Category: Ministry of Public Health

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Prisoner Health, Human Rights and Social Recovery

By Martin Halliwell

On 21 October 2011, at a summit in Rio de Janeiro, the World Health Organization (WHO) released the Rio Political Declaration on Social Determinants of Health, its strongest statement yet of the need to tackle health inequities within and between countries. Focusing on the WHO’s commitment to health as a fundamental right rather than a privilege, the Rio Declaration recognised that to eliminate inequities would require the sustained ‘engagement of all sectors of government, of all segments of society, and of all members of the international community’. By viewing social determinants in both economic and psychosocial terms, the declaration made three policy recommendations: ‘to improve daily living conditions; to tackle the inequitable distribution of power, money and resources; and to measure and understand the problem and assess the impact of action’. The World Health Assembly’s adoption of this policy framework in 2012 was an effort to embed what the Rio Declaration called ‘an intersectoral approach’ to analysing how social groups are classified with respect to quality of life, comorbidities and access to health care.

A decade on from the Rio Summit, the governance role of the WHO is more critical than ever to ensure that economic pressures, polarizing ideologies and faltering international accords, which we have witnessed globally in the 2010s and early 2020s, do not compromise the ideal of health as a fundamental right. Despite this stated imperative, the WHO has been slow to attend to the psychosocial needs of prisoners, especially those incarcerated in the Global South. This sluggishness is despite a growing body of research across the humanities, social sciences and life sciences that shows how incarceration is itself a ‘chronic health condition’, with ‘social, biological, and psychological elements’ which are both ‘poorly documented and poorly addressed’. [1] As an April 2022 School of Oriental and African Studies (SOAS) workshop on the colonialities of incarceration makes clear, this trend not only privileges Euro- and US-centric analyses but it can lead to an exceptionalising (and sometimes racializing) of human rights abuses in the Global South.

The WHO’s Health in Prisons Programme
While heeding the warnings of the SOAS workshop, it is important not to overlook the ways in which WHO has addressed prisoner health, albeit with a largely European focus. We can pinpoint 1995 as a breakthrough year for WHO, with the formation of its Health in Prisons Programme (HPP) across eight European countries, with the aim of sharing good practice and raising national standards, as embodied by the Declaration on Prison Health as Part of Public Health. This 2003 WHO declaration states that economic pressures and social challenges faced by a nation state cannot excuse a government’s failure to uphold their duty of prisoner care, including ‘effective methods of prevention, screening, and treatment’.

This ideal is shared by NGOs, such as Penal Reform International (PRI), established in 1990 to raise global standards in prisons and share best practice, with a particular focus on prisoner support in Africa, the Caribbean and South Asia. In its worldwide emphasis, PRI highlights human rights violations, noting that reducing overcrowding and meeting (or exceeding) the UN Standard Minimum Rules for the Treatment of Prisoners (also known as the Nelson Mandela Rules) are ‘vitally important components of a prisoner’s journey’. [2] Nonetheless, as Katherine McLeod and colleagues have recently argued, there remains ‘a critical lack of evidence on current governance models and an urgent need for evaluation and research, particularly in low- and middle-income countries’. [3]

A case in point is the European focus of HPP. Despite its growth from an initial eight to forty-four national members, the 2014 HPP publication Prisons and Health acknowledges that incarceration falls disproportionately on poor and vulnerable communities, at a time when researchers across a span of disciplines were calling for attention to the health needs of women and older prisoners on a global scale. [4] Despite its Eurocentrism, Prisons and Health develops the insights of Good Governance for Prisoner Health in the 21st Century (2013), with the aim of facilitating ‘better prison health practices’ with respect to human rights and medical ethics; communicable and noncommunicable diseases; oral health; risk factors; vulnerable groups; and prison health management’. [5] Calling for prisoners to receive an equivalent standard of health care to other citizens, Prisons and Health defines the ‘prisoner as patient’ with the same rights as all other patients. We might take issue with the power dynamics of the ‘prisoner as patient’ concept, especially the implication that patients are powerless (or have only limited agency) in the face of diagnostics and interventions. Yet the report focuses as much on governmental responsibility as on ensuring that prisoners have basic health rights and benefit from prison health services that are integrated ‘into regional and national systems’, within and beyond their experience of incarceration. [6]

Clinical Recovery and Social Recovery
Estimating that 40 per cent of prisoners encounter mental health problems during their jail time (some reports suggest this percentage is much higher), not only does Prisons and Health highlight the multiple determinants and co-causalities of mental ill health, but it points to the psychosocial needs of prisoners, noting that ‘clinical recovery’ and ‘social recovery’ are two distinct processes with differing timelines. [7] One of the missing factors in assessing these recovery arcs, as medical anthropologists Johanna Crane and Kelsey Pascoe argue, is that often appraisals of prisoner health fail to engage with what prisoners themselves identify as their needs. Crane’s and Pascoe’s research in Washington State is closely informed by interviews with prisoners who often describe a ‘slow erosion of their well-being over the course of their imprisonment’ due to ‘a frustrating mix of regimentation and unpredictability that derailed their ability to transition to life beyond prison’. [8] This mix is particularly acute for prisoners who experience solitary confinement or who feel locked-in by an aggressive course of medication administered to manage erratic or psychotic behaviour.

Yet ‘erosion of well-being’ can also result from overcrowding, unsanitary conditions, prisoner-to-prisoner violence, mistreatment by prison staff, or health needs that might be either undiagnosed or overtreated. Not only are these realities in tension with the goal of ‘social recovery’, but they evoke what sociologist Erving Goffman calls a conspiratorial form of ‘secret management’ practised by social institutions beyond the prison, where wounds continue to be inflicted on ex-prisoners via tacitly aligned systems that collude with overt forms of carceral management. [9] The WHO’s reminder of health as a human right is pivotal to ensure this kind of collusion does not occur. However, this may not be enough to offset rights violations that can lead to long-term erosion of selfhood, which, in turn, may lead to further offences or to debilitating mental health experiences that jeopardise rehabilitation.

PAHO and Culturally Congruent Research
A related issue is the lack of regional and cultural specificity in these kinds of overview studies, even though PRI’s 2019 edition of Global Prison Trends provides brief case studies from Thailand and Australia to offset the Eurocentric focus of HPP. The dearth of regionally sensitive studies on prison health is particularly relevant for the Caribbean, as University of West Indies psychiatrists Frederick Hickling and Gerard Hutchinson have argued. [10] Although WHO and the Pan American Health Organization (PAHO) have raised awareness and standards of best practice for prisoner health care, their publications tend to ignore both the historical legacies of slavery and colonialism and the ‘clash of cultures and ideologies’ that cut across national identities. [11] At a basic level, in many PAHO publications, the Caribbean is often overshadowed by a Latin American focus on Central and South America, or where Anglophone and Francophone distinctions within the Caribbean are overlooked.

This need for culturally congruent studies is vital, but it is also important to recognise that PAHO has played a major role since the 1990s in working with national governments across the Caribbean to combat health conditions arising from poverty, ranging from pan-regional studies, including the 1998 survey Health in the Americas, through to country specific reports, such as the 2012 Guyana: Faces, Voices and Places in Guyana. These interventions include improving health surveillance; increasing epidemiological capacity; expanding the pool of trained health officials; tackling environmental health; promoting healthy lifestyles; and highlighting co-morbidities in prisons, especially around mental health and addiction. PAHO continues to advocate for good health-care practice and improving public health communications, but its reports tend to be oriented towards disease surveillance and, when they deal with mental health, fail to give a holistic account of what clinical and social recovery might mean within (and beyond) a carceral environment.

