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Anales de la Facultad de Ciencias Médicas (Asunción)

versión impresa ISSN 1816-8949

An. Fac. Cienc. Méd. (Asunción) vol.54 no.1 Asunción abr. 2021

https://doi.org/10.18004/anales/2021.054.01.21 

ARTICULO ORIGINAL

CAPE Vulnerability Index: Compassion, Assertive Action, Pragmatism and Evidence - Version for Latin America and the Caribbean (CAPE VI - LAC) “Globalisation, conflict, climate change, natural disasters: putting mental health into foreign policy”

Índice de vulnerabilidad CAPE: Compasión, Acción Asertiva, Pragmatismo y Evidencia - Versión para América Latina y el Caribe (CAPE VI - LAC) “Globalización, conflicto, cambio climático, desastres naturales: poner la salud mental en la política exterior”

Julio Cesar Torales1  2  3 
http://orcid.org/0000-0003-3277-7036

João Mauricio Castaldelli-Maia4  5 
http://orcid.org/0000-0001-9621-2291

Marcelo Gerardo O’Higgins2 
http://orcid.org/0000-0002-8257-0183

Ligia Florio5 
http://orcid.org/0000-0002-5961-4475

José Almirón Santacruz2 
http://orcid.org/0000-0002-8845-3228

Juan Iván Barrios2 
http://orcid.org/0000-0002-6843-7685

Rodrigo Navarro2 
http://orcid.org/0000-0003-3322-1769

Oscar Enrique García2 
http://orcid.org/0000-0002-0944-0614

Geraint Day6 

Dinesh Bhugra7 
http://orcid.org/0000-0002-0613-2480

Anna Samya Sri8 
http://orcid.org/0000-0002-5335-7332

Antonio Ventriglio9 
http://orcid.org/0000-0002-3934-7007

Albert Persaud10 
http://orcid.org/0000-0002-7349-7615

1Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Psicología Médica. San Lorenzo, Paraguay.

2Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Psiquiatría. San Lorenzo, Paraguay.

3Universidad Nacional de Asunción, Facultad de Ciencias Médicas, Cátedra de Socioantropología, Filial Santa Rosa. Santa Rosa del Aguaray, Paraguay.

4 Fundación de ABC, Santo André, Escuela de Medicina, Departamento de Neurociencias, São Paulo, Brasil.

5Universidad de São Paulo, Escuela de Medicina, Departamento de Psiquiatría. São Paulo, Brasil.

6Salud y Políticas Sociales RU. Londres, Reino Unido.

7King’s College London, Instituto de Psiquiatría, Psicología y Neurociencias. Londres, Reino Unido.

8Fundación Cornwall Partnership del Sistema Nacional de Salud, Hospital Bodmin. Cornwall, Reino Unido.

9Universidad de Foggia, Departamento de Medicina Clínica y Experimental. Foggia, Italia.

10Centro para la Investigación Aplicada y Evaluación-Fundación Internacional CAREIF. Maidstone, Reino Unido.


ABSTRACT

Introduction:

The CAPE Vulnerability Index is a global foreign policy index that identifies the countries to be prioritise for foreign aid. It offers an evidenced, structured and reasoned approach to using aid in bi-lateral agreements with mental health as a foundation. The present version is specifically design for Latin America and Caribbean (LAC) region, which comprises of 33 countries.

Objectives:

To identify the countries to be prioritized for foreign aid, through the LAC version of the CAPE Vulnerability Index (CAPE VI-LAC).

Materials and methods:

Like with the CAPE Vulnerability Index global version we consider various indices or measures at country level that indicate health status or what may influence health. For the analysis we score the worst 20 countries. We used 26 internationally available and validated indicators to explore and perform the analysis.

Results:

The figures and map show the 32 countries that featured in the worst 20 in at least one indicator and also the worst 12 within the CAPE VI-LAC as a whole. Of the 33 LAC countries only St Kitts and Nevis did not feature in any of the worst 20 countries at any time.

