Friday, December 23, 2016
Two years ago, Gwen Welborn was in a rough spot. The middle-age single mom had recently divorced, was dealing with her child’s cystic fibrosis and had just lost both her parents in quick succession. “I just wanted to do something good for myself,” says the 52-year-old Wantagh, LI, resident. So she decided to get breast implants.
Yet despite her friends urging her to go big, Welborn decided on a more subtle enhancement.
“I was always small-chested, and I wanted to stay small,” says Welborn, who owns a beauty salon in Seaford, LI. “I wanted to continue to run and bike and work out. In my mind, I was looking at someone like Cameron Diaz, someone I had heard had a small implant but you would never look at her and say, ‘Oh, she had surgery.’ ”
Now, Welborn is thrilled with her new boobs, which she says are a 32C but look more like a B-cup. “At first I thought they were a little big, because they get swollen after the surgery,” she says. “But now I like them just the way are.”
Breast augmentation is the most popular type of cosmetic surgery in the US, with more than 279,000 women getting boob jobs in 2015, according to the American Society of Plastic Surgeons. But if you’re envisioning buoyant Playboy Bunnies or “Baywatch”-era Pamela Anderson, think again. Today, women are ditching the DDs in favor of a more natural-looking B-cup — a trend bolstered by since denied rumors that willowy celebs like Taylor Swift have gotten “mini” boob jobs, barely noticeable augmentations to help them fill out their clothes better.
“Five years ago, I never saw this,” says Alexes Hazen, M.D., associate professor at the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Medical Center. “Now, it’s around 40 percent of patients who come in [who are] requesting a B-cup.”
Hazen says many women now know that bigger breasts can cause neck pain or back aches, which is why they’re straying away from larger sizes — and in some cases getting reductions or revisions of old implants. “Obviously, a smaller cup size is much more comfortable, but most women don’t want an A-cup,” she says. “It just doesn’t fill most dresses or women’s clothing in the right way a B cup generally does.”
“If you wear a size B you can wear anything,” says Leesa Rowland, a 50-year-old author who lives in Midtown East and just had her last of two breast-reduction surgeries — from a D to a B — a few weeks ago. “It’s the perfect size. I can wear things that are low-cut and look sexy, not matronly. And if you do want to look bigger, you can just wear a push-up bra.
“I didn’t tell anybody. I didn’t think anybody would really notice because I covered [my chest] up, but it was the funniest reaction, because people would ask, ‘Wow! How’d you lose so much weight?’ ”
It helps that fashion trends now tend to favor looks that require the wearer to go braless, adds Hazen, like handkerchief tops, backless dresses, and tight leotards and bodysuits. “If you’re anything bigger than a B, you can’t wear that stuff,” she says.
That was why Madison, an elementary school teacher who prefers not to use her last name for professional reasons, decided to get small implants in December. “I wanted to fill out my clothes, not get new clothes,” says the 28-year-old Upper East Side resident, who had wanted to get a boob job since high school. “When after the first week I took off my bandages, I looked amazing. I just kept staring at myself because my mind needed to get used to my new body. Now, people don’t look at me different, but I feel different. I look better in my clothes and feel more confident.”
Another reason women are opting for smaller cup sizes: They want to work out.
“Women are very athletic now and physically fit,” says Tracy Pfeifer, a board-certified plastic surgeon and adviser for RealSelf.com, a Web site devoted to cosmetic procedures. Pfeifer estimates that 40 to 50 percent of clients at her Upper East Side practice request a full B-cup — up from 25 percent five years ago. “They understand that larger breasts are going to interfere with their exercise.”
That was important to Welborn, an avid runner and biker who wanted to work out easily in a sports bra and maintain her level of exercise. “It hasn’t affected it at all,” she says.
But more important than the cup size, says Pfeifer, is proportion. “It has to do with the body frame and how wide their hips are. Women will come in and say a cup size, but they don’t really know what that cup size actually is. When they say B, they [mean they] don’t want to look out of proportion. I want it to look natural.”
Cassie Cohen, who lives in Westchester, ended up getting between a full B and small C when she got her surgery two weeks ago with Pfeifer. “I didn’t want to have boobs just for the sake of really big boobs,” says the 20-year-old Boston University student, who admits her parents would have never agreed to let her go through with the operation had she wanted DDs. (The surgery was a gift from her mother.) “I was sort of bigger on the bottom so it looked a little strange to be so small at the top. I just wanted more of a curve, more definition. They’re really comfortable and flattering — most people would never guess I had gotten surgery.”
