A Lebanese Healthcare Milestone: Mental Health Is Now Covered By The Ministry Of Health

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One of the major problems that psychiatry patients in Lebanon face is having their mental health disorders not recognized by any insurance or governmental payment agency, which forces them to foot medical bills that can reach astronomical rates very fast.

There are next to zero insurance companies in the country that cover anything mental health related, even though about a quarter of the Lebanese population can be diagnosed with one mental health disorder or another.

On Friday, as reported by The Daily Star, Minister of Health Ghassan Hasbani announced that his Ministry will now, and for the first time ever in Lebanon, begin to cover mental health under its care plans which are available for all Lebanese citizens.

This isn’t the only accomplishment to be attributed to the Ministry. Hasbani also declared that eight mental health institutes will be created by the ministry for treatment and administration of care, as well as more focused training of professionals in the field.

“The Ministry of Health will begin to cover mental health as part of a comprehensive medical plan, managed by the Primary Health Care Department and supported by the World Bank. We will work on curing it of these issues that can frustrate and cause damage to citizens.”

To say how important such steps are in the Lebanese healthcare sector is not enough. Mental Health has always been considered a taboo in Lebanese society, even if perceptions are ever slowly changing. It hasn’t been a year that we spoke about a young Lebanese girl committing suicide because she had become so clinically depressed and unable to seek help, because such help is not as easy to come by as it should.

This measure by the MoH will save lives, and further improve the level of medical care that we can administer as doctors to our patients in this country, by lessening the fragmentation of care that arises when you have an entire facet of medicine without any form of coverage.

The next step that Minister Hasbani and the ministry should undertake is to reform insurance laws in the country to get insurance companies not to stigmatize mental health, by having them cover it like any normal illness that they’d cover in any circumstance.

I commend the ministry of health for this step, with hope to see more like it from other facets of the Lebanese government. It’s a very important step, and an essential one at that, in our fight against the stigmatization of mental health, as we try to remove it from our long list of Lebanese taboos.

Mental Health: The Silenced Killer of Lebanese Youth – إلى نورهان المشاكسة

Nourhan Hammoud

Nourhan Hammoud was Lebanese girl in her twenties, from the South, full of life, her friends had never known her to be fragile, non-smiling or weak. She dreamt of the days when she would leave this country that brought her down, but the afterthought of her mother kept her here.

On August 29th, 2016 – the weights of this world proved too much for Nourhan Hammoud and she decided that ending her own life willingly was the easiest of choices.

Nourhan was not smiling all the time. She was wearing a veneer of strength in a society that viewed her ailment – depression – as nothing more than something of which one could “snap out” of. But depression is never something one could “snap out” of. It’s the weight of a thousand boulders on your shoulders, oppressing your chest, suffocating every breath out of your lungs, as your lips turn into the shadow of a smile to let your friends be fooled into thinking you are okay.

Our ad agencies make fun of anxiety. Our society makes fun of depression. We ridicule schizophrenia. We fear bipolars. We look at these people who are ill and call them “insane,” put them in a corner, chastise them, segregate them, drive them away instead of in.

Nourhan committed suicide not out of cowardice. There are no harder decisions. She did so out of necessity, out of feeling that there was nothing in this life worth living for anymore. We’ve fostered that kind of feeling in her and inside everyone in this country who has done so, or is suffering from a mental health ailment.

We are losing our own youth to our own prejudices in more ways than one. We’ve turned “mdapras” into a joke. We’ve let those who seek help feel ashamed of doing so in the clinics they seek.

Nourhan Hammoud, may you rest in peace.

I leave you with the words of her friend Aly Sleem:

هي من ابشع اللحظات التي لا نعرف ماذا نقول فيها، فنحن لا نحبّ الوداع ونكره الرحيل ونتعلّق بالذكريات. نورهان…. لم أتخيّل يوماً بأن أسمع “خبرك”، عادة لا يموت الا الكبار في السن، لم أتعود بعد على فكرة أن المفعمات بالحياة يُخطفن وهنّ ماضيات في حياتهن، غير آبهات بأحد… أتذكّر منذ اشهر قليلة، في مزيان، قلتي لي انك توديّن السفر، ربما تفكرين بتركيّا، لكنك تخافين فراق الوالدة، وفراق شارع الحمراء وفراق الأصدقاء، لكن أنانيتك أبت إلّا  ان تتخلى عنهم جميعاً، في لحظة، دون استئذاننا، دون تحضيرنا نفسيّاً، بلا حتى رسالة على موقع تواصل اجتماعي حقير وبائس كحالتنا.

