso, A., Ketende, S., Sweitzer, S., Mothopeng, T., Taruberekera, N., . . . Baral, S. (2015). Depression and Social Stigma Among MSM in Lesotho: Implications for HIV and Sexually Transmitted Infection Prevention. AIDS Behav.

Wallace, S. P., Cochran, S. D., Durazo, E. M., & Ford, C. L. (2011). The health of aging lesbian, gay and bisexual adults in California. Policy Brief UCLA Cent Health Policy Res(PB2011-2), 1-8.








We are super-happy that Dr.Jim Sherry, global health leader, has joined CUNY SPH recently..Welcome!! I have been visiting Boston Global health series, Columbia and NYU! : now it was pleasure to travel from washington DC to New York to attend global health event in our own yard! Thanks Dean!!!

At one time, Rwanda had one of the weakest public health system in the world! Now it is example of good governance, economic growth, rationalized use of resources, equitable participation  of women in power and the effective use of outside financial assistance , which ultimately resulted in public health dividends  for once war torn country. In this article, I highlighted the achievement of Rwanda in light of public health, I also tried to find out the causes for its progress. And lastly, I mentioned the areas which need further improvement.. Rwanda emerged from the situation where security of life was first and foremost point on the agenda. Public health infrastructure was completely broken.


Even though Rwandas original inhabitants were Khosian speakers, their descendants now constitutes merely one percent of the total population of country. Hutu, Tutsi and Twa are the major ethnic groups. Hutu were traditionally concentrated in agriculture sector while Tutsi were cattle herder. Tutsi were powerful in military point of view. Rwanda had been witnessing ethnic conflict for almost 19th century, perhaps since the freedom from Belgium, but in 1994, it reached at zenith, which forced historian to term it as genocide. Rwanda genocide in which ten thousand people of Tutsi tribes were killed every day, and this massacre ran for 44 days., touching the number of deaths to one million. European medical staff were also executed who were treating victims. The most scary part of the killing was the people who participated in the massacre were between ages of 18 and 24 years, and from majority group of Hutu which left everlasting mark on all demographic, socioeconomic and health fabric Rwanda. Thousands became orphans and widows; and two million people became homeless. Even first woman Prime Minister  Madam Agathe and her husband  were not spared and were executed along with her Belgium security guards. One thing is sure, this carnage was the result of exclusion policies.

After genocide, Rwanda took eventful journey with optimism. Despite devastated completely by genocide, Rwanda did great comeback showing its resillience skills.  Its performance in public health is second best in Africa and only second to South Africa. It would be unfair to credit Rwandas success to just outside financial assistance. Nonetheless, it is worth to mention that of 49 Sub-Saharan countries, Rawanda is 22nd in getting financial assistance. Per capita income in getting financial assistance is little higher than other countries like Ethiopia and Uganda.  Almost 47% of budget of Ruwandian government comes from outside assistance.

Rwanda signed the declaration of achieving the Millennium Development Goals (MDGs) by 2015. It has scored high on at least two of  the eight goals. First, it achieved universal primary education, and second, it promoted equitable share of women in parliament. Child mortality rate has dramatically come down.  Even maternal heath has improved a lot. Infant mortality rate has come down from 92 in 1990 to 36 in 2012. Life expectancy at birth has also improved.  Rwanda is the country where number of women parliamentary members is higher than any other nation. This progress is credited to education, community health workers and governments insurance policies (muetelles de santé). 10percent of GDP is attributed to health sector.