Faced with this regionally uneven advocacy and policy landscape, our ESRC-funded project, ‘MNS Disorders in Guyana’s Jails: 1825 to the Present’, shows why it is equally important to account for the long arc of colonialism in the Caribbean and to attend carefully to the intersectoral factors that exacerbate ‘the pains of imprisonment’. [12] Since 2019, we have witnessed the collaborative efforts of the Guyana Prison Service and Guyana’s Ministry of Health to improve systems and governance, including the adoption of holistic health care, with the aim of transitioning ‘from a penal system to that of a correctional facility’. [13]

Nevertheless, as our project publications show, the shadow of the colonial penal system still looms large in Guyana’s prisons. Not only do health screening procedures for new prisoners need improving, but overcrowding, unsanitary condition and inadequate care continue to jeopardise UN standards intended to safeguard prisoner health. [14] Intensified WHO and PAHO collaboration will enable Caribbean national governments to share best practice, but ministries also need to improve prison infrastructure and to facilitate a meaningful shift of discourse from ‘management’ towards ‘care’ and a reorientation from eroded to positive identities. A sharper emphasis on ‘social recovery’ may prompt officials to think about prison as a transitory phase within a life-journey rather than a defining experience from which it is difficult to recover. Not only it is crucial to recognise the multiple determinants of prisoner health, but to remember that it is the collaborative task of government, prison and health care officials to uphold human rights and prepare the ground for released prisoners to ‘lead meaningful and contributing lives as active citizens’. [15]

Martin Halliwell is Professor of American Thought and Culture in the School of Arts, University of Leicester. He is the author of American Health Crisis: One Hundred Years of Panic, Planning, and Politics (University of California Press, 2021) and his co-edited volume The Edinburgh Companion to the Politics of American Health will be published by Edinburgh University Press in August 2022. He is grateful for feedback while preparing this blog from Professor Clare Anderson, Dr Tammy Ayres and Dr Dylan Kerrigan.

[1]. Johanna Crane and Kelsey Pascoe. ‘Becoming Institutionalized: Incarceration as a Chronic Health Condition’, Medical Anthropology Quarterly, 35(3), 2020, 2–20.

[2]. Penal Reform International, Global Prison Trends 2019, ‘Healthcare in Prisons’ supplement: https://cdn.penalreform.org/wp-content/uploads/2019/05/PRI-Global-prison-trends-report-2019_WEB.pdf. On prison overcrowding, see also Morag MacDonald, ‘Overcrowding and its Impact on Prison Conditions and Health’, International Journal of Prisoner Health, 14(2), June 2018, 65–8.

[3]. Katherine E. McLeod et al., ‘Global Prison Health Care Governance and Health Equity: A Critical Lack of Evidence’, American Journal of Public Health, 110(3), March 2020, 303.

[4]. See, for example, Seena Fazel et al., ‘Mental Health of Prisoners: Prevalence, Adverse Outcomes and Interventions’, Lancet Psychiatry, 3, 2016, 871–81.

[5]. Stefan Enggist et al., Prisons and Health (Copenhagen: WHO Regional Office for Europe, 2014), i.

[6]. Enggist et al., Prisons and Health, 1–2.

[7]. Ibid., 87–8. See also David Pilgrim, ‘“Recovery” and Current Mental Health Policy’, Chronic Illness, 4, December 2008, 295–304.

[8]. Johanna T. Crane, ‘Mass Incarceration and Health Inequity in the United States, in The Edinburgh Companion to the Politics of American Health, ed. Martin Halliwell and Sophie A. Jones (Edinburgh: Edinburgh University Press, 2022), 520.

[9]. Erving Goffman, ‘The Insanity of Place’ (1969), in Relations in Public Microstudies of the Public Order (London: Penguin, 1972), 415.

[10]. See, for example, Frederick W. Hickling and Gerard Hutchinson, ‘Caribbean Contributions to Contemporary Psychiatric Psychopathology’, West Indies Medical Journal, 61(4), 2012, 442–6. 

[11]. Daniel Nehring and Dylan Kerrigan, Therapeutic Worlds: Popular Psychology and the Sociocultural Organisation of Intimate Life (London: Routledge, 2019), 29.

[12]. ‘Mental Health in Guyana’s Prisons: A Direct Legacy of the Country’s Colonial History?’, Stabroek News, 16 April 2021.

[13]. Guyana Prison Service, 2020 Annual Report (Georgetown: Guyana Prison Service, 2021), 1, 5.

[14]. See ‘Offender’s Mental Health Prior to Incarceration must be Assessed’, Guyana Chronicle, 28 August 2021.

[15]. Jerry Tew, ‘Recovery Capital: What Enables a Sustainable Recovery from Mental Health Difficulties?’, European Journal of Social Work, 16(3), 2012, 360. See also Jerry Tew et al., ‘Social Factors and Recovery from Mental Health Difficulties: A Review of the Evidence’, British Journal of Social Work, 42, April 2011, 443–60.

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Mental Health and Covid-19 Protocols in Guyana’s Prisons

By Queenela Cameron

Interviews conducted at the Georgetown and Lusignan prisons in 2019 as part of a collaborative research on the topic of “Mental, Neurological and Substance Abuse disorders in Guyana’s Jails – 1825 to the Present Day” revealed that a number of mental health challenges (diagnosed and undiagnosed) are experienced by both prisoners and prison staff, with depression seeming to be the dominant one. Depression in the context of Guyana’s prisons, is exacerbated by several factors; limited recreational activities, poor or limited work and education rehabilitation programmes, and an absence of, or limited contact with family members to name a few.

Image: Lusignan Prison 2019, Professor Martin Halliwell, University of Leicester

The Covid-19 pandemic and the measures taken (from March 2020 to early January of this year) to prevent and manage its spread in the prison environment, played additional roles in further alienating prisoners from the already limited activities which aim to contribute to their rehabilitation. It stands to reason, that an absence/suspension of these activities and programs (for approximately two years) as well as the pandemic itself, likely intensified feelings of stress and depression amongst prisoners.  Prison staff who too were subjected to strict Covid-19 guidelines including prolonged periods of confinement in the prison environment likely experienced increased levels of stress on their mental well-being.

Among the measures taken was the suspension of all religious activities and training programs within the prison. One of the key findings unearthed during the interviews conducted in 2019, revealed that religion is one of the biggest coping mechanisms utilized by prisoners, as attending religious services gives them comfort and relieves feelings of stress, depression and hopelessness. These findings are not unique to Guyana’s prison environment, as several studies conducted in other jurisdictions point to the effectiveness of religion in positively impacting the mental health of prisoners. Bradshaw and Ellison 2010, and Ellison et al, 2008 for instance, note that “Participation in religious activities can impact inmate mental health by promoting social support. Attendance at religious services has consistently been shown to be protective against mental distress.” 

The suspension of this vital stress-reliever and depression-combatant implies that many prisoners were likely to become withdrawn, easily agitated, disruptive, fight amongst themselves, experience appetite loss, and harbour escape and/or suicidal thoughts.