لكن مهلاً، انت لست بقويّة، انت خدعتنا جميعاً ولا زلت يا جميلة، حتى برثائنا لك نمجّد قوتك التي لطالما افتخرتي بها، وهل القوة هي بإنهاء حياتنا بأنفسنا يا متمرّدة؟ أتذكرين كم مرّة اطلقتي السباب على السياسيين والوطن؟ لماذا رحلتي دون أن تلعنيهم مرة اخيرة؟

لكن ايضاً مهلاً، كيف كان يحصل كل هذا ونحن غير مدركين؟! كيف لم ندرك ان نورهان متألمة؟ أن مشهد الضحايا في سوريا أدماها، ان الأمل المتلاشي في بيروت خنقها، ان هذا الكيان لن يُكتب له أن يصبح وطناً؟ أن “كبار العيل” في البلد سرقونا ولن يرحمونا؟

كيف يمكن لنا ان نمجّد قرارها “الحر” بالموت؟ لا، هذه الثقافة غير مقبولة، نورهان وغيرها تمنوا لو لم يأخذوا هكذا قرار، لا يمكن لهؤلاء أن يقبلوا بتهليل دموع وصريخ الأحبة… هذا جنون، كان لا بد لنا أن نضع حدّاً لمشاكسة “زهرة الجنوب الصغيرة”، كل ما كانت تحتاجه هو بضعة من الأمل والأمان… نورهان بحثت كثيراً، لم تجدهما فمضت في رحلة بحث عنهما.

وكأن بي أسمعك يا نورهان الآن تقولين: الموت يحاوطنا كما تحيط الدائره بمركزها لكننا لا نشعر به إلا عندما تضيق الدائرة وتمسّنا فى أشخاص قريبة وسرعان ما تصل الينا، دون أن ندري… تشبثوا بالأحباب لا حب فيهم فقط بل لطفاً بعذاب الأمهات والأخوات والأولاد إن نووا الرحيل…

لنحسب أن نورهان نائمة اليوم، لنحسب أنفسنا استيقظنا قبلها لنصلح كل شيء، لنعطي أملاً بأن الحياة لن تله بنا بعد اليوم وتسخر، ثم نوقظها، نوقظها لتسامحنا….
كل الحب…

An event is taking place on Saturday September 10th to raise awareness for suicide. Check it out and go for Nourhan, and every other Lebanese whose conditions we’ve made intolerable.
Lebanon Suicide

Fekko El 3e2de

Fekko el 3e2de

When it comes to mental health, Lebanon has a long way to go. My rotation in psychiatry at one of the country’s hospitals has opened my eyes, as I wrote about here, to a domain of medicine that many don’t want to believe exists, preferring to even have cancer than a psychiatric disorder.

Families, in 2013, would rather revert to exorcisms in order to tackle issues with their sons and daughters, rather than take them to doctors. Explanations of demons instead of some chemical imbalances are preferred. The stigma of the word “insane” haunts any other demon-less explanation.

The victim in all of this, apart from the patient, is our ability to truly advance as communities, especially as we tend to believe that not calling a disease by its name makes it all okay.

Technically independent from AUBMC, the Embrace fund is trying to change how Lebanese view mental health and they’re resorting to a great campaign, in my opinion, that they’re titling: “Fekko l 3e2de,” which translates literally to untie the knot, referring to the “knot” that mental health perception imposes on Lebanese societies.

They’ll be having a gala dinner in a few days to support their campaign, with a performance by Ziad el Rahbani. Find the details here.