Conclusion:

What we can conclude with a great degree of certainty that the worst 12 scoring countries are possibly fragile states; countries where the Governments do not have complete control or authority, are often repressive and corrupt, participate in serious human rights abuses and are characterised by political instability of various forms, disadvantage by the extremes of climate changes, extreme poverty, inequality, social and ethnic divisions, unable to provide basic services and suffer from pockets of insurgency in the form of terrorism, which are often violent and brutal. Governments, aid donors, regional organizations, and mental health professionals and associations should work together in order to address these situations.

Keywords: Policy; foreign aid; failed state; fragile state; vulnerability; index.

RESUMEN

Introducción:

El índice de vulnerabilidad CAPE es un índice global de política exterior que identifica a los países a los que se dará prioridad para recibir ayuda exterior. Ofrece un enfoque evidenciado, estructurado y razonado para utilizar la ayuda en acuerdos bilaterales con la salud mental como base. La presente versión está diseñada específicamente para la región de América Latina y el Caribe (ALC), que comprende 33 países.

Objetivos:

Identificar los países a ser priorizados para la ayuda externa, a través de la versión ALC del Índice de Vulnerabilidad CAPE (CAPE VI-LAC).

Materiales y métodos:

Al igual que con la versión global del Índice de Vulnerabilidad CAPE, consideramos varios índices o medidas a nivel de país que indican el estado de salud o que puede influir en la salud. Para el análisis, calificamos a los 20 peores países. Utilizamos 26 indicadores validados y disponibles internacionalmente para explorar y realizar el análisis.

Resultados:

Las cifras y el mapa muestran los 32 países que figuraron entre los 20 peores en al menos un indicador y también los 12 peores dentro de la CAPE VI-LAC en su conjunto. De los 33 países de ALC, sólo San Cristóbal y Nieves no figuraba en ninguno de los 20 países peores en ningún momento.

Conclusión:

Lo que podemos concluir con un alto grado de certeza es que los 12 países con peores puntuaciones son posiblemente estados frágiles; países donde los gobiernos no tienen el control o la autoridad completos, a menudo son represivos y corruptos, participan en graves abusos de los derechos humanos y se caracterizan por la inestabilidad política de diversas formas, la desventaja por los cambios climáticos extremos, la pobreza extrema, la desigualdad social y étnica divisiones, incapaces de proporcionar servicios básicos y sufren focos de insurgencia en forma de terrorismo, que a menudo son violentos y brutales. Los gobiernos, los donantes de ayuda, las organizaciones regionales y los profesionales y las asociaciones de salud mental deben trabajar juntos para abordar estas situaciones.

Palabras Clave: política; ayuda externa; estado fallido; estado frágil; vulnerabilidad; índice.

INTRODUCTION

The CAPE Vulnerability Index 1 is a global foreign policy index that identifies the countries to be prioritise for foreign aid. It offers an evidenced, structured and reasoned approach to using aid in bi-lateral agreements with mental health as a foundation.

The present version is specifically design for Latin America and Caribbean (LAC) region. To identify and categorised this region we used Worldometer Countries in Latin America and the Caribbean 2.

There are 33 countries in LAC today (Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Dominica, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Santa Lucia, Saint Kitts and Nevis, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Uruguay, and Venezuela, along with 15 dependant territories (Table 1), according to the United Nations. The LAC region consists over 670,230,000 people as of 2016, and covers 21,951,000 square kilometres (8,475,000 sq mi). The people of this large LAC area shared the experience of slavery, indentured migrants, conquest and colonisation by the Spaniards, English, Dutch and Portuguese for centuries followed by movements of independence from the United Kingdom, Spain, Holland and Portugal from the early 19th century and onwards.

Table 1. The 15 dependant territories in LAC 

Overview

After several years of slow growth, the LAC economy is facing a new setback as the COVID-19 pandemic slams the global economy.

Social turmoil affected growth in parts of the region in 2019; the entire region is suffering from low oil prices and the impact of the deadly novel coronavirus - COVID-19. Most countries in the region have enforced social isolation and restricted people’s movement to avoid contagion, slashing economic productivity and raising uncertainty as to how it will affect economic growth in the coming months.

Added to this are external shocks, which vary in impact from country to country. Demand from China and other developed countries, curtailed by the pandemic, will fall dramatically, affecting commodities exporters in South America as well as exporters of manufactured goods and services in Central America and the Caribbean. Flight restrictions are already hitting the Caribbean’s tourism sector, a main source of income for many small island states.