Given that the number of daily Covid-19 positive cases, both outside of and inside of the prison contexts of Guyana has drastically reduced from its peak of 1,558 on January 17 of this year to 5 cases as at March 25, 2022 (WHO), and also given that there is already inadequate mental help support in the form of counselling and therapy for convicted prisoners and that no such service exists for prisoners on remand, it is recommended that religious activities should be resumed, albeit in the contexts of social-distancing, sanitizing and mask-wearing guidelines. Conscious of the limited spacing available for religious worship due to massive overcrowding, small groups could be accommodated at various intervals in order to fulfil the right of prisoners to religious engagements which is vital to prisoners’ mental well-being as well as their rehabilitation.

With respect to training activities, those too were suspended for approximately two-years. However, between January 12 and 15 of this year, all of the Guyana dailies and Newscasts reported that 861 prisoners housed at the various prisons graduated in what is being referred to as “ground-breaking” training courses offered at the various prisons. The programs, prison officials’ note, aim to prepare inmates for life outside of the prison and to assist with their reintegration into society. The inmates had the opportunity to participate in a number of different training areas such as entrepreneurship, anger management, carpentry and joinery, family reconciliation, tailoring, culinary arts, art and craft, cosmetology, barbering, crops husbandry and veterinary sciences. The courses were extended to all prisoners including those on remand and also those who were convicted with several high-profile and special watch inmates taking the opportunity to rehabilitate themselves with the courses. (HGP Nightly News. January 15, 2022). Further, the “Fresh-start” program launched just last month by the Guyana Prison Service with similar programs and more, are all aimed at preparing prisoners for productive life outside of prison. (Stabroek News. February 18, 2022)

These programs must be commended for their role in fostering prisoners’ rehabilitation and likely reducing rates of recidivism as “the impact of education goes well beyond the walls of the prisons themselves, extending into the home communities of the incarcerated.” (North Western University Prison Education Program). Their importance in assisting the mental health of prisoners whose time would have been more than likely spent on unproductive activities which contribute to depression, anxiety, stress and other mental ailments cannot be overstated. Further, the inclusion of these programs to prisoners on remand must also be applauded for its progressiveness given that the current laws do not extend those privileges to remand prisoners, many of whom sometimes spend several idle years behind bars before sentencing or release.

Another of the measures taken was the suspension of the (external) work rehabilitation program. Prior to the pandemic, some prisoners were able to capitalize on work rehabilitation programs which not only helped in the provision of financial resources for them to supplement their prison-provided supplies, but also contributed to their families’ upkeep, occupied their time, helped provide meaning in their lives by providing them with something to focus on, and prepared them for post-prison productive life. North Western University Prison Education Program notes that work rehabilitation aids in preparing prisoners for life outside of prison as “reentry is far smoother and more successful for those who took classes in prison, especially insofar as gainful employment is one of the defining features of successful reentry.” The suspension of this privilege likely impacted the mental health of prisoners in a negative way.  Existing literature suggests that “inmate boredom caused by the lack of work and absence of recreational activities could be linked to depression and aggressive behavior.” (Tartoro and Leaster, 2009). Such behaviors could spread among the prison population thereby leading to prison riots, fires etc., all of which could make the work more challenging for an already thinly-stretched and over-worked prison staff.

The suspension of family visits was another measure implemented to prevent and manage the Covid-19 pandemic in Guyana’s prison setting. During the interview sessions with prisoners in 2019, many bemoaned the lack of/limited visits form their family members, while others were in praise for supportive family members who visit often and supplement their supplies. The complete removal of this social support privilege (though replaced by electronic means using the “Google Hangouts app” and/or telephone) likely increased feelings of depression and other mental health issues amongst prisoners. De. Claire Dixon, 2015 notes that “Visits help offenders to maintain contact with the outside world, promoting successful reintegration back into society and reducing recidivism. This scarcity of social support might make adjustment to prison more difficult, risking the use of maladaptive coping strategies.”

A further measure taken was the suspension of actual (face-to-face) court hearings, and the establishment of virtual courtrooms. While this measure must be lauded for its role in respecting the rights of prisoners to a trial within a reasonable time period as well as the possible reduction of time spent on remand, the positive mental-health benefits of actually leaving the confines of the prison environment for a trip (however temporary), to be in a setting with non-prisoners, to perhaps have a moment to socially interact with family members and their attorney, cannot be ignored.

While most of these measures impacted prisoners, their impact on the mental-health of prison staff cannot be ignored. Prison Officers were already in-line due to the prolonged March 2020 elections and they were forced to remain in-line (for time frames as long as two weeks) as a precaution against bringing the virus into the prison environment.  Devoid of the vital social interaction of family, being forced to work long hours in an overcrowded setting in the face of a massive human resource deficit, fearful of contracting a deadly virus in the contexts of agitated, violent, dangerous and scared prisoners are all factors which likely intensified the stress levels of prison staff.

It should be recalled that a number of undiagnosed prisoners, specifically those on remand, complained of experiencing bouts of depression and anxiety as a result of their incarceration. They also bemoaned the absence of competent mental health personnel on whom they could unburden themselves. Similar sentiments were expressed by officers and other prison staff who, like most prisoners, also use religion as a coping mechanism.

In light of the foregoing, and in the context of the almost- completed “modern” prison and proposed new prison headquarters at Lusignan, it is hoped that this facility would be equipped with a modern mental health facility and staffed by competent metal-health personnel, including therapists and counselors to assist prisoners (including remand prisoners who do not benefit from existing arrangements) and prison staff.

Such facility would greatly augment prisoners’ rehabilitation, prepare them for life outside of prison and ultimately reduce the rates of recidivism. For Prisons Officers and other staff, working in both one-on-one and group sessions with a therapist could help them cope with the challenges associated with a highly stressful, time-consuming, low-paying, and sometimes under-valued profession.

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Research during Covid: The three Rs (Reflexivity, Resilience and Rum)

By Members of the Research Team

Research never goes to plan. As academics, we all know this. It is also a fact we constantly share with our students as an expected part of academic research. Whether it is a failure to gain access, or find enough people willing to participate, we all face research challenges. Like most things however, Covid has added a new set of challenges to academic research (as well as opening up new opportunities), which our research team recently faced on a trip to collect data in Guyana. This reminded us all about the importance of the three Rs – Reflexivity, Resilience and Rum (rum is used to emphasise the importance of relaxation and researcher self-care as well as the importance of looking after each other when out in the field, something that is to commonly forgotten about in research). Subsequently, this blog outlines how Covid recently impacted upon our data collection plans and how we, the team of three (the three musketeers), responded to the challenges they faced, illustrating the importance not only of the team – its members, relationship, reflexivity, and resilience – but also of building the networks of support that became an invaluable source of help on this trip. Although often over-looked, networks of support – academic as well as practitioner – are invaluable as we travel the globe in person or virtually undertaking research and delivering research papers at conferences.