It may be apparently debatable that Rwanda’s good result in light of public health is attributed to its business friendly environment policies and overall economic development.World Bank has ranked Rwanda at 28th in view of business friendly. According to Rwanda development Board (RDB), Rwanda is the most  competitive place for investment in the East Africa.Many of business initiatives were taken by present government since 2000. Construction permits, which used to takes years, are issued fast, perhaps in few days.  Foreign investment is encouraged. New business licenses are served in a day. Significant reduction in poverty by 11% was reported.   New Special Economiz Zones (SEZs) have been develed by the government. In addition. Labor in Rwanda is cheaper and efficient. According to Dr.Jim Sherry (CUNY SPH grand round lecture on 5/4/2015), success in public health goes hand in hand with economic prosperity and which seem largely applicable in case of Rwanda. Rwandas business and information technology initiatives are helping   to create job opportunities.

Malaria, HIV and tuberculosis yet account for estimated twenty percent of deaths. Rwanda has done well in view of fighting HIV/AIDS,  With funding from US presidents Emergecny Plan for the AIDS Relief , and Multisectoral AIDS program (mAP). Cancer as the cause of death is still far less than developing world, which stands at 3 percent. Since the life expectancy of Rwanda is less than 60 years, and large chuck of cause is attributed to infection and chronic diseases, low rate of cancer as cause of death is understandable.

One person who really deserves accolades for bringing Rwanda from death bed to the new hope of better life, for converting Rwanda from devastation to the new hope of edifice,  and for successfully meeting the herculean  challenge of changing Rwanda  from insecurity to the business friendly situation, is none other than sixth president of the nation, Dr.Paul Kagame . He has been head of Rwandan Government for last fifteen years. He once famously said that Rwanda is in hurry. What is the contribution of political part? Present government adopted inclusive growth, and tried not to widen the economic disparity across tribes. It also cancelled the identity of people on the basis of tribes. During our brief conversation, Dr.Jim Sherry, who did extensive public health work in Rwanda, also highlighted the enthusiasm and passion of President Kagame. The functioning of Rwanda government rely on 2020 vision-namely, human development, poverty reduction, economic growth, good governance. Population density of Rwanda is highest in the African continent.

Ethics and epidemiology were another pillars for the successful public health story in Rwanda. Performance was the criteria to provide benefits, allowances and rewards to health care workers. Data driven approach was taken into consideration before formulating policies. Evidence based public health practice as well as evidence based medical approach was emphasized while dealing with population and patients.

Good road network and market infrastructure helped to reduce food insecurity in some ways. Yet, according to 2012 report, 14% of Rwandan Households have to face hurdles to provide food to their families. Unequal distribution of food security is noted, especially in rural areas, Households with inadequate food consumption was especially high (42%). In addition, East and West of Congo Nile Crest also shows the seme results  because of soil erosions. Here, GIS can help in creating hotspots and assist in decision making process for policy makers.

No health is possible without mental health. Rwanda has been struggling to provide quality mental health care. Rwandan medical schools lack psychiatry clinical training. Its being almost 20 years passed, much of victims still suffers the effect of genocide. During hundred days genocide, HIV positive men were released from prison , and were asked to rape Tutsi women.  33% of genocide survivors experienced rape. Number of Psychiatrists per 1,00,000 population is 0.05 exact number in all country is 5. Nurses are the bulwark for the mental health care in Rwanda. . Rieder et al (2013) conducted mental health status study in conflict survivors. There are genocide survivors who were even raped and infected with HIV need extensive mental health therapy. Bolton et al 2002 reported that Bugesera had 15% prevalance of depression.   79% population was exposed to traumatic events. There is need of integration of mental health services. Mental health still carry stigma, it need cultural shift. It can be done through the channel of education and communication, where media can paly big role. Psychopharmacologic approach to deal with mental health patients, specially when drugs and quality mental health professionals are available, will work. In many condition, depression act as comorbidity. Though Rwanda is host to 0.13 percent population of world, it carries 5 percent burden of mental health illness. This magnitude speaks the quantum of the problem,

Though Rwanda has done dramatically well specially post-genocide, it has to go a long way to meet challenges such as unequal distribution of infrastructure between rural and urban areas, increasing population density, shortage of high-skilled physicians, shortage of tertiary centers, alarmingly high rates of chronic malnutrition for children under five, and high  burden of neuro-psychiatric disorder. Population control measures need to be in place. Rwanda had one the highest birth rates. If this issues is looked through the triad of environment, population and health,  it becomes obvious that increasing population will add burden on already limited resources. Despite, the journey of Rwanda is successful and can be labeled as template for other nations.