The result: gross domestic product (GDP) in the LAC region is expected to shrink 4.6% in 2020 before returning to growth of 2.6% in 2021, according to the World Bank 3.

There are other challenges. Many of the region’s countries do not have the fiscal space of developed countries. Indeed, some were facing financial crises before the COVID-19 outbreak. which prior to this was affected by a previous virus Zika. What’s more, high levels of informality make it hard to provide relief through tax deferrals and wage subsidies to many firms and households. This informality combined with the low levels of funds makes designing an adequate policy response covering health, economic and environmental much more crucial. The hardship from the crisis will be enormous for large segments of the population. Many households live hand to mouth, they do not have the resources to cope with the economic lockdowns and quarantines needed to contain the spread of the coronavirus virus. Many workers are self-employed, and a raft of wage earners are paid under the table. Reaching these workers through financial transfers is more challenging than in formalized economies. Many households also depend on remittances, which are collapsing as shutdowns in host countries affect the incomes of migrants.

Given the unprecedented nature of the COVID-19 pandemic, forecasts of economic performance in 2020 could change dramatically and this poses a major challenge. The types of policy responses needed to rekindle economic activity are vastly different in a sharp, temporary downturn than in a major, long-lasting recession. Assessing the situation correctly is crucial for countries to operate under common assumptions about the breadth and depth of the crisis, make policy decisions, and build consensus for them from the public and key stakeholders. Unfortunately, the severity of the global economic decline remains highly uncertain, and as such the impact on the region’s economies. Latin America has an additional challenge: the worst immigration crisis in its history with almost 5 million Venezuelans have left their homeland, fleeing an economic, political and social crisis now extending for more than five years.

LAC are also exposed and vulnerable to natural disasters, from earthquakes to floods that can ravage entire regions, and hurricanes that devastate Caribbean states 4.

Taking into account the aforementioned context, we used the LAC version of the CAPE Vulnerability Index in order to identifies the countries to be prioritized for foreign aid. As far as we know, this exercise has never been done before for the LAC region.

MATERIALS AND METHODS

Like with the CAPE Vulnerability Index global version we consider various indices or measures at country level that indicate health status or what may influence health. They cover health-related factors, healthcare provision, wealth and poverty, intra-nation inequality, conflict and disaster, forcible displacement of persons, corruption (which impacts inequality) and external aid. We cross reference and rank a number of health, healthcare, socio-economic and aid indicators (where available). 2016 is the most recent time where we can get the maximum amount of complete data to undertake this analysis. For the analysis we score the worst 20 countries which include: life expectancy, disability-adjusted life years, physicians per person, gross domestic product (GDP), Gini coefficient (intra-country income or consumption inequality), current conflicts (≥ 1 000 deaths/year), refugees by country of origin, Corruption Perceptions Index and external aid received.

We used 26 internationally available and validated indicators to explore and perform the analysis, as with many summary statistics used to describe matters across the globe there is a fundamental reliance on national reporting or gathering of the underlying information used in their derivation. This exercise can be refined and repeated every year.

For the purpose of this analysis the dependant territories are not included; however, we have included a short profile for each so that a collective geopolitical picture can be visualised.

Ethical considerations

The study was approved by the Department of Psychiatry of the National University of Asunción, School of Medical Sciences, Paraguay.

RESULTS

Country Profiles 5-9

Latin America: North America

Mexico: Former Spanish colony, was the site of several advanced Amerindian civilizations (Aztec, Maya, Olmec and others). One of the leaders of the region with its economical and geopolitical importance. Population of 128,649,565. The main ethnic group is mestizo (mixed Amerindian and white) with 62%, important Amerindian minorities. Spanish is the most used language (92.7%). The principal religion is Christianity, with Catholicism as the main denomination. Life expectancy 73.9% (men), 79.6% (women).

Latin America: Central America

Belize: Former British colony. In recent time it has experimented demographical change due to immigration from other Central American nations. Population of 399,598. The principal ethnic group is mestizo, with important Creole and Maya minorities. The official language is English. The main religion is Christianity. Life expectancy is 73.7 years (men), 77 years (women).

