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Stigma and Barriers to Care in Disaster 37
Study Section. In that capacity, I am often in a room like this reviewing grants with
folks from multiple disciplines, and we have the potential to get into arguments
that we are trying to resolve to come to some sort of agreement. I think we need
to fastidiously think through the different disciplines that are around the tables
and come up with higher order constructs that may help us have dialogues over the
course of the next day-and-a-half.
Sandro, I just came back from nine days in Haiti earlier this month. You have
talked about, from an epidemiologic perspective, how population impact and safe
population impact is related to the effect, the quality and the reach of an intervention.
Say I am the frontline provider delivering care after a hurricane in my trauma center
in Haiti. I am like Charles Hoge, screening a veteran after a buddy has been blown
away the day before. I realize that there is treatment effect heterogeneity. The issue
of tailoring that intervention is key. How would you take the goal of wanting to
have a large population impact and meld it with my desire to tailor and deliver care
in a very unusual context very far from where the interventions were developed
DR. GALEA: Doug Zatzick and I have had this argument for about a decade
and I think we are never going to resolve it. We did a paper together trying to
resolve it but it seems to somehow not have stopped the argument. There is a
tension between improving population mental health and improving individual
mental health. We have to be very careful about conflating the two. The evidence
around the drivers of population mental health suggest certain approaches that
would improve the mental health of everybody, both those who are at the high end
of disability versus the low end of disability. For example, given the data I showed
here, one would think that improving social support across the board would
improve people’s access to care. Other data from many other areas including HIV
in marginalized populations shows that people who are networked and have social
support actually get care. If you improve networks and supports in populations,
I would expect us to see increase in the utilization of mental health services. This
is population-based information.
You are asking about the individual level. At the individual level, the fact that I
have low social support has relatively poor predictive value for the outcome of having
barriers to care, because the population of observation is not necessarily telling us
about a given individual. Epidemiologists and population health scientists have been
poor at providing guidance to clinicians who need algorithms for tailoring interventions.
You cannot state from my data the characteristics of the individual that should
be targeted for care. We need specific studies that identify the features that are most
likely to predict poor access to care among individuals. Nothing that I showed can
tell you that.
DR. ZATZICK: The VA is refining and honing and delivering evidence-based
treatments. To increase population access, would you think about generating on the
fly, in-setting kinds of treatments that focus on engagement How would you think
about this notion of reach
DR. GALEA: It depends on what you mean by the word treatment. If you have
a “population-wide treatment” that improves networking, linkage, and support
among everybody then my data would support that. If by treatment you mean you
are targeting a particular subset of the population, nothing from my data can tell
you that a treatment is going to work and you actually need separate trials to tell
you that it is going to work for a particular subset of individuals.
DR. FRIEDMAN: Putting these issues in a public health preventive context