On unfateful morning yesterday, Himalayan kingdom of Nepal, sharing border with China and India , suffered earthquake of magnitude 7.8. Last major earthquake in Nepal was reported in 1934. We hardly have any control over the natural calamities like Tsunami,or earthquake and we merely can do anything to avert it. Forecasting of such dangers are still not accurate. Only perfect scientific invention and technology, if discovered in future, might help in preventing human lives from it, if people are given pre warning about it. But to tackle emergencies stemming from such natural disaster is one of the big challenges for public health professionals. Patterns of natural calamities can help in understanding and responding to deal with it. For example , Bangladesh is well prepared for cyclones and flood, because it faces any of these calamities every three four years.
2011 earthquale in Japan resulted in loss of $365 Billion US dollars. Hurricane Katrina of 2005 was 45Billion dollars loss for United States. Because of lack of insurance, the loss might not be that huge when compared with US and Japan loss. However, in confrimance with the Nepal economy, this loss might be more difficult for Nepal to meet. Other health priorities, such as achieving millennium goals take backside, because of such emergencies,which have long run consequences. First and foremost challenge before government remain for the government is providing basic needs to affected people and then rehbiliating them. Nepal like country whose GDP is $ 67Billion and which depend largely on international aid(especially India), would completely fall if international agencies community do not  come forward to provide assistance.

I witnessed two natural calamities so far, first was Mumbai deluge in 2005 and then Sandy in New York. Mumbai deluge was complete administration failure , most of the portion of city was submerged in water , and thousand of people lost their lives in few hours , and unfortunately,  I don’t think any lesson were learnt from it.  On the other side, Sandy was effectively handled. Though I was in San Fransisco, I observed it very closely. One major difference observed was that how quickly administration responded to calamity. Then Mayor Bloomberg gave warning signs and evacuated major areas to make sure that Sandy loss is minimized. And then once Sandy passed, Bllomberg administration wisely managed the quick response in all aspects. But again, it was emergency response in difference setting (developed vs developing).

To survive an earthquake and reduce its health impact, three Ps  Preparation, Planning, and Practice are required. Mortality stems from trauma, asphyxia, burns, and dust impacting  in the Lungs. People are left with disabilities. Surgical need are very important in first few weeks . Sufficint supply of suturing materials, instruments and disinfectants is need of hour. Severe cases of  burns are also rusually reported. All wounds and burns should be carefully checked as clostridium titani spores are present int the soil and can infects wounds and burns. Adequate stocks of tetanus vaccines for children is important to prevent tetanus related morbidities. Case fatality rate of tetanus is very high if left untreated. Dysphagia and trismus are few of first symptoms of tetanus, hence, cases with these symptovs should be reported to epidemiologists and surveillance officers. Good surveillance and collection of data helps in any future disasters. Few studies have reported increased cases of HIV/AIDS, perhaps because of faulty blood donation or unprotected sex (since unavailability of condoms and other barrier methods). Overcrowding of people cane xpose peole to scabies like infectious diseases. Surgical team, equipments, well trained CPR team, and  blood availability (blood bank with standard storage facility) is the cornerstone of saving human lives in medical point of view. If people are given CRP training and for genral wound management,  in emerncy situation, physician and nurses can handle cases on priority bases ,and over-burdened health professionals can be used judiciously to give adequate timely treatment to patients. Infectious dieseases (waterborn like cholera , diarrhea), food born diseases such as dysentery become rampant. Timely measure to remove dead bodies animal corpses , and cleaning and applying disinfectiong methods  can help