Costa Rica: Former Spanish colony. Is one of the most stables countries in the region, with better standard of living than its neighbours. Population of 5,097,988. The main ethnic group is mestizo or white, with black and indigenous minorities. The official language is Spanish. The main religion is Christianity, with Catholicism as the main denomination. Life expectancy is 76.5 years (men), 82 years (women).

El Salvador: Former Spanish colony. Is the smallest and most densely populated country in Central America. Population of 6,481,102. The principal ethnic group is mestizo (86.3%) with white and Amerindian minorities. The official language is Spanish. The main religion is Christian with Catholicism as the main denomination. Life expectancy 71.3 years (men), 78.6 years (women).

Guatemala: Former Spanish colony, was part of the territories under the influence of the Maya civilization. Population of 17,153,288. The main ethnic group is mestizo (mixed Amerindian and white) with an important Maya minority. Spanish is spoken by 69.9% of the population, with an important use of Maya languages (at least by 29.7% of the population). The main religion is Christianity. Life expectancy 70.3 years (men), 74.5 years (women).

Honduras: Former Spanish colony with a history of political unrest and natural disasters in the last decades. Important emigrant efflux. Population of 9,235,340. The main ethnic group is mestizo (mixed Amerindian and white), with important black and Amerindian minorities. The official language is Spanish. The main religion is Christianity. Life expectancy of 71.1 years (men), 78.3 (women).

Nicaragua: is striving to overcome the after-effects of dictatorship, civil war and natural calamities. Nicaragua has traditionally relied on agricultural exports to sustain its economy but the country's meagre national wealth benefited mainly a few elite families of Spanish descent, in particular the Somoza family in the mid-20th century. This dynasty ruled the country with US backing between 1937 and the Sandinista revolution in 1979. Nicaragua population is approximately 6 million people, its main religion is Christianity with Spanish the main language with English and indigenous languages. Life expectancy 71 years (men), 77 years (women).

Panama: Former Spanish colony. In the last decades has experienced significant economic growth. Population of 3,894,082. The main ethnic group is mestizo, with important black and Native American minorities. The official language is Spanish. The main religion is Christianity. Life expectancy 76.4 years (men), 82.2 years (women).

Latin America: South America

Argentina: A former Spanish colony, being one of the largest countries in South America. It has a diverse population from different periods of immigration. Population of approximately 45,479,118 with different languages having Spanish as the official one, but there are communities that still use Italian, English, German, French, indigenous (Mapudungun, Quechua). The main religion is Christianity, with Catholicism as the main denomination, but with important Protestant and Jewish minorities. The life expectancy is 74.7 years (men), 81.1 years (women).

Bolivia: A former Spanish colony, with great influence of the Andes Mountains on the culture and the economy. Population of 11,639,909 with mestizo (mixed Amerindian and white) as the main ethnic group (68%). At least 44% of the population identifies as part of an indigenous group. Spanish with other 36 indigenous languages are official, with Spanish being used by 60.7% of the population. Christianity is the main religion with Catholicism as the main denomination. Life expectancy of 67.6 years (men), 73.4 years (women).

Brazil: A former Portuguese colony, Brazil has a highly diverse population, including indigenous native Americans and the descendants of African slaves and European settlers. Population of approximately 213, 000,000 with the main language being Portuguese with Christianity being the major religion. Life expectancy 72 years (men), 79 years (women).

Chile: A former Spanish colony. The geography and the culture are mainly influenced by the Andes Mountain range. Population of 18,186,770 with white and non-indigenous population as the main ethnic group (88.9%) and the Mapuche people as the main minority (9.1%). Spanish is the official language. The principal religion is Christianity. Life expectancy of 76.3 years (men), 82.5 years (women).

Colombia: A former Spanish colony, with various regions with different cultural characteristics. It has coastlines on the Caribbean Sea and the Pacific Ocean as well as an important Amazonian forest region. The main ethnic group is the mestizo and white (87,6%) with important Afro-Colombian and Amerindian minorities. In the recent years with an important influx of Venezuelan refugees. It has a population of approximately 49,084,841 inhabitants and the official language is Spanish. Christianity is the main religion, with Catholicism as the main denomination (79% of the population). Life expectancy 73.5 years (men), 80 years (women).

