Psychosocial pathology

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What of psychosocial pathologies and the social circumstances that underlie them? The 1995 report of the World Health Organization, (1Z> entitled Bridging the Gaps, provides a sobering introduction to the leading cause of mortality and morbidity:

The world's most ruthless killer and the greatest cause of suffering on earth is... extreme poverty. It is the main cause of reduced life expectancy, of handicap and disability, and of starvation. Poverty is a major contributor to mental illness, stress, suicide, family disintegration and substance abuse... For many of the people in the world today, every step in life, from infancy to old age, is taken under the twin shadows of poverty and inequity and under the double burden of suffering and disease. For many, the prospect of a longer life may seem more like a punishment than a prize.

The external debt of developing countries grew 15-fold over the past two decades; in 1970 it was $100 billion, by 1980 it had increased to $630 billion, and by 1992 to more than $1500 billion/18 Growing economic disparities between and within countries fuel conflict. The gulf between the poor and rich of the world is widening. The gap in per capita income between the industrial and developing world has tripled in the past 30 years. Developing countries, with 80 per cent of the world's people, control only 21 per cent of the global gross national product (GNP). Differences in economic and health status within countries are as great or greater than those between countries. Brazil, classified by the World Bank(2) as an 'upper-middle income country' has a per capita GNP of $2940, yet one in six Brazilians subsists on less than $1 per day, and one in three on less than $2 per day. The United States ranks in the upper 5 per cent of nations in average life expectancy, but the life expectancy of black men aged 15 to 44 years living in Harlem is lower than that of a male Bangladeshi of the same age. (1„9)

Of the 40 instances of armed conflict under way at the time of writing, not one is a significant war between states. (20) The goal is no longer the destruction of opposing armies, but the terrorization of civilian populations who constitute 'the enemy.' Such low-intensity warfare results from the political and economic legacies of the Cold War, from the disintegration of state authority and the breakdown of civil and political order, from illegitimate state institutions, from social cleavages based on religious, cultural, or ethnic origins, inflamed by power-seeking demagogues, and from widespread illiteracy, poor health, political repression, and economic deprivation in countries the world over. (21) There are 20 million officially recognized refugees worldwide, twice the number that there were 10 years ago; there are at least as many internally displaced persons. Refugees and internally displaced persons exhibit high rates of depression, anxiety disorders, post-traumatic stress disorder, and other forms of mental distress.

Hunger, deprivation, depression, and violence affect women disproportionately. Women bear more heavily the negative effects of economic restructuring on families. Selective abortion, female infanticide, differential triage of sick children in poor families, and maternal mortality have all taken a substantial toll on women's lives and mental health. Sen(22) has calculated that in Southeast Asia 100 million women are missing; that is, the only viable explanation for the high male-to-female ratio in the Southeast Asian population, in contrast with the female preponderance in the West, is the premature death of 100 million women. Child abuse in exploitative settings, in the commercial sex industry, among the hundreds of thousands of street children, in settings of ethnic and political conflict, and in families under stress is a major source of degradation and wretchedness for millions.

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