Transformed occupational prospects for HIV-associated brain syndromes.

We report a case of a full-time worker with late undiagnosed HIV disease presenting as encephalopathy with motor features and a manic-like picture. HIV encephalopathy was a terminal condition before the advent of combination highly active anti-retroviral therapy (HAART). Treatment with HAART, with follow-up in a neuropsychiatric service and rehabilitation involving the occupational health department of his employer, produced a successful return to work. This case demonstrates a remarkable transformation in occupational and other outcomes of HIV-related brain disease in the era of HAART.

Polymorphous Low-Grade Neuroepithelial Tumor of the Young as a Partially Calcified Intra-Axial Mass in an Adult.

Polymorphous low-grade neuroepithelial tumors of the young (PLNTYs) are recently described CNS tumors. Classically, PLNTYs are epileptogenic and are a subtype of a heterogeneous group of low-grade neuroepithelial tumors that cause refractory epilepsy, such as angiocentric gliomas, oligodendrogliomas, gangliogliomas, and pleomorphic xanthoastrocytomas. Although they are a relatively new entity, a number of imaging and histologic characteristics of PLNTYs are already known. We present the imaging and pathologic findings of such a tumor as well as the surgical approach and clinical management.

Mixed Solid and Cystic Mass in an Infant.

Desmoplastic infantile tumors are rare supratentorial brain tumors that occur in pediatric patients. Desmoplastic infantile tumors are made up of 2 subtypes: desmoplastic infantile gangliogliomas and desmoplastic infantile astrocytomas. Desmoplastic infantile tumors are often identifiable on imaging on the basis of multiple characteristics. Nevertheless, pathologic analysis is required to confirm the diagnosis, particularly when the imaging features are atypical. Here, the radiology findings, surgical approach and subsequent management, and pathology of a desmoplastic infantile ganglioglioma are described.

Primum non nocere. The case for a critical approach to global mental health.

The Movement for Global Mental Health (MGMH) argues that there is a moral imperative that psychiatric treatments should be made available to all communities across the world. But psychiatric theories, categories and interventions emerged in the Western world are based on a set of assumptions about the nature of the self and society, nature and the supernatural, health and healing that are not universally accepted. In this paper we argue that there is a stronger moral case for caution with regard to the export of psychiatric thinking. Without a critical interrogation of such thinking the MGMH is at risk of doing a great deal of harm to the diverse, and sometimes fragile, systems of care that already exist across the world.

A critique of seven assumptions behind psychological trauma programmes in war-affected areas.

Programmes costing millions of dollars to address 'posttraumatic stress' in war zones have been increasingly prominent in humanitarian aid operations, backed by UNICEF, WHO, European Community Humanitarian Office and many nongovernmental organisations. The assumptions underpinning this work, which this paper critiques with particular reference to Bosnia and Rwanda, reflect a globalisation of Western cultural trends towards the medicalisation of distress and the rise of psychological therapies. This paper argues that for the vast majority of survivors posttraumatic stress is a pseudocondition, a reframing of the understandable suffering of war as a technical problem to which short-term technical solutions like counselling are applicable. These concepts aggrandise the Western agencies and their 'experts' who from afar define the condition and bring the cure. There is no evidence that war-affected populations are seeking these imported approaches, which appear to ignore their own traditions, meaning systems, and active priorities. One basic question in humanitarian operations is: whose knowledge is privileged and who has the power to define the problem? What is fundamental is the role of a social world, invariably targeted in today's 'total' war and yet still embodying the collective capacity of survivor populations to mourn, endure and rebuild.

Psychological responses to war and atrocity: the limitations of current concepts.

Because of the prevalence of wars, political violence and other forms of man-made disaster in Third World countries many individuals and communities suffer prolonged and often multiple traumas. In Western psychiatry certain conceptions of the response to violence and trauma have been developed, including the widely used category of post-traumatic stress disorder (PTSD). We argue that because concepts such as PTSD implicitly endorse a Western ontology and value system, their use in non-Western groups should be, atmost, tentative.

Raising the dead: war, reparation, and the politics of memory.

All societies attach a different range of meanings to war than to natural disasters, and questions of societal recognition, reparation, and justice are generally central. Most modern conflict has been grounded in the use of terror to control and silence whole populations. Those abusing power typically refuse to acknowledge their dead victims, as if they had never existed and were mere wraiths in the memories of those left behind. This denial, and the impunity of those who maintain it, must be challenged if survivors are to make sense of their losses and the social fabric is to mend. For the names and fate of the dead to be properly lodged in the public record of their times also illuminates the costs that may flow from the philosophies and practices of the Western led world order, ones which health workers should be in a position to influence.

The social, cultural and political dimensions of contemporary war.

There have been more than 160 wars and armed conflicts since 1945, almost all in the Third World, and more than 50 currently. More than 90% of these are internal rather than between sovereign states. There has been a sixfold increase in the number of war refugees worldwide since 1970, who now number 1% of the global population. Ninety per cent of all casualties are civilians. A key element of modern political violence is the creation of states of terror to penetrate the entire fabric of grassroots social relations as a means of control. The valued institutions and ways of life of whole populations are routinely targeted for destruction. In the 1980s many such wars were played out on a terrain of subsistence economies. The back-drop is of environmental degradation, poverty, embedded social injustice, pressure on the nation-state, a global rise in food insecurity and a widening gulf between the wealthiest 20% and the poorest 20% in the world. The World Health Organization is warning of a health catastrophe, with life expectancy in the world's poorest countries falling by the year 2000 and one-third of the world's children undernourished. Understanding a complex and evolving set of causes and effects surrounding war is a considerable challenge to the international humanitarian field, not least the health professions. In recent years there has been a burgeoning interest in the psychological impact of the atrocities of war, and in trauma programmes based on Western psychological concepts and techniques. This individualistic focus risks neglecting the core issue: the role of a social world, invariably targeted in war and yet still embodying the capacity of survivor populations to manage their suffering, adapt and recover on a collective basis. Using the example of Mozambique, Guatemala and others, this paper will discuss the way in which contemporary war damages social and cultural forms, and the range of traditions, values and understandings which these carry. However, society and culture also engage actively with war, with changes in the social order that may come to outlast the violence itself. This paper will also pinpoint the quest for justice as an issue that may distinguish the subjective experience of war from those that arise after peacetime or natural disasters. The work of anthropologists, sociologists, historians and poets in both West and Third World, allied to the voices of survivors themselves, can help the humanitarian field to acquire a more richly textured understanding of the range of responses to war and atrocity, and outcomes over time.