And while smaller implants have long been a trend in tony Manhattan, says Dr. Daniel Maman, of 740 Park Plastic Surgery, it is becoming a national trend. “I think there’s a shift in mentality from women just wanting larger breasts to wanting to go back to the size that they were prior to bearing children and breast-feeding,” says Maman, who adds that about 95 percent of his clients — “very sophisticated, in very good shape and avid exercisers” — ask for more covert enhancements. “There’s a higher percentage of women who work now, and they want something discreet,” he says.
“The artificial augmented look is no longer desirable.”
(Photo : Michael Buckner / Staff)
Botox and other botulinum neurotoxin (BoNT) products are widely known for their use in treating facial wrinkles but did you know they can also be used to treat a wide range of non-cosmetic problems? Eight conditions with good evidence of effective treatment with BoNT are identified in a special review in the August issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).
The international review analyzed the research evidence on plastic surgery procedures using BoNT. "The use of botulinum neurotoxins has revolutionized the treatment of several different problems seen in the plastic surgeon's office, from facial wrinkles to painful conditions with limited treatment options," comments lead author Marie E. Noland, MD, of Dalhousie University in Halifax, Nova Scotia, Canada. Her coauthors were Donald H. Lalonde, MD, of Dalhousie University in Saint John, New Brunswick; G. Jackie Yee, MD, of Baker Plastic Surgery, Miami; and Rod J. Rohrich, MD, of University of Texas Southwestern Medical Center at Dallas.
Evidence and Experience Show Benefits of BoNT: A purified protein derived from bacteria, BoNT acts as a "neuromodulator"-it interferes with communication between nerves and muscles, causing local paralysis in the areas where it's injected. Two types of BoNT are available: BoNT-A (with brand names including Botox and Dysport) and BoNT-B (Myobloc).
The review identifies eight conditions treated by plastic surgeons with high-quality evidence of good responses to BoNT. The evidence is strongest for minimally invasive treatment of facial wrinkles (rhytides). The FDA has approved BoNT-A for treatment of forehead lines or wrinkles, while Botox specifically is approved for treatment of "crow's feet" at the corner of the eyes.
Studies support the use of BoNT for other types of facial aging problems as well. Cosmetic injection of BoNT-A is by far the most common plastic surgery procedure, with more than 6.5 million procedures performed in 2015, according to ASPS statistics.
Botulinum neurotoxin is also effective for some types of facial movement disorders (dystonias)-for example, tics caused by benign essential blepharopasm. It can also be used to treat issues related to facial nerve palsy and abnormal facial nerve regeneration, which can cause problems such as abnormal tears or sweating.
Two studies have reported that Botox can reduce hand tremors in patients with essential tremor, although hand function may not improve. Both BoNT-A and BoNT-B show evidence of effectiveness in patients with chronic, excessive sweating, especially of the hands (palmar hyperhidrosis).
Botulinum neurotoxin is a safe and effective treatment for upper limb spasticity of the arm and hand in adults. It also shows promise for treatment of muscle spasticity in children with cerebral palsy.
Neuromodulator therapy with BoNT has emerged as a useful new treatment for migraine headaches. This benefit was discovered coincidentally when patients undergoing cosmetic BoNT injection for forehead wrinkles reported decreased migraines. Based on three large studies, Botox has been approved for treatment of chronic migraine headaches.
More recently, studies have supported BoNT for treatment of neuropathic (nerve-related) pain-a common problem with few effective treatments. Injection is effective for the treatment of some important causes of neuropathic pain, including diabetes and surgical nerve damage.
The review includes figures and online videos illustrating proper BoNT injection technique for plastic surgeons. In a featured video on the Plastic and Reconstructive Surgery website, Editor-in-Chief Dr. Rohrich comments: "Neuromodulators are safe, but they must be done appropriately-in the right dose, in the right area, in the right way.
" Plastic and Reconstructive Surgery® is published by Wolters Kluwer.
Thursday, November 3, 2016
FGM can cause a host of health problems. In some cases girls may bleed to death or die from infections. — File pic
Indonesia is embarking on a renewed campaign to end female genital mutilation (FGM), according to its women’s minister Yohana Yembise, despite opposition from religious leaders who have stymied past efforts to combat a practice that is common.