Covid-19: The Challenges

We have all had to face new challenges arising from the global Covid pandemic, and this includes research. The ever-changing requirements for travel alone can be a minefield especially when multiple destinations are involved. Do you need a PCR test? A lateral flow? A vaccine record? Although the team joked about the possibilities of Covid negatively affecting this research trip as we completed the usual research risk assessment form, we did not for one minute think that this would become our reality. As we navigated the various government requirements for travel to Guyana, and as transit passengers (currently there is no direct flight from London to Georgetown), we quickly became all too familiar with the challenges when these documents expire. Three days prior to travel our connecting flight was cancelled; due primarily to the knock-on effects of Covid the carrier was required to consolidate some of its existing flights. This delay in being able to fly to our final destination meant that our existing Covid PCR tests (taken in the UK before departure) became invalid while we were in transit. As a result, two hours before we were due to leave for the airport, we had to retest, and then found ourselves faced with the unenviable decision of whether to abandon the research trip as one of us tested positive. Despite the UK being only days away from dropping all restrictions the rules of quarantine in our transit destination, as in many areas of the Caribbean, remained in full force. After a frantic hour of rearranging hotel rooms, contacting our colleagues, updating the insurance provider, and ensuring the Covid patient had the basic necessities for a possible ten-day stay in isolation, the remaining two members of the team apprehensively continued on with the trip.

Reflexivity

We reflect on a daily basis in both our personal and professional lives, and the importance of being reflexive when undertaking research is well documented.  It facilitates self-awareness and allows researchers to respond to unexpected challenges and situations in appropriate and ethical ways. It also allows researchers to improve and build on instances of good practice as well as to learn from their mistakes. Thanks to Covid we had to revisit and alter our itinerary for the trip. This was mainly owing to the fact that as a team we were now lacking in the expertise required for certain elements of data collection, namely the interviewing of prisoners and a focus group with their families. The added scrutiny that this placed on our planned activities ensured that we worked together, albeit remotely, to create a workable plan. As a result, two of the most invaluable research tools on this trip quickly became Zoom and WhatsApp, as we adapted to the circumstances to ensure the trip was a success. This technology enabled us to further refine our research questions and aims as we prepared for the interviews with our colleague in isolation. Due to the circumstances, we also made the decision to employ a local researcher with experience of working with prisoners and their families. In addition to helping with the language barrier (many speak a variation of English known as Guyanese Creole) this also had the unexpected benefit of producing more in-depth data as the prisoners connected with the interviewer over their shared experiences of living in the same country. Furthermore, where possible one of our key activities – a session in which we co-created a new tool that will enable the Guyana Prison Service to gauge the experiences of prisoners and officers – was moved to an online session. This had the added benefit of enabling officers, and members of our team, from a wider geographical area to take part. This reflexivity not only ensured we were able to successfully carry out our designated activities, it also strengthened our relationships with our partners, both in Guyana and the UK, as we worked together to overcome difficulties.

Resilience 

Although not a fan of the word resilience – which seems to have become a contemporary buzz word – it best describes the reaction of the team members to the situation they found themselves in during this research trip. Instead of letting it get them down they did their best to make the best out of a bad situation (thanks to being reflective), which actually resulted not only in a very productive data collection trip, but also one that contained some genuine moments of comradery, good humour and bursts of hysterical laughter despite the adverse and at times disappointing situation that faced us. As Charles Darwin exclaimed/outlined: ‘It is not the strongest of the species that survive, not the most intelligent, but the one most responsive to change’. Sentiments that stand true for the recent predicament we, the research team, found themselves in and how we chose to respond to it.

We had always planned for Covid, in that we decided that three persons would go on this trip, so that in the event of sickness and isolation the others could complete the research activities. Despite our pact that if one of us tested positive for Covid then the team would carry on without them, like many plans in life, you never really expect them to happen so, the reality and its accompanying shock was somewhat overwhelming and definitely unexpected. In fact, the first 5 minutes after the initial news of the positive test was spent asking the medical team if they were joking, as is often the way in the Caribbean. It was however no joke. One of us had tested positive and was going to have to stay behind in transit and in quarantine in a different country on their own, while the remaining two went on to Guyana. This is when true teamwork and collegiality really come into play as everyone (bar the infected who had to stay outside) pulled together to rectify/address the situation in the 2-hour window before everyone was due to fly. A team member in the UK liaised with our travel agent. We called and discussed the situation with our partners, and later on the British High Commission in Guyana, with whom we have built excellent working relationship over the past few years.

Once the initial shock of one of us testing positive for Covid had worn off the team revisited their itinerary and data collection plans for the forthcoming week to ensure everyone was still involved where practically possible/needed. Despite the initial disappointment, and the frustration of not being able to go and collect data in Guyana, the Covid patient endeavoured to come up with an exit plan until they heard from the Ministry of Health. The idea was to rest up, clear the virus and follow the team on after 5-days. However, this was not to be. Instead, the Ministry made it quite clear that the minimum isolation period was 10-days, although the patient was given a hotline number to call. After a frustrating day with 7-hours spent just redialling but being unable to get through on the telephone number provided by the Ministry of Health, the Covid patient also explored other avenues of help/support to ascertain the situation. It was at this point that the importance of networks was emphasised: the team was in touch with the High Commission of Guyana, and it was willing to help. Once the Covid patient knew that they were quarantined for 10-days and the research team had created a new itinerary for the trip, it was easy to plan their time and make the best use of the situation both to recover but also to catch up on some of the background project reading, reading the interview transcripts and coding frames as well as numerous other tasks that often get postponed.

The team debriefed every morning and/ or evening where practicably possible not only to catch up on the day’s progress but also to relax, and jolly each other along. The daily debriefs with their colleagues in Guyana, including meetings where the Covid patient Zoomed in, also helped to ensure that they felt part of the project and part of the team. It also kept them busy and helped the time to pass quickly, with some days feeling quite busy despite not leaving the hotel room. We had a job to do, and Covid was not going to stop us. We just had to get on with it.

Rum

Undertaking research in the Caribbean is challenging. Although, Guyana is often seen by many as a desirable research location, many often fail to consider the subject matter of our project, the political/cultural sensitivities, and the fact that despite being a desirable destination, our time is often spent in old colonial prisons – some of which have been deemed to violate the United Nations Minimum Standards for the treatment of prisoners – talking to prisoners, staff, communities and families about often upsetting and traumatic experiences, which the research team then have to process and deal with. It is in this context that the importance of self-care and looking after each other comes into play. Although there are more formal channels of support offered to everyone working on the project, there are also informal support practices that have been an integral part of this research project, which is also reflected in the relationship of the team.

The research team on this project are very close, familial like even – but without much of the negativity associated with families. We all genuinely support each other. There are no egos. There is no competition. Instead, there is clear leadership, collegiality and care. Whether it is coffee and cake or catching up over a meal, regular debriefs, relaxation and humour have always been an important part of the team’s R and R, emphasising the importance of relaxation and researcher self-care as well as the importance of looking after each other when out in the field, something that is to commonly forgotten about in research. It was this which got us through what one of the researchers described as the most difficult situation in their 25-year career. With pride, we returned to the UK together, having completed all our planned activities and with our research team stronger than ever before.

Acknowledgements: The Covid patient would like to thank their two travel/research companions, as well as the team in Guyana, and everyone that looked after them, especially the High Commission in Georgetown in Guyana, and the Chief Medical Officer of the transit country, who went above and beyond in their support.

