Intersectional public health: filling the gaps for adolescents

Note: This piece was originally posted on the London School of Hygiene and Tropical Medicine’s MARCH (Maternal, Adolescent, Reproductive and Child Health) Centre blog on June 22, 2016.

Healthcare is notorious for its silos. Doctors specialize by disease type or body part, and hospitals often have a designated floor for each major organ system. Pediatric, adult and often geriatric units divide patients by age. Because of the legacy of stigma surrounding psychiatric conditions, mental health departments are often inseparate buildings entirely.

In this highly specialized environment where every pot has a lid, how do we create a space for intersectionality?

Consider the adolescent. She’s not a girl, not yet a woman. She may need the pediatrician and the sexual health clinic in equal measure. She will often be at increased risk of school-acquired infection, but she may also have a child of her own. On the whole, her all-cause mortality risk is lower than nearly all other age groups, so it’s easy to focus on others when prioritizing health programs.

But adolescent mortality is low because teens shouldn’t die, which makes the deaths that do happen all the more jarring. Historically, most women who died in their teens did so during childbirth, a rate that is thankfully falling throughout the world. As care before, during and after childbirth improves, new harms have overtaken the top spot. Among 15–19 year old girls, the leading cause of death is now self-harm and suicide.

Authors Suzanne Petroni, George Patton and LSHTM’s Vikram Patel explored this unsettling revelation in The Lancet last November. The global rate of maternal mortality has been nearly halved in the past 25 years, and though self-harm and suicide rates have also fallen slightly, improvements in infection control around pregnancy have far outpaced the neglected area of mental health. All three authors returned this year to take part in Our Future: A Lancet Commission on Adolescent Health and Wellbeing, launched at LSHTM’s May 10th symposium on Adolescents.

Despite improvements, every country in the world still struggles with stigma associated with mental health conditions. Even independent adults in supportive communities have difficulty recognizing mental health problems, finding a well-matched therapist or psychiatrist, and calibrating their medications to function most effectively. Add financial dependence, gender-based discrimination, or even intimate partner violence and child marriage into this equation, and mental health battles can seem insurmountable.

Dr. Patel and colleagues point out that girls are significantly more likely than boys to suffer emotional problems from victimization, that three in ten girls aged 15–19 experience violence from an intimate partner, and that girls and that women who suffer from intimate partner violence attempt suicide at higher rates. Many of these girls are child brides, who are twice as likely to experience intimate partner violence than women who marry after the age of 18.

The prevalence of self-harm and suicide among 15–19 year old women encompasses gender discrimination and violence in its starkest display. It also exposes areas of weakness in the public health safety net built to protect the vulnerable. The fact that the self-harm statistic was hidden behind maternal mortality statistics reveals multitudes about the way we understand adolescent health. To the extent that adolescents do receive targeted care, it typically focuses on sexual health and reproduction, and even then is often hard or impossible to obtain without the consent of a parent. Non-communicable and mental health repercussions are often neglected, despite the fact that most mental health conditions and risky health behaviors develop during adolescence. Though the majority of people with a mental health condition never attempt suicide, over 90%of people who die by suicide had a diagnosable psychiatric condition at time of death. Moreover, many who experience clinical depression and anxiety during adolescence do not suffer from these conditions throughout adulthood. Appropriate intervention and supportive environments through this critical time could reduce the dual burden of morbidity and mortality from mental health conditions. Preventing suicide in adolescents could increase the number of children who make it to adulthood and improve their quality of life once they’ve grown.

This revelation can teach us how to prevent surprises in the future. It’s hard to know how to approach a problem until one understands its magnitude. Improved reporting of maternal deaths during childbirth has helped to understand the scope of the problem, track risk factors, and find pathways to mortality that can be diverted or blocked. A similar tracking mechanism is needed to prevent suicide.Previous attempted suicide is, unsurprisingly, the strongest predictor of suicide completion, yet most nations fail to even attempt to track this statistic.

In addition, data monitoring systems must be organized to exhume these realities when buried within a mess of mortality data. Men die by suicide at more than triplethe rate of women, and the majority of suicides happen at older ages, so this revelation about late-teen girls would have hidden behind aggregate statistics. Dis-aggregating the data even further could tease out potential protective elements or risk factors. High-risk groups are often masked by country-level statistics. Stratifying the data further, by geography, environment, ethnicity, social capital and other factors may reveal areas most in need of care and intervention.

Programs can’t reach those at risk if we don’t know who they are, and programs can’t solve a problem if they don’t know where to look. By focusing on the intersections between pre-set groups, public health can start to work for everyone.

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