Home to the world’s largest Muslim population, Indonesia tried to ban FGM a decade ago but opposition from influential Islamic clerics has meant it is still widely practised.
Almost half of Indonesian girls aged 11 and under have undergone some form of FGM, the United Nations’ children agency, UNICEF, said in February, citing government statistics fromIndonesia for the first time in a global study of FGM.
Together, Indonesia, Egypt and Ethiopia account for half of the estimated 200 million women and girls around the world who have been cut, according to UNICEF.
Yembise, Minister for Women's Empowerment and Child Protection, said the government has begun working with women's and religious groups to raise awareness of the dangers of FGM and a survey was underway to provide “scientific evidence” to support the government's goal to halt the practice.
“We try to approach the traditional and religious leaders to understand and to be aware that we have to end this female genital mutilation,” Yembise told foreign journalists.
FGM, which involves the partial or total removal of a girl’s external genitalia, is practised across a swathe of African countries and in pockets of Asia and the Middle East.
FGM can cause a host of health problems. In some cases girls may bleed to death or die from infections.
Others may suffer fatal childbirth complications later in life.
Rights groups in Indonesia have long called for a ban on FGM, while supporters of the practice argue that in Indonesia a less drastic form of cutting is usually carried out.
The UNICEF study showed that three in four Indonesian girls underwent FGM when they were under six months old, and the procedure was usually carried out by midwives.
After the government tried to ban FGM in 2006, the country’s top Muslim clerical body issued an edict arguing that the practice was a required part of religious tradition.
Grata Endah Werdaningtyas, a senior foreign ministry official, said the new campaign would target families.
“We have to target the concerned groups like the parents because they are the one who decide (on children’s circumcision) — not the doctors, not the religious leaders,” she told the Thomson Reuters Foundation.
But widespread superstition remains a hindrance, she said.
“In some parts of Indonesia, they say a girl has to be circumcised or else she can't cook rice properly, or she can't get a husband,” Werdaningtyas said.
In developing countries, it is a problem decades old but the rising antimicrobial resistance in Indonesia has rarely been raised in a public awareness campaign — even though the government has quietly been putting in a great deal of effort to reverse the trend.
Few people may have even heard that the Health Ministry runs a task force called the Antimicrobial Resistance Control Committee, or KPRA. To support the antimicrobial resistance campaign, the task force has been commissioned to draft a national action plan.
The basic concern over antibiotic resistance is that it can reverse decades of advances in medicine, bringing the world back to an age before the discovery of antibiotics, in 1928, when millions of people died from infections that could have been prevented today.
In Indonesia, doctors now already have to prescribe new types of antibiotics or higher dosages of current medicines because the bacteria are getting stronger.
The action plan will dictate a nationwide effort to reduce the abuse of antibiotics in human, animals and plants, as the medicines are also often misused for treatment and prevention of diseases in livestock, aquaculture, as well as crop production.
“If antibiotics are used on livestock, they will infect people who consume its products, such as meat and milk. This also applies to shrimp and fish. We also have to monitor antibiotics used on them,” KPRA head Harry Parathon said.
According to the Agriculture Ministry, unchecked use of antibiotics is also rampant among farmers without them knowing it. The chemicals are found in the animals’ drinking fluids and feed.
Andi Hendra Purnama, a ministry official in charge of monitoring animal feed, says some antibiotics are disguised as “feed additive” as stated in their labeling.
Harry warns that excessive use of antibiotics on livestock can also adversely affect plants.
“Let’s say I have a chicken farm and give antibiotics to all of my chickens. Their feces on the soil find their way into plants. As a result, the plants will absorb the antibiotics, creating a cycle.”
Hence the government will adopt the “One Health” concept in its action plan. Introduced in the early 2000s, the concept assumes that human and animal health are interdependent and bound to the health of the ecosystems in which they exist.
The KPRA expects it will take a long time to draft the national action plan because it is an interdepartmental undertaking that involves such institutions as the Maritime Affairs and Fisheries Ministry and the Agriculture Ministry.
The committee also aims to tackle other major causes of the increasing antibiotic resistance in Indonesia, like public misperception on antibiotics, unrestrained doctors’ antibiotic prescriptions and easy access to antibiotics in the market.