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Enhancing Mental Health Communications in Guyana

Martin Halliwell

Two of the trickiest aspects of mental health care to get right are psychiatric diagnosis and public health communications. The challenge for health providers around the world is to maintain consistent standards of classification for mental health and illness without imposing a rigid framework that overlooks social determinants and cultural specificities. Similarly, while public health education is part of the machinery of government – advising citizens about healthy behaviour or instructing them what to do in emergencies – this top-down model sometimes overlooks the importance of horizontal modes of communication within and between communities.

In this blog, I reflect on these two different types of health communications – the first directed towards health care providers, the second towards the public – to think through implications and challenges for developing a dynamic model of public health in Guyana, especially at the intersection of mental health and incarceration for a multicultural society.

Mental Health Diagnostics

Guyana, like the Caribbean as a whole, uses the International Statistical Classification of Diseases and Related Health Problems (ICD) for its diagnostics. This is a globally held standard for both physical and mental health, except for in the United States and parts of Canada, where the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM) has more specifically informed psychiatric classification since the early 1950s. First established in Paris in 1900, the ICD has gone through 11 editions in the 120 years since and is closely wedded to health standards upheld by the World Health Organization (WHO). This compares to the DSM, established by the American Psychiatric Association in 1952 to provide consistency to the hitherto psychiatric categories deployed in the medical department of the US Armed Forces. DSM has expanded dramatically through five editions, moving away from psychoanalytic language in the third edition of 1980 to develop an organic framework for describing psychiatric disorders and, since 1994, a multi-axial system for understanding the various causes and components of mental illness.

The most obvious commonality between ICD and DSM is the word ‘disorder’ for describing a group of conditions that includes mood disorders, neurotic disorders, schizophrenia, personality disorders, neurodevelopmental disorders, and mental and behavioural disorders due to using psychoactive substances. As well as variance in scope, there also some key differences between the two systems. In a July 2014 article, Peter Tyrer points to the global reach of ICD and its attention to primary care in low and middle-income countries, in contrast to DSM’s focus on high-income countries and its specificity as a psychiatric manual. The ICD also stands apart from DSM’s links to health insurance, which determines whether a patient in the US with a diagnosed condition is eligible for co-pays, Medicare or Medicaid. Given its global reach and flexibility as a system, researchers like Cary Kogan and Peter Tyrer hope that ICD will eventually replace DSM in Canada and the US. Published in June 2018, for adoption by member states from January 2022, ICD-11 has moved away from a categorical to a dimensional approach to mental, behavioural and neurological disorders, offering a more nuanced account of a patient’s changes over time and seeking to integrate traditional medicine.

The main problem about both diagnostic models is that psychiatrists deem ‘disorder’ to be a neutral term referring to a disequilibrium or impairment within the human organism, yet from an analytical sociological lens it is a heavily coded word shaped by social determinants and cultural experiences. In clinical terms, diagnosing a disorder can sometimes lead to relief for a patient. Just as often, though, it can lead to the medicalization of a person who might be experiencing a temporary fluctuation in mood and behaviour; or who needs interpersonal support rather than medical treatment; or whose environment is not conducive to the best of health.  Crucially, sometimes the diagnosis of a major disorder can be stigmatizing and can resonate more forcibly within certain demographic groups. For example, there were numerous studies in the post-World War II period that linked ‘disorder’ to the perceived behaviour of Black males, with discourses commonly slipping fluidly between health, home and society. It is easy to see how the term becomes mired in ideology if a disorder in or of the self mirrors a breakdown in family or social order. This insight has led critics like Daryl Michael Scott in Contempt and Pity (1997) and Jonathan Metzl in The Protest Psychosis (2010) to critique what they see as the invidious racial coding of this kind of psychiatric language.

This does not mean that we should dismiss ICD and DSM as being part of the micropolitics of the state, especially as ICD seeks to cross borders and promote health access globally. Through their numerous revisions, the two manuals have attempted to balance questions of scale and duration and take into account multiple factors before reaching a diagnosis. However, even if we embrace the progressive spirit of ICD, the consequences of a clinical diagnosis for treatment and operational practice are subject to significant variations in national health infrastructures across global regions. This is especially the case if we think about the availability and cost of certain therapeutic drugs, if and how comorbidities are treated, and to what kind of interpersonal care a patient has access – whether it is in a state or private facility or within an outpatient setting. Used crudely, an ICD or DSM diagnosis can be life transforming in the wrong way. A diagnosis of a major disorder, particularly among some demographics, can lead to custodial care or a course of drugs that might not be in the patient’s best interest, leaving social determinants largely untouched.  

Public Health Communications

In contrast to diagnostics, public health communications seem to be, on the surface, less controversial. Surely, the balancing of official communications at state level and a sensitivity to the needs of a particular community offers a balanced way forward for health officials. This balancing of vertical and horizontal approaches is one that Chelsea Clinton and Devi Shridar uphold in their 2017 book Governing Global Health, aligned with WHO’s view that health is a right and not a privilege. The Pan American Health Organization, established in 1902, embodies the views of the WHO within the Americas, and in 2018 it mapped out a sustainable health model through to 2030, which places as much emphasis on human resources and crisis response as it does on access to medicine and the resilience of health systems. On this view, the most effective kinds of public health communication are less about the balancing of vertical and horizontal axes, and more about promoting a holisitic understanding of physical and mental health as part of an ecosystem of well-being.

This PAHO model shares with a ‘One Health’ approach a recognition of the interconnected nature of human health and animal and planetary health. Yet, this does not necessarily provide public health workers with easily distributable public health information. This is especially true when budgets are tight, or where there are barriers of language and literacy, or where some communities are hard to reach. This last factor is true of Guyana, which centres its state health apparatus on Georgetown and the seaboard, leaving a number of rural regions and localities (in the interior and close to the borders with Venezuela, Brazil and Surinam) underserved in terms of access to well-staffed health services, instead relying on sparse health units operating on a part-time basis.

On visiting all of Guyana’s prisons in April 2019, in collaboration with the Guyana Prison Service and Guyana’s Ministry of Public Health, members of our research team were struck with how patchy and out-dated health information was, and in some prisons was lacking altogether. Where we did see posters or leaflets in the prison system, or in allied medical facilities, they focused almost entirely on physical health and disease, such as malaria, anaemia or HIV/AIDS.

Only occasionally did we see very basic information on mental health. At the National Psychiatric Hospital near New Amsterdam Prison we saw three versions of the 2017 PAHO World Mental Health Day poster ‘Depression: Let’s Talk’, representing different ethnicities and genders (as illustrated here), despite the conditions of the hospital ward being almost unbearable and not conducive to talk therapy. We also saw a ‘Break the Silence’ poster on domestic sexual violence in the prison hospital at Mazaruni (a men’s prison), with an emphasis on abused women speaking up against hidden crimes that are often covered over, and with the tagline at the bottom of the poster: ‘A real man can control himself’.

Recommendations for a Dynamic Public Health Model

Whether or not health information in communities and prisons are improved and updated, it may still overlook the WHO’s view that health is a dynamic process that needs underpinning by care-oriented facilities, not simply a textbook issue to diagnose and treat. The implications of the WHO and PAHO model are that public health communications should not just be offered to a community as a service, but be embedded in that community in a co-owned space in which prevention is prioritized over treatment. We saw an example of this co-ownership in Georgetown, with the participation of many students in a World Suicide Prevention Day march on 10 October 2019 (see my December 2019 blog), alongside the Ministry of Education’s efforts to integrate classes on health and family life into school curricula from age 5 upwards. Nevertheless, there are three key aspects of an integrated public health model that might be usefully adopted.