Ecuador: A former Spanish colony, located within the Andes Mountains and the Pacific Ocean. Population of 16,904,867 with mestizo (mixed Amerindian and white) as the main ethnic group (71.9%). The official language is Spanish. The main religion is Christianity, with Catholicism as the main denomination, with an important Evangelical community. Life expectancy of 74.5 years (men), 80.6 years (women).

Guyana: Situated between Venezuela and Suriname, this former British colony (British Guiana) is the only English-speaking country in South America and a member of the Commonwealth. Population of 773,000 with English being its main language with Creole, Hindi, Urdu and indigenous languages. Main religions are Christianity, Hinduism, Islam. Life expectancy 64 years (men), 69 years (women).

Paraguay: A former Spanish colony. A landlocked country, with great cultural influence from the Guarani people. Population of 7,191,685 with the main ethnic group being mestizo (mixed Amerindian and white) with 95% of the inhabitants. Spanish and Guarani are the official languages since 1992. Christianity is the main religion with Catholicism as the main denomination (89.6%). Life expectancy of 75.2 years (men), 80.7 years (women).

Peru: A former Spanish colony, with important Amerindian influence in the culture. Population of 31,914,989 predominantly mestizo (mixed Amerindian and white) (60.2%) with white and Afro-peruvian minorities. The official language is Spanish, with the co official status for the Quechua and Aymara. The main religion is Christianity with Catholicism as the main denomination, but with important Protestant congregations. Life expectancy is 72.6 years (men), 76.9 years (women).

Suriname: A former Dutch colony. A diverse country, with descendants of African slaves and workers from India and Java. Population of 609,569 with a variety de ethnic groups being the main ones: Hindustani (27.4%), Maroon (21.7%), Creole (15.7%) and Javanese (13.7%). The official language is Dutch. The main religions are Christianity (23.6% Protestant, 21.6% Catholic), Hindu (22.3%) and Muslim (13.8%). Life expectancy of 70.8 years (men), 75.9 years (women).

Uruguay: A former Spanish colony. Historically influenced by the decisions of its neighbors Brazil and Argentina. Population of 3,387,605. The main ethnic group is white (87.7%) with black and indigenous minorities. The official language is Spanish. The main religion is Christianity with Catholicism as the main denomination, important non-Catholic and non-denominational minorities as well as an important agnostic minority. Life expectancy of 74.8 years (men), 81.2 years (women).

Venezuela: A former Spanish colony, in recent years with important political unrest and with an efflux of refugees to other parts of the region and to the rest of the world. It has a diverse population, of approximately 28,644,603 inhabitants, descendants from Spanish, Portuguese, Arab, German, African immigrants and indigenous population. Spanish is the official language, with numerous indigenous dialects. The main religion is Christianity, with Catholicism as the main denomination. Life expectancy is 67.5 years (men), 74.7 years (women).

Caribbean

Antigua and Barbuda: Former British colony. Gained full independence in 1981. Population of 98,179. The main ethnic group is African descent (87.3 %). The official language is English. The main religion is Christianity. Life expectancy of 75.2 years (men); 79.6 years (women).

Bahamas: Former British colony. Gained its Independence in 1973. Population of 337,721. The main ethnic group is black (90.6%). The official language is English. The main religion is Christianity. Life expectancy 70.8 years (men), 75.8 years (women).

Barbados: Former British colony. Gained its independence in 1966. In the colonial era was one of the principal suppliers of sugar. Population of 294,560. The main ethnic group is African descent (92.4%). The official language is English. The main religion is Christianity. Life expectancy 73.6 years (men), 78.4 years (women).

Cuba: Former Spanish colony, since the 1950s under a communist regime and an international embargo that has prevented its economic development. Population of 11,059,062. The main ethnic group is white (64.1%) with important black and mixed minorities. The official language is Spanish. The main religion is Christianity, with important folk religion. Life expectancy 76.8 years (men), 81.7 years (women).

Dominica: Former British colony. Gained full independence in 1978. Population 74,243. English is the official language. The main religion in Christianity. Life expectancy 74.7 years (men), 80.9 years (women).