A recent survey conducted by the Indonesian Caring Parents Foundation (YOP) with 92 doctors in Jakarta and 35 doctors in Papua found that 91 percent of the doctors always prescribe antibiotics to their patients, while 75 percent of them prescribe antibiotics for mild illnesses like the common cough and influenza.
According to the YOP survey, 85 percent of pharmacies in Jakarta sell antibiotics without prescriptions. What’s more, 83 percent of them recommend that customers buy antibiotics, even when people only ask for drugs for mild ailments, like the flu.
Research by the Health Ministry in 2013 showed that only 27 percent of doctors in Indonesia had given the right dose of antibiotics and prescribed them for the right purposes.
It also gave a glimpse of how easy it was to access antibiotics in Indonesia. The survey found that 10 percent of families had antibiotics in their homes and that at least 86 percent of those obtained the drug without a prescription.
It turns out that unnecessary antibiotics are not only prescribed by doctors who open their private services, but also by hospitals, as Harry has noted.
“Patients have already developed antibiotic resistance from home. Then they are given antibiotics again at the hospital. Instead of being killed, these bacteria grow stronger. This is called healthcare associate infection. So the infection happens at hospitals,” Harry said.
In response, Health Minister Nila F. Moeloek has called on doctors to exercise maximum care in prescribing antibiotics.
She specifically asked the Indonesian Doctors Association (IDI) to remind its members to not authorize the use of antibiotics unless it is really necessary.
IDI secretary-general Adib Khumaidi promises the association will take action against any of its members who go against the rule. “Disciplinary actions will be in the form of membership termination or suspension,” he says.
But IDI doctors have an excuse. Very often, doctors prescribe antibiotics on the patient’s demand although they know the medicines are unnecessary.
“Besides, patients sometimes buy antibiotics over the counter because they know the drugs. We have to stop it,” Adib says.
Even worse is the fact that many people also fail to take antibiotics in the right dosage or fail to get through their prescriptions.
“Once patients begin taking antibiotics, they can’t stop midway. They must finish their prescribed duration of taking the drug,” Adib says.
Aside from the national action plan, the ministry actually had issued a regulation in 2011, which serves as a general guideline on antibiotic use. Then last year, it launched a campaign called “GeMa CerMat”, aimed to encourage the public to wisely use antibiotics.
For a better grasp on this critical issue, the government is currently researching the level of antibiotic resistance in 18 hospitals in major cities of the country.
Currently, it is assessing how well hospitals have been implementing the antibiotic-resistant management program.
“If the prevalence of antibiotic resistance is high in a hospital, its use must be unrestrained. And that hospital might fail to get accreditation. So the assessment will become part of hospital accreditation,” Harry says.
Hans Nicholas Jong
An aerial view of a forest fire burning near the village of Bokor, Meranti Islands regency, Riau province, Sumatra, Indonesia in this March 15, 2016 file photo taken by Antara Foto. REUTERS/ Rony Muharrman/Antara Foto/Files
Harvard and Columbia university research showing smoke from land fires in Southeast Asia led to more than 100,000 premature deaths last year "makes no sense at all," an official at Indonesia's Health Ministry said on Tuesday.
Indonesian government records show only 24 deaths related to forest fires in 2015, but the disaster was estimated to have left more than half a million Indonesians suffering from respiratory ailments.
Indonesia is under global pressure to put an end to slash-and-burn land clearances for palm and pulp plantations which send clouds of toxic smoke over the region each year.
The university research estimates pollution exposure from last year's fires killed 91,600 people in Indonesia, 6,500 in Malaysia and 2,200 in Singapore in 2015 and 2016, significantly higher than government records.
"Given the severe haze in Equatorial Asia in 2015, the 100,000 premature deaths in that region are not so surprising," said Loretta Mickley, a senior researcher at Harvard focusing on atmospheric pollution, who contributed to the research.
Health Ministry director general of disease prevention and control Mohamad Subuh told Reuters the research data was wrong.
"Data on deaths is clear. We have surveillance," Subuh said, adding that the assumptions of mortality based on mathematical calculations were "irresponsible".
Every year, Indonesia faces criticism from its neighbors Singapore and Malaysia over the smog, euphemistically known as "haze", and its failure to stop the fires from being lit.
Last year's fires were among the worst in the region's history, with billions of dollars worth of environmental damage, weeks of flight and school disruptions and thousands suffering from respiratory disease.