The most obvious aspect is for an updated and more nuanced set of posters, leaflets and online resources about the signs and symptoms of mental distress that might help to deepen social views of mental health and would support the work of health officials in terms of education and outreach. It presents an opportunity, for example, to ensure health education among male prisoners does not simply skew towards anger management, as is the case in Guyanese prisons. This opportunity might link to a broader programme of prisoner rehabilitation classes, including sociological, historical and literary topics, in order to help inmates better understand their behaviour and to learn about harm prevention from a wider frame of reference.

Secondly, we could point to the need to ensure that public health literature brackets off discourses of ‘right behaviour’ understood in moralistic, religious or legalistic terms – which is particularly tricky when it comes to countries that criminalize recreational drug use across a broad spectrum. Such a move needs to be carefully considered and managed, in order to focus less on punitive discourses and more clearly on self-care, care of others, and how to access health services. The independent Drug Policy Alliance in the US, established in 2000, offers a model of this, given that one of its key values focuses on ‘empowering youth, parents and educators with honest, reality-based drug education’ that moves beyond ‘fear-based messages and zero-tolerance policies’.

A third important area would be to ensure that prisoners, as well as patients treated for lengthy periods in inpatient facilities, have broader access to two-way communications beyond the institution. Within the US prison system, one example is the Restorative Radio Project, run by Sylvia Ryerson, a researcher at Yale University. This project enables families of prisoners in Appalachia to share ‘audio postcards’ and music with imprisoned family members via toll-free public radio – and there is potential for inmates to reciprocate with their own audio postcards. Such an opportunity can help alleviate loneliness, isolation and a loss of self-esteem among prisoners, as well as what Johanna Crane and Kelsey Pascoe call the ‘chronic health condition’ of incarceration itself.

This radio-facilitated model can be linked to larger step changes, such as Yale University’s efforts to expand prisoner education via for-credit courses with the aim of imagining ‘a future beyond mass incarceration’ and ensuring that prisoners and empowered and educated rather than being treated or managed. The fact that this is an elite Ivy League institution with a $1.5 million Mellon grant to develop an educational initiative that dovetails with criminal justice reform takes us back to structural questions about capacity, economics and racism which are never easy to resolve. However, the initiative also speaks to other national models, such as in Norway in which all prisoners have a right to education and a commitment to rehabilitation through positive experiences.

Concluding Thoughts

There is much promise at state level in Guyana of meeting the challenge of tackling the burden of mental illness, as the development expert Ramesh Gampat recommended at the end of his two-volume 2015 book Guyana: From Slavery to the Present. In addition to the aim of the Ministry of Public Health to reduce suicide rates and destigmatize mental illness with the aid of WHO’s mhGAP Intervention Guide for use in non-clinical settings, we saw evidence of art therapy practised at Mazaruni Prison, alongside (patchy) library material and outdoor recreational facilities in most of Guyana’s prisons. This reveals a growing awareness that health and well-being are multifaceted.

The challenge remains for us, though, across the intersecting global communities of the early twenty-first century, to imagine a future where public health information is a shared resource rather than an arm of government that flourishes or withers on the strength of budgetary priorities.

Martin Halliwell is Professor of American Studies in the School of Arts and a research expert at the University of Leicester. His new book American Health Crisis: One Hundred Years of Panic, Planning, and Politicsis published by the University of California Press. He would like to thank Clare Anderson, Queenela Cameron, Dylan Kerrigan and Kellie Moss for their valuable help in developing this blog.

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Substance Use in Guyana: The Cannabis Conundrum

Traditionally Guyana’s approach to drugs has been punitive, with imprisonment being used as a tool to eradicate drug use and supply, which includes cannabis. Cannabis users in Guyana still face a mandatory prison sentence of three years for the possession of one joint (a cannabis cigarette). However, this policy has failed and like many other countries, Guyana is proposing to remove custodial sentences for small amounts of cannabis (30 grams or less). Last year the government made the first steps towards changing the law by drafting amendments to the Narcotics Drug and Psychotropic Substances (Control) (Amendment) Bill 2015. Although nothing has changed yet, and the possession of cannabis remains illegal, the proposed changes show that Guyana is moving with international opinion and implementing similar practices as those adopted in other countries, including those in the Caribbean. The implementation of a prison sentence for personal use of cannabis has been described as excessive and disproportionate and has been shown to have a negative impact on the life chances, travel and future careers of those prosecuted and imprisoned under these laws. Therefore, this blog focuses on some of the issues at stake in the shift in Guyana towards a less punitive and more rehabilitative treatment orientated approach to substance use, particularly in relation to cannabis.

Substance use in Guyana has been identified as a problem in the National Mental Health Action Plan (NMHAP) and the National Drug Strategy Master Plan 2016-2020 (NDSMP). Both include the use of legal substances like alcohol, tobacco and prescription medications alongside illegal substances like cannabis, cocaine and ecstasy. It is acknowledged that in Guyana, there is a need to better understand the use of substances and address the number of shortfalls in responding to substance use. These include inadequate service provision, inter-sectorial and multi-agency collaboration; inadequate treatment and rehabilitative facilities; and insufficiently trained personnel. As with most other countries the substances most widely used in Guyana are alcohol and cannabis. These are the most popular substances among the general population but also among those with more problematic patterns of substance use/dependence like prisoners and/or those accessing drug treatment. Cannabis use has been linked with psychosis and mental ill-health in Guyana, while evidence has shown that alcohol plays a prominent role in suicide, which has also been identified as a public health issue in Guyana (see Halliwell, 2019). Alongside cannabis and alcohol, cocaine and its derivatives, particularly crack, are also prevalent among those with more problematic patterns of substance use/dependence. However, it is cannabis, rather than other narcotic substances that dominates the Guyanese statistics and has been subject to much scrutiny over the last decade.

Like many other countries across the globe the legal status of and laws on cannabis have been subject to much criticism, protest and debate in Guyana; a country where a minimum mandatory sentence of three years imprisonment is still imposed for possession of a small quantity of the drug. In fact, the laws prohibiting drugs in Guyana and other Caribbean countries, particularly pertaining to cannabis, have been described as draconian, ‘ineffective, incongruous, obsolete and deeply unjust’ (CARICOM, 2018). This is largely due to the disproportionate sentences imposed in Guyana for the possession of small amounts of cannabis for personal use (5 grams) and the low thresholds utilised for the presumption of drug trafficking (15 grams) in a country where cannabis is grown and used by approximately 5% of the population every year.