Earthquake survivors are exposed to post traumastic syndrome, hypertension , insomnia and depression. It is worth to mention one movie I watch recently,  based on tsunami (I watched Spanish version), in which one married couple of Germany visited Phuket of Thiland with their two gorgeous kids.Tsunami stuck just after two days of their stay and wife lost her husband and children. She wanders one hospital to another, she couldn’t, but only thing she could see the dead body of  one of her kids. Her life was devastated in minutes, natural calamity changed her life totally. Eventually she returned Germany, her family gave her support and she was provided psychiatric help. Finally she was able to get over the trauma. This is very nice movie to know how to treat patients with post traumatic stress syndrome (one of therapies). Distruction of homes and inappropriate living condition add up their stress level.


Linnen et al study, conducted in Harvard medical school (2011) vividly describe how fear and pain are affected in post traumatic stress syndrome. It implied that putamenand caudate activity is increased in post traumatic syndrome when subjected to heat pain, in addition, Biologically point of view speaking. Prefrontal cortex and amygdala is involed with emotion and behaviorVery few studies of its kind, Khachadurian (2015) et al reported that earthquake related loss and concurrent psychopathological stress affect adversely on their quality of life. Rwanda was exposed to terrific war in 1990s and their were huge human lives. Boston massachusset depaArtment sent few of their psychiatrist to help people to deal with post traumatic stress syndrome stemming from war.  Talk therapy, cognitive behavioral therapy and support from family friends also can be useful Sometimes antidepressant (though black box sign by FDA) can be sueful innot all patients though.. But question crops up, do they have those resources, do they have human resources and experts to tackle it, do they have trained peole , and more importantly money. Here timley international help can make wonder.


International agencies like UNICEF, World Health Organization and World Bank  have big role to play.  For example, world bank helped Pakistan (project:P099110) to build 80,000 houses under team leader  Raja Arshad. It was possible with the assistance of US $ 400 millions. Estimated 9,40,000 children need humanitarian assistance.  I was reading tweets from Alex Gavan , mountaineer, who has pleading for immediate help for Nepal to avoid further damages. It is scary to imagine rock and ice falling on the mounaineers. I am worried about rurtal pockets aroung Kathmandu. Media, government officials and international agencies focos on big cities, but I think, rural help should be managed through effective measures. Technology is again going to be blessing here. Gis role in earthquake: Google use in finding the person.Facebook and twitter are part of emergency preparedness.Facebook can creates pages for earthquake survivors to connect with each other.

Public health communication plays very important role in first few weeks of earthquakes. People should be educated about emergency preparedness. It also included educating them about safe water and food preparation. They should be stressed on maintaining hygience . Since Nepal is zone for malaria and dengue, use of mosquito nets should be emphasized.

Present problems:

Hospitals are overloaded and running out of medical equipments, drugs and supplies. Dwindling water and food supplies.  Enhancing risk of water born disease.  No enough equipments to dig out bodies, as many places bodies were searched with hands (lack of technology resources). Space shortage for cremation of dead bodies.



Rosa Park refused to vacate  the  seat in the colored section of the bus  for the white passenger when white-section was filled, for which she was arrested later(Bus is in Henry Ford museum).  We can imagine how much America has traveled since then and now it has Barack Obama who is the head of constitution.

Many sociopolitical scientists, researchers and human right activists might consider United States as template or reference for all these rights: Reproductive rights, immigration rights, civil rights, equal employment opportunity rights, marriage rights; but for such display on the actual screen, it had struggle, movements, sacrifices, lawsuits and politics behind the screen.Visit to this glorious place opened my *policy* eyes. National Archives Museum traveled me through sequence of shaping up of policies in the United States. Would you believe that United States was not different from any of conservative country  where women are still not even allowed to have driving license. Not so extreme, but till 1920,women didn’t have voting rights in this oldest democracy.
Immigration rights: United States is proud to be land of immigrants and land of opportunities. It is ,therefore,known for its diverse and dynamic society/community. One of pictures in museum  depicts how Irish workers as new immigrants  fought discrimination, long hours, and demand to work faster. It also have pages on display, collected  from the census schedule for Lowell , Massachusetts, 1860, which provides wealth of information for genealogists tracing family ties. It also helps in understanding the settling pattern of different immigrant groups. In my own observational research, I found people from Central America (especially Hondarus, Nicargua, Salvador and Guatamala) settled around Virginia and maryland. Recorded from immigrant case files,   a lady from HongKong was suspected as prostitute by immigrant officials,  and then she was kept under detention. After three appeals, she was granted entry.