(This story corrects dateline and day of attribution in the lede.)
(Editing by Nick Macfie)
Indonesian police extinguish a fire in the Kampar District of Riau Province, Indonesia on Aug. 28, 2016. Photographer: Afrianto Silalahi/NurPhoto via Getty Images
Jakarta, Indonesia (AP) -- Indonesian forest fires that choked a swath of Southeast Asia with a smoky haze for weeks last year may have caused more than 100,000 premature deaths, according to new research that will add to pressure on Indonesia's government to tackle the annual crisis.
The study by scientists from Harvard University and Columbia University to be published in the journal Environmental Research Letters is being welcomed by other researchers and Indonesia's medical profession as an advance in quantifying the suspected serious public health effects of the fires, which are mostly set to clear land for farming. The number of deaths is an estimate derived from a complex analysis that has not yet been validated by analysis of official data on mortality.
The research has implications for land-use practices and Indonesia's vast pulp and paper industry. The researchers showed that peatlands within timber concessions, and peatlands overall, were a much bigger proportion of the fires observed by satellite than in 2006, which was another particularly bad year for haze. The researchers surmise that draining of the peatlands to prepare them for pulpwood plantations and other uses made them more vulnerable to fires.
The estimate of premature deaths linked to respiratory illness that covers Indonesia and its neighbors Singapore and Malaysia dwarves Indonesia's official toll of 19 that included deaths from illness and the deaths of firefighters. However, the possible scale of serious heath consequences was indicated by a statement from the country's disaster management agency in October that said more than 43 million Indonesians were exposed to smoke from the fires and half a million suffered acute respiratory infections.
The study considered only the health impact on adults and restricts itself to the effects of health-threatening fine particulate matter, often referred to as PM2.5, rather than all toxins that would be in the smoke from burning peatlands and forests. The bulk of the estimated deaths are in Indonesia, by far the most populous of the three countries and the country with the biggest land area affected by haze.
The fires from July to October last year in southern Sumatra and the Indonesian part of Borneo were the worst since 1997 and exacerbated by El Nino dry conditions. About 261,000 hectares of land burned. Some of the fires started accidently but many were deliberately set by companies and villagers to clear land for plantations and agriculture.
Rajasekhar Bala, an environmental engineering expert at the National University of Singapore, one of five experts who reviewed the paper for The Associated Press and were not involved in the research, said the study is preliminary and involved a "very challenging" task of analyzing the sources and spread of fine particulate matter over several countries and a lengthy time frame.
Even with caveats, it should serve as a "wake-up call" for firm action in Indonesia to curb peatland and forest fires and for regional cooperation to deal with the fallout on public health, he said.
"Air pollution, especially that caused by atmospheric fine particles, has grave implications for human health," he said.
Frank Murray, an associate professor of environment science at Australia's Murdoch University, said the death estimates are not "precise health outcomes" but their overall scale should trigger intensified efforts to deal with the crisis. The study is a major contribution to addressing an international problem, he said.
The study finds there is a high statistical probability that premature deaths ranged between 26,300 and 174,300. Its main estimate of 100,300 deaths is the average of those two figures. It predicts 91,600 deaths in Indonesia, another 6,500 in Malaysia and 2,200 in Singapore.
The researchers involved in the study say the model they developed can be combined with satellite observations to analyze the haze in close to real time. That gives it the potential to be used to direct fire-fighting efforts in a way that reduces the amount of illness caused, they say.
The annual fires have strained relations between Indonesia and its wealthier neighbors Singapore and Malaysia, who are at the mercy of winds that carry the haze into their territory from Sumatra.
But the brunt of the crisis is faced by millions of Indonesians in Sumatra and Kalimantan, many of them poor and with little or no means to protect themselves from the blanket of smoke.
"Particles penetrate indoors, and housing in Indonesia is very well ventilated, so I don't think there is any avertive behavior that people there could have taken that would have been effective," said Joel Schwartz, an air pollution epidemiologist at Harvard who co-authored the study. "In Singapore, if you close all the windows and turn on the air conditioning you get some protection, which may have happened."
The Indonesian Medial Association's West Kalimantan chapter said Indonesia faces an overall decline in the health of future generations with social and economic consequences if the situation is not tackled.
"We are the doctors who care for the vulnerable groups exposed to toxic smoke," said Nursyam Ibrahim, deputy head of the West Kalimantan chapter of the association. "And we know how awful it is to see the disease symptoms experienced by babies and children in our care."