Cannabis is widely used across the Commonwealth Caribbean and throughout history has been used culturally, religiously and medicinally around the globe. Despite many of these cultural and religious practices originating in Asia, the use of cannabis also has a long history among Caribbean peoples and countries, including in Guyana (formerly British Guiana). The production, use and prohibition of cannabis in British Guiana was intertwined with the history of colonialism, enslavement and immigration. In fact, cannabis was introduced to Guyana post-emancipation by East Indian indentured labourers (CARICOM, 2018). Much of the early legislation passed to control cannabis in British Guiana – the 1861 Ordinance to Regulate the Sale of Opium and Bhang (an edible form of cannabis that is also an integral part of Hindu rituals and festivals) and the 1913 Indian Hemp Ordinance of British Guiana – can be attributed to the cultural practices of Indian indentured labourers, and the implementation of international treaties that deemed cannabis a dangerous drug, despite persuasive evidence suggesting the contrary. The role of cannabis in religious practices among Caribbean peoples, particularly among Rastafarians, is also well documented. It is also the Rastafarian community who have been fighting for cannabis law reform in Guyana. They regard cannabis as a holy herb, a gift from God that has medicinal and spiritual benefits and believe they should be exempt from the laws prohibiting it. Cannabis laws have been shown to disproportionately affect poor, minority communities that are marginalised, particularly when it comes to the offence of drug possession and trafficking.

There are high levels of incarceration for drug offences in Guyana. In 2017, the majority of individuals charged and convicted with drug possession by Guyanese authorities were for cannabis (93% and 90% respectively), with just under a fifth (18%) of these people being under the age of 18 years old. The majority of those charged (88%) and convicted (81%) of drug trafficking was also for cannabis. In fact, drug offences (both possession and supply) are the second most prevalent crime for which prisoners are arrested for in Guyana, after intentional homicide or murder. This is particularly true for females; despite comprising less than 5% of the prison population, the majority of women in Guyana are incarcerated for drug offences (54%), particularly for drug trafficking (GUYDIN, 2017; Sarsfield and Bergman, 2017). In fact, just under a quarter (21.3%) of all prisoners are in prison for drug possession or trafficking, and drug offenders have the third highest recidivism rate (21.6%). Thus, drug offences, which mostly relate to cannabis, are contributing to an already overwhelmed, overstretched and under resourced prison system (USDS, 2019). The issue of non-custodial sentences for the possession of cannabis and its subsequent overcrowding were factors that led to the 2017 fire started by prisoners in Georgetown Prison, which killed 17 prisoners (see Ifill, 2019).

Not only are a significant proportion of the prison population incarcerated for drug offences, prisoners in Guyana tend to have higher rate of substance use than the general population. Just over a fifth (22.7%) of prisoners in Guyana admitted to using alcohol and/or drugs in the last month while in prison, with the majority using cannabis (84%) and alcohol (33%) (Sarsfield and Bergman, 2017); substance use was found to be highest among those held in Lusignan (44%) and Timehri (42%) prisons. Despite being rife in prison, drugs have a negative impact on both staff and prisoners. The use and supply of drugs in prison, and the debts arising from the drug trade contribute to high levels of violence, corruption, intimidation, self-harm and mental ill-health. While drugs are brought in by prisoners and their families, prison officers are also reported to supply drugs and other contraband to prisoners (see Ifill 2019). In fact, last year, Guyana’s Prison Service (GPS) confiscated 12.81 kilograms of cannabis indicating the problem of maintaining the levels of security necessary to stop drugs entering Guyana’s prisons. There has also been a move by GPS towards a more rehabilitative approach that proposes more drug treatment for prisoners. However, there are a number of limitations delaying the implementation of drug treatment provision across Guyana’s prisons (e.g., the infrastructure, limited resources and inadequately trained personnel). Currently, the Drug Demand Reduction Unit of the Ministry of Public Health has drug and alcohol counselling programmes in the Timehri, Mazaruni and New Amsterdam, Female prison. There have also been steps taken to look at alternatives to incarceration for drug dependent, nonviolent offenders in Guyana in line with United Nations Special Session on Drugs Outcome Document and the US-sponsored CND resolution (2016). As a consequence, Guyana is piloting a Drug Treatment Court in Georgetown, which aims to divert drug users out of the criminal justice system and into treatment, which has been outlined in the new drug strategy for Guyana.

In fact, the new Guyanese National Drug Strategy Master Plan (NDSMP) 2016-2020 was ‘triggered by the need to bring it in line with most recent national and international dynamics of the drug problem and built on Guyana’s previous drug strategies (NDSMP 2005-2009 and NDSMP 2014-2018). The plan outlines national drug policy, identifies key priorities, assigns responsibilities and delineates the operational plans of each government department involved in implementing the NDSMP, which will be overseen by National Anti-Narcotics Agency (NANA) that was established in 2017.

The new strategy emphasises a holistic Public Health approach and the Guyanese government are putting measures in place to improve the provision of drug treatment at all levels of the healthcare system. Substance use in Guyana is largely dealt with by utilising a public-private, holistic multi-agency approach to drug prevention and treatment, although fostering a rehabilitative culture in prison is also a part of the drug strategy. Currently the Georgetown Public Hospital, Psychiatric Unit provides outpatient treatment services, the Ministry of Education delivers drug education in schools, while two NGOs (Phoenix Recovery Project and the Salvation Army Men’s Centre) provide inpatient treatment for substance use, which utilise the 12-step model; in fact, in the new drug strategy the Phoenix Recovery Project and the Salvation Army will get a subvention to aid in carrying out their services and increase capacity. Substance users are not only detained in Guyana’s prisons but also in the National Psychiatric Hospital, which is used to treat those suffering from substance induced psychosis and other substance related mental health issues. Last year, two-thirds of the 180 in-patients at the National Psychiatric Hospital were suffering from substance induced psychosis, with nearly three-quarters of these identifying as cannabis users. This has led to concerns being raised about the removal of custodial sentences for cannabis possession by some of the country’s psychologists working in this area.  

                             NANA in Guyana (Photograph: Martin Halliwell)

While the legal status of cannabis remains under debate in Guyana and the piloting of Drug Treatment Courts gets underway, the Guyanese government have made it clear they are not ready to legalise or decriminalise cannabis as recommended by the CARICOM Commission on Marijuana (CARICOM, 2018). Although some might argue the proposed initiatives do not go far enough, the removal of custodial sentences for small amounts of cannabis will mean fewer people are being sent to prison for non-violent drug related offences imposed by laws that have been described as ‘draconian’ ‘discriminatory’ and ‘outdated’. It will also help to alleviate the overcrowding currently experienced in Guyana’s prisons and the subsequent inhumane conditions that arise from said overcrowding (see Ifill, 2019). However, these amendments have been with the National Assembly for years with little progress being made either way to solve the current cannabis conundrum. Although the new drug strategy proposes ‘offering treatment, rehabilitation, social reinsertion and recovery support services to drug-dependent criminal offenders as an alternative to criminal prosecution and imprisonment’, this approach is extremely costly. To treat someone at the Phoenix Recovery Project costs $60,000 a month compared to the $27,884 – $40,416 a month it costs to keep someone in prison without access to sufficient rehabilitative services and reintegration programmes, which also has an impact on reducing recidivism and relapse. Despite the new rehabilitative focus proposed by the new policy, treatment resources for drug use remain limited and costly. Therefore, if Guyana is to successfully achieve the aims set out in the current drug strategy these initiatives will not only need adequate funding, but also infrastructure, resources, staff and political support. Although drug courts are not without their criticisms, they pose a potentially preferable alternative to a custodial sentence in Guyana’s already over stretched prison system, which has been described as ‘harsh and potentially life threatening’ (USDS, 2017). Even though the debate surrounding the legal status of cannabis in Guyana continues and there is no clear indication if the custodial sentences will be removed for possession, while we await the results on the impact from the piloting of Drug Treatment Courts, there is clearly a new era in drugs policy emerging in the nation today.