Dominican Republic: Former Spanish colony. Since its independence has experienced political unrest that gave path to different dictatorships, however since the last decades have improved the standard of living of its population. Population of 10,499,707. The main ethic group is mixed (70.4%) with important black and white minorities. The official language is Spanish. The main religion is Christianity. Life expectancy is 70.3 years (men), 73.8 years (women).

Grenada: Former British colony. Gained full independence in 1974. Population 113,094. The main ethnic group is African descent (82.4%). The official language is English. The main religion is Christianity. Life expectancy 72.6 years (men), 78.1 years (women).

Haiti: Former French colony. Since 1930s was led by autocratic rulers that have corrupt and repressive regimes until 1986. It is considered the poorest country in the Western hemisphere. In 2010 an earthquake of magnitude 7.0 struck Haiti and significantly worsened the country’s situation. Population of 11,067,777. The main ethic group is black (95%). The official languages are French and Creole. The main religion is Christianity. Life expectancy 62.6 years (men), 68 years (women).

Jamaica: Former British colony. Before the British, the Spanish displaced the original inhabitants of the island and replaced them with African slaves. Gained full independence in 1962. Population of 2,808,570. The main ethnic group is black (92.1%). The official language is English. The main religion is Christianity. Life expectancy is 73.4 years (men), 77.1 years (women).

Saint Kitts and Nevis: Former British colony. Gained full independence in 1983. Population of 53,821. The main language is English. The main ethnic group is African descent. The main religion is Christianity. Life expectancy 74.1 years (men), 79.1 years (women).

Saint Lucia: Former British colony. Gained full independence in 1979. Population of 166,487. The main ethnic group is African descent (85.3%). The official language is English. The main religion is Christianity. Life expectancy 75.7 years (men), 81.4 years (women).

Saint Vincent - Grenadines: Former British colony. Gained full independence in 1979. Population 101,390. The main ethnic group is African descent (71.2%). The official language is English. The main religion is Christianity. Life expectancy is 74.1 years (men), 78.3 years (women).

Trinidad and Tobago: Is one of the wealthiest countries in the Caribbean, thanks to its large reserves of oil and gas, the exploitation of which dominates its economy. Inhabited mostly by people of African and Indian descent, this former British colony is a two-island state which enjoys a per-capita income well above the average for Latin America and the Caribbean. Trinidad and Tobago population is about 1.3 million people, its main language is English with Hindi and Urdu spoken amongst the Indian descent population. The main religions are Christianity, Hinduism and Islam. Life expectancy 67 years (men), 74 years (women).

Dependant Territories

Anguilla: Overseas territory of the United Kingdom. Population 18,090. The main ethnic group is African (85.3%). The official language is English. The main religion is Christianity. Life expectancy 79.2 years (men), 84.5 years (women).

Aruba: Constituent country of the Kingdom of the Netherlands. Population 119,428. The main ethnic group is Aruban (66%). The official languages are Papiamento and Dutch. The main religion is Christianity. Life expectancy 74.4 years (men), 80.7 years (women).

British Virgin Island: Overseas territory of the United Kingdom. Population 37,381. The main ethnic group is African (76.3%). The official language is English. The main religion is Christianity. Life expectancy 77.7 years (men), 80.8 years (women).

Caribbean Netherlands: Are the 3 special municipalities of the Netherlands located in the Caribbean Sea; They consists of the islands of Bonaire, Sint Eustatius and Saba also referred to as BES Islands. These islands are administered by the The National Office for the Caribbean Netherlands on behalf of the Government of the Netherlands and is responsible for taxation, policing, immigration, transport infrastructure, health, education, and social security in the islands. The main language is Dutch with English; Christianity is the major religion. Life expectancy 76 years (men), 82 years (women).

Cayman Island: Overseas territory of the United Kingdom. Population 61,944. The main ethnic group is mixed (40%), followed by white (20%) and black (20%). The official language is English. The main religion is Christianity. Life expectancy 78.9 years (male) y 84.4 years (women).

Curacao: Constituent country within the Kingdom of the Netherlands. Population 151,345. The main ethnic group is Curacaoan (75.4%). The official languages are Papiamento and Dutch. The main religion is Christianity. Life expectancy is 76.6 years (men), 81.4 years (women).