Howard Frumpkin, dean of the School of Public Health at the University of Washington, said it is possible the health consequences are greater than indicated by the study because higher incidence of certain health problems in developing countries could make populations more susceptible to the effects of fine particulate matter.
Bracing for a stream of foreign medical professionals entering the country after the implementation of the ASEAN Economic Community (AEC), the government is devising a set of incentives to encourage local specialists to work in the regions.
The Health Ministry hopes the incentives will lure surgeons, pediatricians, internists, obstetricians and anesthetists to areas in short supply of specialists for at least a year.
The plan also aims to keep local specialists competitive compared to the foreign doctors that will soon be allowed to move freely between countries in Southeast Asia.
The ministry’s Director General of Community Services, Bambang Wibowo, when opening the Indonesian Medical Council (KKI) national coordination meeting in Surabaya, East Java, said foreign doctors would make efforts to take over regions in Indonesia that have a shortage of doctors.
“The number of specialists is very limited in those regions, especially in the eastern part of Indonesia as well as in border regions and on islands. This requires awareness of the doctors that they are needed there,” said Bambang Wibowo in Surabaya on Tuesday.
Indonesia, according to Bambang, has become a lucrative market for players in the health service. Doctors are still in short supply at many of the country’s 9,754 community health centers (Puskesmas) and 2,573 hospitals. Moreover, the population of Indonesia is estimated to reach 270 million people in 2020, which would include a significant number of middle-income earners able to afford private health care.
The policy to assign specialists to areas that lack doctors for at least a year is backed up by an existing program to assign teams of newly-graduated physicians, dentists, midwives and health analysts to remote areas in a bid to cover the shortage of doctors in Indonesia.
Based on KKI data, Indonesia currently has 175,410 registered doctors, 31,414 of whom are specialists.
KKI chairman Bambang Supriyatno said synergy between all stakeholders was needed to address the issue.
“This month, we will discuss domestic regulations in response to the potential and threat of the influx of foreign doctors to Indonesia,” said Bambang.
At the same occasion, University of Defense professor Rear Admiral (ret.) Setyo Harnowo said Indonesia faced no obvious military threats from outside in the next 10 years, but it faced non-military ones instead.
“Indonesia is facing the threat of a proxy war, or a weakening of the nation using non-military means, such as economic and health threats, and the health threats must be faced by those in the health sector,” said Setyo.
Separately, House of Representatives Commission IX chairman Dede Yusuf Macan Effendi, who also spoke at the forum, said he was encouraging the Health Ministry and KKI to maintain an equal distribution of doctors across Indonesia.
The Democratic Party politician related his experience in meeting with the regent of Membramo in Papua, who he said was willing to provide Rp 50 million as “settling-down” cash, aside from regular income and other facilities, to specialists willing to serve in the regency.
“Seeing that the administration is willing to give Rp 50 million, imagine the desire of the regency to have specialists there,” said Dede.
Dede urged KKI to encourage the presence of medical schools in regions with a shortage of doctors, because doctors generally gathered in campuses with medical schools.
Health Minister Nila Djuwita F. Moeloek said that she had not received official reports about fund flows from pharmaceutical companies to doctors.
“I just found out about it from a running text,” Nila said at the Research and Technology and Higher Education Ministry’s office in Jakarta on Friday, September 16, 2016.
Nila explained that it would be irregular for doctors to receive money from pharmaceutical companies.
Earlier, Corruption Eradication Commission (KPK) chairman Agus Rahardjo revealed an indication that a pharmaceutical company had sent money amounting up to Rp800 billion (US$61.5 million) to doctors over the last three years. The KPK received the report from the Financial Transaction Reports and Analysis Center (PPATK).
According to Agus, the money was channeled by a pharmaceutical company. In addition, he said that the company was not a major one. He viewed that the report could not be used to describe the actual condition of the pharmaceutical industry.
Agus revealed that the company’s expense reflected the huge amount of money spent for health care services. Based on a research conducted by the KPK, Indonesia’s expenses for health care services accounted for 40 percent of the country’s total expenses, which were higher than those in other countries, such as Japan and Germany.The PPATK’s report was in line with Tempo magazine’s investigation into a graft allegation involving doctors and pharmaceutical companies. The investigation, conducted in 2015, revealed that about 2,000 doctors were involved in the practice.