Woman rights: Fight for suffrage escalated at the time of World War 1.  Women protesters were jailed in Virginia’s Occoquan workhouse (Fairfax county). Finally replying to women suffrage movement,  then President Woodrow Wilson endorsed  a federal woman suffrage amendment, and ultimately it became law in  August 1920.

Women didn’t have property right and she was subordinate to husbands. After marrying husband of different nationality, she was certain to lose her nationality. Museum mentions one case where a woman from Texas lost her citizenship after marrying the person from Czekoslovakia in 1941 (Continue)

Have you ever noticed Margaret Sanger Square in Manhattan? Yes, struggle of  Margaret Sanger is credited to the landmark judgement of  Griswold vs Connecticut when birth control in the United States was legalized. She is regarded as prominent figure in the fight for American woman’s right. It is also worth to write here that her mother was pregnant for 18 times in 22 years. I wish she was alive today , perhaps she would have provided useful guidance in Purvi Patel ‘s case.




Nigeria is the most populous country in Africa and is host to 47% population of West Africa , and two percent population of the world. It has around 250 tribes, 300 languages and two major religions. Nigeria has been playing constructive role in the African Union and in the Economic Community of West African States (ECOWAS). West African nation dedicates 6 percent of its budget on health, which is satisfactory compared to other developing nations. However,  Nigeria faces various public heath challenges: high unemployment rates. high mortality from HIV/Malaria/Tuberculosis. high infant mortality rates, poverty rates, and poor governance . All of these issues are interlaced with economic fabric of the country. And in addition, government politics is the driver for most of public health initiatives and economic reforms. So the triad of economy, governance and global assistance is important to look at  while understanding the  clear concrete picture of Nigeria in light of global health.

The present election result has consolidated democratic regime which began in 1999. Election was fought particularly on the issue of corruption and quality of governance.   General Buhari with clean image attracted masses, his brief stint as president in 80s also validated his clean image. Finally he won the elction with massive marging, and Nigerian democracy this time gave clear verdict in favor of change. It expects new government corruption free  with quality governance.  President elect Gen.Buhari was president of Nigeria in its economic hay days, which were followed by Ibrahim Babangida and then worst Regime of Gen Sania Abacha.

Nigeria progress will rely on 1) good governance 2) less dependency on oil 3) employment opportunities and improved health sector. Nigerian economy depends largely on oil for appreciable percentage of its foreign exchange earnings (Monoculture economy). According to available statistics, ninety-percent of export is attributed to oil. But less production of oil and recent slashing of oil prices badly affected Nigerian economy. I spoke to a student from Nigeria who recently finished his master’s degree from West Virginia University. He vividly told me apparently understandable reason for booming economy in Nigeria during 80s. The reason was increased cocoa production and agro based policies by then government. My brief research also supports his comment. Prosperity of southwest region compared to other regions is largely credited to over cocoa production in the region. In 2009, Nigeria produced around 250 thousand tones cocoa, and one ton market values was around $2500. According to the PESTLE technique, where ‘P’ stands for political, political is important element which affect business. Depend largely on oil for appreciable percentage of their foreign exchange earnings. The annual budget of Nigeria is based on crude oil prices benchmark. Strong laws and its effective implementation can prevent oil theft.