Falkland Islands: Overseas territory of the United Kingdom; also claimed by Argentina as Islas Malvinas. The territory was part of a military conflict between the United Kingdom and Argentina in 1982 that ended with the surrender of the Argentinian forces. Population 3,198. The main ethnic group is the Falkland islander (48.3%) followed by the British (23.1%). The official language is English. The main religion is Christianity. Life expectancy 75.6 years (men), 79.6 years (female).

French Guiana: French overseas region. Population 290,691. The main ethnic group is the Creole (30-50%). The official language is French. The main religion is Christianity.

Guadeloupe: French overseas region. Population 395,700. The main ethnic group is the Afro-Caribbean. The official language is French. The main religion is Christianity

Martinique: French overseas region. Population 376,480 (2016). The main ethnic group is the Afro-Caribbean. The official language is French. The main religion is Christianity

Montserrat: Overseas territory of the United Kingdom. Population 5,373. The main ethnic group is African descent (88.4%). The official language is English. The main religion is Christianity. Life expectancy 76.4 years (male) y 74.1 years (women).

Puerto Rico: Unincorporated organized territory of the United States of America. Population 3,189,068. The main ethnic group is white (75.8%) followed by African American (12.4%). The most used languages are Spanish and English. The main religion is Christianity. Life expectancy 78 years (men), 84.7 years (women).

Saint Martin: French overseas collectivity. Population 32,556. The main ethnic group is Creole. The official language is French. The main religion is Christianity. The main religion is Christianity. Life expectancy 77 years (men), 83.4 years (women).

Turks and Caicos: Overseas territory of the United Kingdom. Population 106,235. The main ethnic group is African-American (76%). The official language is English. The main religion is Christianity. Life expectancy 77.6 years (male) y 83.3 years (women).

US Virgin Island: Unincorporated organized territory of the United States of America. Population 3,189,068. The main ethnic group is white (75.8%) followed by African American (12.4%). The most used languages are Spanish and English. The main religion is Christianity. Life expectancy 76.6 years (men), 83.2 years (women).

(Table 2 - Table 3 - Table 4)

Table 2. Health, healthcare, socio-economic and aid indicators (where available) for LAC. Year 2016 (except where indicated) - worst 10 countries highlighted in bold (and see notes for where no data were available) 

Table 3. Human freedom index 2016 

CAPE Vulnerability Index - Version for Latin America and the Caribbean (CAPE VI - LAC)

CAPE VI - LAC has been calculated from the number of times each country is listed in the worst 20 within each of the nine parameters examined. The figures and map show the 32 countries that featured in the worst 20 in at least one indicator and also the worst 12 within the CAPE VI-LAC as a whole. Of the 33 LAC countries only St Kitts and Nevis did not feature in any of the worst 20 countries at any time.

The CAPE VI - LAC was constructed arithmetically and without weighting from the number of occurrences of the country in the 20 worst ranked of nations for each of the nine parameters. Each of the nine parameters is an independent measure of a particular characteristic, although it is to be expected that there may be correlations between some of them for example life expectancy and DALYs, and physician numbers and GDP. Note that some of the original sources - the Gini coefficient and the CPI - are themselves compound indices based on a number of individual variables.

Life Expectancy (Gráfic 1)

Gráfic 1. 

Health related disability-adjusted life years (DALYs) (Gráfic 2)

Gráfic 2. 

Healthcare provision: physicians per person (Gráfic 3)

Gráfic 3. 

Economies: GDP (Gráfic 4)

Gráfic 4. 

Inequality: GINI (Gráfic 5)

Gráfic 5. 

Current conflicts (Gráfic 6)

Gráfic 6. 

Refugees by country of origin (Gráfic 7)

Gráfic 7. 

Corruption (Gráfic 8)

Gráfic 8. 

External aid received (Gráfic 9)

Gráfic 9. 

Human Freedom (Gráfic 10)

Gráfic 10. 

Corruption Perception & Human Freedom (Gráfic 11)

Gráfic 11. 

Table 4.  Cape vulnerability index - version latin america and the caribbean (CAPE VI - LAC) 

CAPE Vulnerability Index Latin America and the Caribbean (CAPE VI - LAC): The 12 worst scoring countries (Gráfic 12)

Gráfic 12. 