The article also mentioned that the transaction value for medicines reached Rp69 trillion (US$5.3 billion) as pharmaceutical companies allegedly bribed doctors to put their products in prescriptions for patients.
The KPK and the Health Ministry worked together to make an agreement that strictly governed the practice of providing funds from pharmaceutical companies to doctors. Despite the regulation, Nila said that a doctor would be allowed to receive a gift from a pharmaceutical company if the aim was to improve the doctor’s competency or to conduct a research.
Mental illness is often considered a silent disease in Indonesia, with many sufferers remaining undiagnosed and not getting the proper treatment, but Get Happy — a new campaign to reshape the way people think about mental health — is now trying to turn things around.
Traditionally in Indonesia, many people with psychosocial disabilities are confined to their homes, some even in shackles. Although shackling was banned in the late 1970s, a recent study from Human Rights Watch (HRW) estimated that around 19,000 people with mental problems are still confined at home or at unofficial institutions where they face very high risk of abuse.
Clinical psychologist Wulan Danoekoesoemo said many Indonesians choose not to seek help from mental health professionals because they do not want to be labeled as "crazy."
The HRW study also cited a 2015 report from the Ministry of Health that described spending on mental health as "negligible" and showed only 10 percent of Indonesians who need mental health services actually have access to them.
The country currently only has 800 psychiatrists and 48 mental hospitals — this in a country of 250 million people. Combine that with a deep-seated stigma against mental illness, it is no wonder that many Indonesian with mental illness are often left alone and untended.
"A lot of people are suffering in silence and unable to ask for the help they need because of the taboo and stigma surrounding mental illness," Caecilia Tedjapawitra, one of Get Happy’s co-founders, told the Jakarta Globe recently. "We believe providing free access to mental health education can help reduce the stigma."
To put their ideas into action, Get Happy runs light-hearted monthly workshops where the public can learn how to take care of their mental health from a variety of resources and take time to focus on their mental well-being.
The group's most recent workshop featured an advertising agency executive talking about creative thinking and finding new ways to express yourself. Other workshops have featured zen doodling, drumming exercises and vocal jamming.
Caecilia said the idea to form Get Happy stemmed from a genuine concern about the widespread misunderstanding of mental illness. She said, "It’s easy for people to understand physical illness; people can see if you have a broken leg or need stitches. But it’s much harder to understand an illness you cannot see."
She said in Indonesia, when people are feeling depressed or overwhelmed, they often refrain from talking about it because they feel doing so would be tantamount to "airing their dirty laundry."
When Caecilia started sharing about her own mental struggles on social media, many people reached out and said they were feeling the same way. What Caecilia found out is that people who experience or are in touch with mental illness on a daily basis feel good knowing they were not the only ones feeling stressed or sad.
This inspired Caecilia and her husband, Andreas Adianto, to start Get Happy to create a space to discuss mental health issues.
"We’d like to provide a safe place for people who have mental health issues to share their stories without being judged," Andreas said. "It is very rare to find a place where people can share their experiences without getting judged by people around them."
In only eight months, the movement has already helped educate and raise awareness about the importance of mental well-being to more than 500 people through their offline events and online platforms.
The group hopes to continue to promote the importance of mental well-being, and educate the public about resources available to cope with mental illness. They hope these small steps can start to change the way people think about mental health and create a "happier Indonesia."
"Too often, the only help people need [to improve mental well-being] are other people who are willing to listen to them, hugs, smiles and happiness," Wulan said.
"I personally think Get Happy has been doing an amazing job providing a safe haven where people can educate themselves about healthy coping mechanisms, self-inserting happiness and providing supportive and positive surroundings."
Every year, nearly 800,000 people commit suicide. Suicide was the fifth leading cause of death among those aged 30 to 49 in 2012, globally, and the second in the 15 to 29 age group. The International Association for Suicide Prevention (IASP) and the World Health Organization (WHO) are committed to preventing suicide.
Suicide is complex because it has no single cause. Suicide is most of the times caused by a combination of many different factors, such as psychiatric disorders, social pressure, psychological trauma, biological factors, genetic factors and physical disorders.