Considering deaths from various causes, only three percent  deaths were attributed t0 cancer, which doesn’t mean that cancer incidence is lower in Nigeria. Since age is important predictor of cancer, Nigeria and developing world aging population succumb to infection, and also, there are no diagnostic modalities to detect the cancer early. When it comes to death rates attributed to Malaria, Tuberculosis, Influenza, Diarrheal diseases and HIV/AIDS, World Health Organization  ranks Nigeria as 11,15,18,19 and 18 respectively. Nigeria rank alarmingly at 17th place for mortality rates resulted  from breast cancer. Jonathan government acted on save millennium lives program in 2012. Thought home to 2 percent population of the world, 10 percent infant t mortality cases are reported from Nigeria. Almost 3.1 million people are still living with HIV/AIDS. 20 percent of overall deaths in Nigeria are attributed to single cases as malaria. Current infant mortality rate in Nigeria is 129 per thousand, and it should be brought down to 71 according to millennium goals.

Unemployment rate in Nigeria is all time high at 23.9%. There are around 50 million unemployed people in Nigeria. For new government, it would be one of the biggest challenges. McGee et al report the association between unemployment rate and depression. Okoro et al(2007) finding is also consistent in supporting this association. Study conducted in Neuropsychiatric hospital in Nigeria reportedly established association between unemployment and aggressive behavior (Amoo 210). Promoting skills based education will help in creating more jobs. And then again non-oil industries also should be encouraged. Unemployment is strong predictor of crimes, and mental health issues.

United States global fund has promised funding for various causes across the world. . Recent budget of FY16 has kept the HIV budget flat, declared budget for tuberculosis, however increased budget for malaria and maternity reproductive health. Accurate data is not available yet which could show how much this allocated fund is promised for Nigeria.   As a part of strategy, World Bank has effectively supported Nigeria in tackling polio. WB is also committed to stabilize HIV epidemic by measures such as carrying out epidemiological analysis to identify states with highest prevalence rates, and strengthening prevention aeffrtos aimed at commercial sex workers. IBRD (International Bank for Reconstruction and Development) and IDA (International Development Association) wing of World Bank has been facilitating in providing good governance, creating employment through programs and projects; and encouraging non-oil growth (sustainable agriculture). If all programs are honestly implemented in accordance with policies led down by USAID or agencies supporting the cause, I think millennium targets are achievable.Effective collaboration with CDC and active support to its activities could be of paramount help.

Government role in implementing policies and allocating fund is crucial in light of public health. Recently Nigeria was declared polio free and it was safe  zone for  Ebola despite havoc in neighboring countries. It highlights Nigeria’s edge over other neighboring African Nations. However, compared to other developed or developing nations, many things need immediate attention:  primary care need to strengthened, HIV drugs should be made easily available to stop maternal child transmission, malarial prevention programs should be effectively implemented, and  ancer drugs should be available at cheaper rates. In addition,  Nigeria should focus more on export, for example, Nigeria imported 230 million $ from USA, while exported just $150 million . Nigeria import more from Australia than export(19 million vs 12 million). In last April 2014, Nigeria overtook South Africa as largest economy in Africa.

Coupled with experience in both government and military institutions, President elect Gen Buhari may help in effective implementation of polices, and if his attention is brought to the public health issues, his vision and effective leadership can bear the fruits. In other words,  Nigeria can deliver expected results in the context of  public health to achieve millennium goals. Taking the size of population (manpower) and its economy into account, Nigeria has potential to shoulder the burden of African continent.. Policies directed at development, non-oil based economy, and  transparency in tackling oil economy,  and in addition, focus on generating  more   revenues  by emphasizing on more export than import is paramount important fo rthe health of nation and for the health of people. To add further, fiscal decentralization  gives states enough share of revenues, improved governance in respective  state  would bring about desirable results.

Policy matters!

