Health and historical levels of freedom.

BACKGROUND: The link between political freedom and health is unclear. We aimed to determine the association by exploring the relationship of historical and cumulative freedom levels with important health outcomes. METHODS: We obtained countrywide health indicators for life expectancy, infant mortality, maternal mortality ratio, % low birth weight babies, Gini coefficient (a measure of wealth inequality) and various markers of freedom based on political rights and civil liberties. We applied multivariable logistic regression to examine the association between health indicators and within-country years of freedom as determined by Freedom House rankings. RESULTS: The total proportion of free years from 1972-2005, the duration of current freedom level, and the Gini coefficient show independent positive associations with health indicators, which remain after the adjustment for national wealth, total government expenditure, and spending on health. Countries identified as having high total proportion of free years demonstrated significantly better health outcomes than countries with low levels of freedom (life expectancy, Odds Ratio [OR] 7.2, 95% Confidence Interval [CI], 2.3-22.6, infant mortality OR 19.6, 95% CI, 5.6-67.7, maternal mortality ratio, OR 24.3, 95% CI, 6.2-94.9, and % low birth weight babies OR 3.8, 95% CI, 1.4-10.8). This was also the case for infant mortality (OR 3.4, 95% CI, 1.0-8.4), maternal mortality ratio (OR 4.0, 95% CI, 1.2-12.8), and % low birth weight babies (OR 2.6, 95% CI, 1.0-6.6) among countries considered as having medium levels of freedom. INTERPRETATION: We found strong associations between country-level freedom and important health outcomes. The cumulative level of freedom over time shows stronger associations with all health indicators than the duration of current freedom level.

Users' guides to the medical literature: how to use an article about mortality in a humanitarian emergency.

The accurate interpretation of mortality surveys in humanitarian crises is useful for both public health responses and security responses. Recent examples suggest that few medical personnel and researchers can accurately interpret the validity of a mortality survey in these settings. Using an example of a mortality survey from the Democratic Republic of Congo (DRC), we demonstrate important methodological considerations that readers should keep in mind when reading a mortality survey to determine the validity of the study and the applicability of the findings to their settings.

Dangerous journey: documenting the experience of Tibetan refugees.

OBJECTIVES: Since the 1950 invasion of Tibet by China, Tibetan refugees have attempted to flee into Nepal over the Himalayan mountains. We documented the experiences of a group of refugees making this journey. METHODS: We conducted semistructured interviews with 50 recent refugees at the Tibetan Refugee Transit Centre in Kathmandu, Nepal. RESULTS: Participants ranged in age from 8 to 56 years, and 21 were female. The average length of their journey from Tibet to Nepal was 34 days. During their journey, a majority of the refugees encountered authorities or became involved in altercations with Nepali Maoist groups. Most of these interactions resulted in extortion and threats of expulsion. Several Tibetans were tortured, beaten with weapons, threatened with being shot, and robbed. Three women were sexually assaulted at gunpoint. CONCLUSIONS: The refugees who took part in this study experienced physical and mental hardships and, often, human rights abuses on their journey to Nepal. International pressure is needed to prevent human rights violations and reduce potential long-term physical and mental health effects associated with this dangerous crossing.

Prevalence of mental disorders and torture among Tibetan refugees: a systematic review.

BACKGROUND: Many Tibetan refugees flee Tibet in order to escape physical and mental hardships, and to access the freedoms to practice their culture and religion. We aimed to determine the prevalence of mental illnesses within the refugee population and determine the prevalence of previous torture reported within this population. METHODS: We performed a systematic literature search of 10 electronic databases from inception to May 2005. In addition, we searched the internet, contacted all authors of located studies, and contacted the Tibetan Government-in-exile, to locate unpublished studies. We included any study reporting on prevalence of mental illness within the Tibetan refugee populations. We determined study quality according to validation, translation, and interview administration. We calculated proportions with exact confidence intervals. RESULTS: Five studies that met our inclusion criteria (total n = 410). All studies were conducted in North India and 4 were specifically in adult populations. Four studies provided details on the prevalence of torture and previous imprisonment within the populations. The prevalence of post-traumatic stress disorder ranged from 11-23%, anxiety ranged from 25-77%, and major depression ranged from 11.5-57%. CONCLUSION: Our review indicates that the prevalence of serious mental health disorders within this population is elevated. The reported incidence of torture and imprisonment is a possible contributor to the illnesses. Non-government organizations and international communities should be aware of the human rights abuses being levied upon this vulnerable population and the mental health outcomes that may be associated with it.