Data from psychological autopsies carried out in 1999 showed that mental illness was among the major factors for suicide with more than 90 percent of suicide cases accompanied by mental disorders. Based on data from the Indonesia Health Research (Riskesdas) in 2013, the prevalence of severe mental disorders (psychosis or schizophrenia) in Indonesia's population was 1.7 per 1,000 people. The prevalence of mental emotional disorder in the population aged 15 and above was 6 percent.
Previous research shows that artists were more susceptible to committing suicide than other population groups because of the ostensible prevalence of mental disorder in artistic people. Two contemporary painters, S (1973-2003) and A (1975-2005), both decided to end their lives by hanging themselves in 2003 and 2005, respectively.
This is my story of performing a psychological autopsy of the two deceased painters.
Coming to Yogyakarta
I tried to locate S’s and A’s paintings in Yogyakarta and a curator introduced me to their family members and fellow painters.
I managed to find the locations of the deceased painters’ rented houses. One of the painters committed suicide in a rented house in Yogyakarta while the other did it in his parents’ house in Magelang, Central Java. There was a similarity to both houses: quiet and isolated, providing an opportunity for a painter to seek ideas, think, and reflect.
Both painters hung themselves at the age of 30, still considered within the young adulthood group, according to Erik Erikson’s psychosocial development category. At this stage, people share themselves more intimately by exploring relationship toward long-term commitments with someone other than family. Successful completion of this stage can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression.
Back in Jakarta: Psychological autopsy
In my psychological autopsy on photos of the paintings by the deceased painters and the interviews with family members and fellow painters, I found streaks of psychopathology appearing.
S’s psychopathology began to appear with a change in behavior beginning 2001. He complained of hearing voices that he felt as an attack against himself (auditory hallucinations). He felt that he was being harmed by black magic and persecuted by those devilish people (persecutory delusion). Approaching his death, he felt his hands were rotting and ravaged by maggots (bizarre delusion). Affective components can be seen from the great energy he had in painting various paintings of great size, day and night without stopping, and sadness towards suicide. Meanwhile, A experienced dominant psychotic symptoms, such as auditory hallucinations, delusion of being controlled, and persecutory delusion. There were somatic symptoms and sadness toward the end of his life. Family witnessed him cry and lose interest in painting.
Protective factors did not prevent them from committing suicide. S showed social withdrawal prior to suicide. He also came home and showed worsened psychopathology, but the family did not take him for psychiatric treatment. A turned to religion but was misguided by a spiritual healer. Both had precipitating factors: S got dumped by his girlfriend, while A became increasingly desperate with his illness and showed warning signs by saying he wished to die and bought rope at the nearest warung. He even came back to look for a longer rope.
Family history also plays a major role. S had no family history of suicide or substance abuse. Neither did A, but A’s brother showed signs of psychopathology in auditory hallucination.
An expert, Dr. Eugen Koh, who is a psychiatrist from the art psychiatry unit of St. Vincent's Mental Hospital, director of the Dax Collection and Anthony White Lecturer in art history at the University of Melbourne, has also helped me analyze the paintings.
Koh analyzed the photographs of the paintings I sent through e-mail and came up with possible differential diagnoses. A definite diagnosis was not possible because the deceased painters did not undergo psychiatric interviews.
Koh’s Differential diagnosis on S:
Possible schizophrenia and schizoaffective with narcissistic personality traits. Narcissistic Personality Disorder tends to use the defense of mania. There seems to be an impression of mania (visible from the habit of painting the whole night while singing) in the early stages of his psychosis.
Koh’s Differential Diagnosis on A:
Possible schizophrenia or anxiety neurosis with episodes of depression with obsessional personality.
Are these differential diagnoses stigmatizing their suicide? No. These diagnoses are evidence that mental illness should have been treated like any other disease before it leads to suicide.
I conducted my research in 2008, until now, no further research has been done on this psychological autopsy level.
Stigma often inhibits the reporting of suicide cases so that not all cases are reported. In many countries, suicide cases are underreported. The World Health Organization (WHO) and the UN recommend all governments to have a national suicide prevention program linked to related public health policies.
Screening mental illness in vulnerable groups is a form of suicide prevention. Connection is crucial to individuals who may be vulnerable to suicide. World Suicide Prevention Day sponsored by the IASP that fell on Sept. 10, promotes the theme "Connect. Communicate. Care." And the media—according to the 2014 Mental Health Law, has a role to play in socializing the importance of being aware and taking part in suicide prevention in a way that is conducive to the growth and development of mental health.