I got an email from one of students  in California  enquiring about CUNY SPH programs.. I should take it take as compliment!  Things are moving great, fresh wind is flowing in CUNY.  I am also writing merits and demerits of every department in CUNY SPH. I will focus more on merits (strengths). Our Chancellor is great humanBeing and amazing leader!!

Recent initiatives taken by CUNY SPH for capstone projects and innovation awards is super example of one of policy changes. It will help students to grow their interest and passion in public health. I was exactly yearning for such changes in my time.

Dr. Diane Romero announced research opportunities for qualitative research and she even included Lehman College students. She won my heart! All campuses should get opportunities.

I am following CUNY SPH :)








Being located in the Bronx, being home to diverse group of population, Lehman college need  access to resources. Lehman college has potential to to address public health issues in the Bronx. For that, we need public health professionals. I am sure present dean and administration are already aware of the fact and their committment to fix it reflects in their recent action. For example, Dr.Sherry teaching global health and Dr.Lee teaching policy is sort of good news for Lehman college. I am in  DC here, the home of policy makers, and as an alumnus, I will do whatever in my capacity.  For example,  meeting policy makers and making them aware of our problems. I am sure their help in small drop could prove ocean for us. We are committed to make CUNY SPH with other top schools.

We need more new faculty. There are so many good students in Harvard, Columbia finishing their doctorates and doing fellowships. Why dont we catch them early. I was going through the profile of Dr.morgan philbin, working in HIV center, quite so interesting. She has been doing lot of good work, using both quantitative and qualitative skills. I can count many names on  my fingers and their interested research work.  I attended Dr.Welch presentation, why she is not assigned some epi courses in Lehman if she agreed to it. Students should go with skills in hand, not grades. Off course grades are important, however based on experience, skills matter a lot.That is what to do  more in actual scenario.

The same instructor teaching research method and capstone course (Especially we had complained so many times)  is not good for our students. We need instructors good at knowledge, communication, cultural competency and positively responsive to students concerns and question. No one on this earth is perfect, and no one is supposed to know everything. But there are ways to make students motivated and encouraged. Their few inappropriate words and actions can put them back in their career .

We need to connect dots in CUNY. I am glad it is happening.  CONTINUED..


Dear Dr.Barbot, estamos muy contentos de tenerte en CUNY. Usted está bien logrado en la salud pública, fuente de inspiración para nosotros. Su trabajo en Baltimore fue maravilloso. También queremos lo mismo para la ciudad de Nueva York. Bienvenida! Tenemos la suerte!!

Dr.Oxiris Barbot, fluent spanish speaker, is from the Bronx. That is also the reason I am pretty excited to meet her. I lived in various neighborhoods of Bronx and even had my public health education in the same Borough. Thanks to Dr.Alysson Model, I had my first ever presentation in American Public Health Association conference based on the work done in the Bornx. And in addition, I am getting better in Spanish day by day :)

I am super busy in computer technology stuffs/Spanish and so, I could not write because of technology commitments lately. Though in capital city, I miss public health articles, epidemiology, journalism and medicine. SO I am sorry for short articles, will extend it later!

Its an honor for CUNY SPH that  Health Commissioner is offering lecture today and enlightening students with her rich experience in health policy.  Since American Public Health Associations  upcoming conference center around policy, it would be interesting to see what is stored for our school.

There are many projects DOH and CUNY SPH are collaborating on.

Under Dr.Basset’s remarkable and visionary guidance, Department of Health has handled Ebola very effectively and efficiently. The response of NYCDOH  deserve accloads from World Health organization and United Nations.

What do we wish from DOH?

1) I wish CUNY SPH is included in epi scholar program like other schools, 2) Students from our school get internship and career opportunities. 3) Working at DOH is really rich experience and can be turning-point  in career for many, so atleast creating volunteer opportunities  would be rewarding for our students and alumni.  4) GIS department of NYCDOH collaborate with Lehman College as it has wonderful GIS lab and GIS program. (Continued..)


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