Tammy Ayres is a Lecturer in the School of Criminology, University of Leicester, UK.

The author would like to thank Tiffany Barry (Head of Guyana Drug Information Network and NANA) for her comments and input on an earlier draft of this blog.

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Mental Health and Suicide Prevention in Guyana

World Mental Health Day was first observed on 10 October 1992. At that time, globally, not only was mental illness commonly associated with social stigma, but it was often unhelpfully and sometimes dangerously elided with cognitive and developmental disabilities. In 1992, the authors of the ICD (the International Classification of Diseases, then just into its tenth edition) and the DSM (the Diagnostic and Statistical Manual of Mental Disorders, favoured in the United States, then awaiting its fourth edition) were beginning to understand that mental illness spans a range of multiaxial conditions that require nuanced clinical diagnoses. Both classification systems recognized that mental illness has an organic cause but is frequently exacerbated by environmental pressures.

World Mental Health Day, as it was conceived just over a quarter of a century ago, has been focused on raising consciousness about mental health and in ensuring mental illness is treated equally to physical disease. It has also provided a platform to urge governments to adopt policies that integrate individuals who have been or are being treated for mental health conditions into community life, rather than long-term hospitalization in often inadequate state or county facilities. At a time when Western nations, such as the United States, are witnessing more than 25% of its citizens being treated for diagnosable mental health conditions, and when a further 25% are likely to suffer from depression during the course of their lives, it is hard to know where to begin to deal with experiences that stem from multiple factors, some biological and others environmental.

The ICD was adopted in the Caribbean region as the official diagnostic manual by the Pan American Health Organization prior to the independence of many of its nation states. But, partly due to the colonial histories of the region, including a tense relationship with Western medicine, the topic of mental health has only emerged as a priority across the region in the last decade. During the 2010s, CARICOM governments and advocacy groups came to realize that heightened awareness is just part of the solution to what the World Health Organization (WHO) calls a “global health burden” that requires sustained funding, a robust healthcare infrastructure, and treatment courses that integrate drug interventions with person-centred therapy. In Guyana, where there are only 10 trained psychiatrists (3 of them newly graduated in autumn 2019) and limited hospital provision for mental health care (centred on Georgetown Public Hospital), and where mental, neurological and substance abuse disorders are prevalent among the nation’s prisoner population, this is a difficult task.

A starting point for the Guyanese government has been to increase funding for the Ministry of Public Health to ensure that its Mental Health Unit (formed in May 2016) has the physical infrastructure to identify, document, and consciousness-raise about mental health. Led by Dr Util Richmond-Thomas, the Mental Health Unit has used capital development funding (the mental health budget was $105 million Guyanese dollars in each of 2017 and 2018, compared to $17 million GYD in 2016, followed by $43 million GYD in 2019) to better integrate with social care services, to ensure that it is representative of Guyana’s rural regions, and to prioritise specific causes, such as the 2019 focus of World Mental Health Day on “Mental Health Promotion and Suicide Prevention”. This theme dovetailed with World Suicide Prevention Day, which had its own dedicated date a month earlier, on 10 September, organized by the International Association for Suicide Prevention in collaboration with WHO. While Dr Richmond-Thomas recognizes that only a coordinated effort will reduce the health burden of suicides in Guyana, numerous conversations during my two visits to Georgetown in April and September 2019 give me a sense of hope that the national health narrative is on the turn.

Self-harm and suicide rates in Guyana were one of the worst globally in 2017 and they have become a high priority for its Ministry of Public Health, set against the recognition that 79% of suicides occur in low- to middle-income countries (according to recent WHO statistics). Part of the solution is for citizens to feel that they can, without stigma or shame, ask for help in crisis situations, though social and gender coding means (as is the case in parts of the UK and US) that mental health challenges for men and boys often goes undetected until it reaches crisis point.

Another element of the solution is to try to reduce, if not eliminate, social isolation that many advocacy groups identify as the major cause of depression globally but is often a trigger for suicidal ideations. While no national healthcare or social services system is expansive enough to prevent all suicides, the fact that a high prevalence of cases occur in the rural regions of Guyana where access to health facilities is limited (particularly amongst farming communities, where a common means of suicide is the ingestion of agrochemicals), and that mental, neurological and substance abuse disorders are common in Guyana’s jails, are illustrations of the importance of such developments.

On World Suicide Prevention Day 2019, following a 500-person march through the streets of Georgetown, Util Richmond-Thomas delivered a powerful speech titled “Working Together to Prevent Suicides” at the National Cultural Centre, focusing on the complex interplay of factors that contribute to mental health challenges and the need for public-private partnerships to help promote anti-suicide messages. The statistics about the reduction in documented suicides in Guyana in 2018 are positive, reducing from 184 suicide-related deaths nationally in 2017 to 141 documented deaths from suicide in 2018 (according to Ministry of Public Health statistics) out of a population of 747,000. The success of reducing this prevalence was also evident in the awareness of the young Guyanese marchers on 10 September on their two-mile march through the streets of Georgetown. It was an uplifting experience for me, but I was left to wonder whether the message and resources are getting through to the 25% of Guyanese living in rural regions away from the Atlantic coastline.

Given that mental health challenges are part of the fabric of everyday life, only medical interventions via inpatient treatment or a course of prescribed drugs are easy to document and trace. Unless suicide has a clear cause it is also difficult to know if a more accessible health centre or more visible public health information in scattered communities or better job prospects would make a difference overall. The truth is that all these measures would help. As other countries have found, no single-step solution to tackling debilitating mental health conditions is likely to work in the long term, while drug interventions might only temporarily mask complex underlying issues.

There is a temptation to turn to faith for the answer to the despair that can sometimes leads to suicide. This faith can take lots of forms. It can be the faith of organized religion, which is particularly important for Guyana, a country in which 63% of its citizens (according to the 2012 Census) are Christian, 25% Hindu and 7% Muslim. It can be faith in a scripture or a faith in a community of believers, but it is important that it also a faith attuned to the complex socio-economic pressures that might sometimes strain against what these three great religions deem as right living. Or, on a secular level, it can be the faith that life goes on despite hardships, linked to the belief that all individuals can be agents of change, especially when they share and work collaboratively.

Reflecting on the 2019 Suicide Prevention Day March in Georgetown, I was particularly struck by a young University of Guyana student, Dwright Ward, studying in the Department of Communications, who proudly held the banner “You have the power to say this is not how my story will end!” I have looked at this photograph a number of times since that day – a bright young Guyanese student with a powerful message – and I have thought about both its cultural specificity and its transnational resonances because it puts into action the 2018 theme of “Young People and Mental Health in a Changing World”.

On that day of 10 September 2019, so many young Guyanese were willing to put hope and awareness over their studies and their work. This image offers hope for an open narrative that can help safeguard mental health, though it can never guarantee it. And the image offers a powerful symbol for a young nation that recognizes only a sustained, collaborative and multi-pronged approach will shift the dial on suicide prevention long term.

Guyana Inter-Agency Suicide Prevention Helpline: +592-600-7896, guyagency@yahoo.com

Martin Halliwell is Professor of American Studies and Head of the School of Arts, University of Leicester, UK. All photographs taken by the author.