The Ultimate Lebanese Medical Taboo: Mental Health, Not Demons. Psychiatry, Not Exorcisms

“Tell me I have cancer please,” she said as I stood next to her in the Emergency Room. “Tell me I have cancer,” she repeated again as if repetition would make it true. “I have cancer, yes I do. But I’m not insane.”

1 out of 5 Lebanese will have a mental disorder during their lifetime. This is in sync with international averages, which is interesting given the proficient history that serves as precipitating factors galore that we’ve had. But be sure of this: we all know someone who has or will have a mental disorder.

50 is the approximate number of registered and licensed psychiatrists that could potentially treat these patients. 50 for slightly less than one million. We have incredible shortage and yet it doesn’t show to everyone. Why? Because we simply don’t talk about mental health.

0 is the number of local insurance companies that cover for psychiatry. People don’t care enough about the issue in order to pressure them to make it included with their healthcare bundle. It will never happen, they’d say. It only happens to other people, just like every other serious illness I suppose.

A patient my age thought she was living inside a snake on Mars. That was where she was when she presented for hospitalization with bruises all over her body.
Her family denied knowledge of those bruises at first. But they were too systematic to be coincidental. She had bruises over here wrists, torso and legs. Her parents still didn’t budge.
The patient in question was living on Mars for a few months now. She wasn’t brought in earlier because her family thought she was possessed. A religious man had tried to perform an exorcism. We live in a country where it’s more acceptable to say demons are inside a family member than to say he was admitted at a hospital and is on a few meds.

That patient wasn’t the first nor the only one I saw who had attempted many exorcisms at the hand of religious figures before finally deciding that what was wrong wasn’t, in fact, spiritual as much as it was simply biological and chemical. It’s always that way: demons, not disease. Exorcisms, not medicine.

Wasn’t it at the times of our great-great-to the power ten-grandfathers that illnesses were associated with evil spirit?
That seems to still be the case today in Lebanon, and many other countries around the world, when it comes to mental health. The way we view mental health is also that of a taboo whereby we try to hide from it, shut it away as something not to be talked about. Even the suicide of Amina Ismail, sensational as it was, didn’t turn in the media into a discussion about mental health. It was a discussion about her private life. We have it among family members but instead of looking at those family members as sick people, akin to any person with any chronic illness, we look at them as burdens who got themselves into the mess they are in. My family is no exception to the statistics. And I’ve seen both ends of the spectrum: the cancer patient is seen as the sick one. The mentally ill patient is seen as the spoiled one.

The extent that mental health is a taboo in this country is best manifested when you observe the way people act around the possibility of a mental disorder diagnosis. Some of them exchange their names with numbers as identifiers. You can name me thirteen if you want to. Others would panic when psychiatric people are called in for a consult. “I’m not crazy, get out of my room.” Few are the people who are open about the idea of possibly going to the psychiatric ward. Even fewer are those who actually present voluntarily. The least of all people are those who are open about any possible mental disorder they might have and who actually view such disorders the way they view any other illness. You should also see the reaction that doctors who are specializing in psychiatry get every time they tell people of their plans.

Then there are the diseases which have been ridiculed by people to the extent that few seem to actually see them as illnesses anymore. Schizophrenia becomes split or multiple personalities just because Hollywood says so. Substance abuse becomes an issue that doesn’t concern us because we have willpower. “Tu deprimes today?” becomes the reference for depression.

I have a friend who was diagnosed a while back depression. Treatment has greatly improved his entire lifestyle and approach. And I’ve been thinking lately how lucky my friend was to be surrounded by people who viewed his diagnosis and treatment as a true medical case, not him being a wuss. If his case had been the latter, he’d have probably never improved and he would have never known that there is a better view of life than that of a person who was always sad, who had decreased interests, decreased appetite, guilt, suicidal thoughts.

“Madness is like gravity, all it takes is a little push,” the famous saying goes. Except “madness” is nothing like gravity and it takes more than just a push to get there. It’s a collection of genetics, biological predispositions and psychological stressors – sort of like any other disease, really. A mark of the development of a society is the way they view mental health. Lebanese tell their friends who are truly depressed to suck it up. They’d rather seek out exorcisms and justify diseases with demons than with simple facts. A person who develops substance abuse is weak-minded, his abuse never seen as an actual disorder. That patient who wished she had cancer has been “living with a demon” in her house for 6 years. She had brought in a priest every month. She still doesn’t know nor does she accept that the problem is probably with her and it could have been fixed 6 years ago. I guess some people would rather find solace in demons and live in Mars in the process because society thinks a Martian habitat is better for people like them than to acknowledge the simple and yet vitally important fact that it’s mental health, not demons. It’s psychiatry, not exorcisms and voodoo.

Thoughts on the Newtown, Connecticut Shooting

Newton Connecticut Shooting Children School

Sandy Hook Elementary

Children are dying everywhere around this world. Be it in Syria where they die daily (NSFL pictures) or in any war zone. Those deaths though, however tragic and cruel, are a byproduct of a civil strife taking place in their country. 20 children of Newtown, CT had no idea that their school-day on Friday would be their last day of life. The parents who dropped off their children at school didn’t know that would be the last time they would see their son or daughter breathing.

This is the third shooting to take place in the United States in 2012. After each of those massacres, the same debate among Americans erupted before it died down when the mania subsided: gun control and mental health.

Some people believe that their guns should be off limits. Their right to bear arms in the face of a possible tyrant government, as protected by the 2nd amendment, is sacred. I wonder though: how many more innocent children need to die until some Americans realize that the current state of their gun legislation is unacceptable?

Those who can fathom the current gun laws in the United States are jumping on the mental health bandwagon: the mental health sector in the United States is horrendous. Stigma regarding mental health issues is so enrooted in American society that few seek help – and when people crack, they do what Adam Lanza did to the children of Newtown.

On the other hand, you have many Americans who want tighter gun regulations, if not banning of civilians getting access to firearms altogether.

But I am not American. I don’t believe I should get a substantial say about internal regulations of a country I’ve never visited. Personally, I believe it should be a combination of both: Everyone being able to buy guns as easily as chewing gum should not be allowed. Why not require a psychiatric evaluation of the person wanting to buy a weapon before they’re able to purchase one? 

Eventually, those who want to commit crimes and massacres will find a way. But at least don’t make it a walk in the park for them.

The question to be asked about Newtown’s shooting, however, is the following: wasn’t this shooting very similar to the Aurora shooting which took place in July? And wasn’t that Aurora shooting very similar to the one that took place at Virginia Tech? The list goes on.

And herein lies the real problem: the media – American and international.

News of a shooting at an American school or movie theatre immediately gets turned into a sensational story as news anchors are instructed to amp up their look of concern while their producers scramble on the phone to bring in advertisers who want to make profit off the ratings that networks will be making by hosting people from around the area of the shooting.

When the media craze subsides and the shooting becomes second degree news, what’s the only thing immortalized out of the entire event? The shooter.

Does anyone remember any of the names of those who died in Aurora? In Virgina Tech? In Newton?

Now ask yourself this: do you know the names of the three men who committed those separate massacres?

When it comes to these shooting massacres, there’s a need for a lockdown. The media should refrain from going on news frenzies about the shooting because minute-to-minute, second-to-second coverage is effectively telling those with biochemically imbalanced, mentally ill people that they can become instantly famous, instantly known, instantly feared by bringing a gun to a school and gunning down enough people to become the country’s “it” news. The idea of playing God, of controlling the fates of the people they’re about to kill, of controlling their own life that they’re about to take, is implanted in these people’s heads. And the idea is so irresistible that it brings them to the tipping point.

I honestly don’t know what’s the one and true reason that the United States has this many shootings taking place but I don’t think there’s one reason to explain it all. The situation is strange to say the least. I only need to look at my country, Lebanon, where guns are more numerous than people and people with mental health issues would total the entirety of the Lebanese population and where security is as fragile as breadcrumbs – and yet we’ve never had such mass shootings.

My thoughts go to the families who lost their children, to the heroic teachers Dawn Hochsprung, Victoria Soto and Mary Sherlash who died to save their students. I would say hopefully this doesn’t get repeated. But we all know better.