32 countries from data ranking 12 + 20 countries in Latin America and the Caribbean by: life expectancy, DALYs, physicians per person, GDP, Gini coefficient, current conflicts (≥ 1 000 deaths/year), refugees by country of origin, Corruption Perceptions Index and external aid received (funds/resident population) (Gráfic 13)

Gráfic 13. 

DISCUSSION

What we can conclude with a great degree of certainty that the worst 12 scoring countries are possibly fragile states; countries where the Governments do not have complete control or authority, are often repressive and corrupt, participate in serious human rights abuses and are characterised by political instability of various forms, disadvantage by the extremes of climate changes, extreme poverty, inequality, social and ethnic divisions, unable to provide basic services and suffer from pockets of insurgency in the form of terrorism, which are often violent and brutal. Of the remaining 20 countries, there are about 5 countries with scores between 47-69 CAPE VI - LAC who can easily become fragile states because of the impact of COVID19, deepening economic crisis and political instability in Venezuela, political violence and instability in Nicaragua, Chile and Columbia worsening the migration crisis in Central America and an intensification of organized crime-related violence in Mexico creating more political, economic, security and social instability.

CAPE VI - LAC and Mental Health

It is not an exaggeration to say that the world is facing a number of crises at the geopolitical level. From the current COVID-19 pandemic along with an increase in population to climate change, human‑made and natural disasters and ongoing conflicts leading to mass migration and increase in refugees and asylum seekers to the impact of climate change with droughts and floods, geopolitical factors are being recognized. However, often their impact on mental health of individuals or their communities and environment often the invisible mental health scars are not taken into account at all. Even with spread of infectious disease spread, often the focus remains on the control of infection without taking into account the impact of survivor guilt, loss, and grief resulting from such loss, etc, on an individual’s mental health and well‑being.

On a global level, human rights violations are perpetually experienced by individuals with mental illness. In many middle and low-income countries, they do not have access to basic mental health care and treatment required. The only care available is psychiatric institutions, which are commonly inhumane and degrading living conditions 10. Certain cultures and religions view mental illness as a “weakness”, and those diagnosed with a mental health disorder and deemed “unproductive” and “unable to upkeep a family”.

The stigma associated with mental health problems must be considered. People with mental health problems have difficulties with seeking professional help for their conditions and this have been associated with internalized and treatment stigma, particularly in ethnic minorities, youth, men and those in military or health professions 11. Primary care providers could be subject of the influence of stigma in taking decisions about the adherence to treatment of patients with mental health problems and even are less likely to refer to a specialist or to refill the patient prescription based on their own experience with other mental health patients 12.

However, as the COVID-19 pandemic continues, it has exposed the detrimental impacts of individual’s and communities’ mental health (whether they have a pre-diagnosed mental disorder or not), as they have been forcefully relocated following ongoing pre-COVID war conflicts, poverty, and disasters (natural and man-made) 13. Major migration and displacement events have risen over the last two years, which have resulted in great hardship and trauma, as well as loss of life 14. The extreme violence (such as inflicted upon Rohingya forced to seek safety in Bangladesh), the conflict (such as from Syrian Arab Republic), or severe economic and political instability (such as faced by millions of Venezuelans) consequently results in an uprising scale of international migration 14. Even weather-related hazards (tsunamis in Sri Lanka and Japan; natural disaster in Haiti) leads to planned migration, change of location and displacements 14,15, which has now involved international policies to be written up to address the impacts of climate change. Consequently, stress and mental illness are associated with migration, and settling down under such circumstances are often complicated and goes unnoticed due to infections and other physical illness 15.

Psychiatry, Human Rights and Geopolitics

The WHO defined health crises as having their “own unique markers”, including clear protocols and preparedness procedures. However, migration is rarely included in relevant policies, which significantly impacts the migrants and communities alike 14. Mental health is a public health issue, and the right to access healthcare is a human right issue, but both are being deprived from asylum seekers, refugees and internally displaced people.

The Universal Declaration of Human Rights (United Nations, 1948) and European Convention on Human Rights (Council of Europe, 1950) are general declarations of human rights (16). However, the most precise declaration of rights for the perspective of mental illness, is provided by the United Nations, in its Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (United Nations, 1991). It accentuates that every human being is entitled to receive the best mental healthcare available, receive the upmost respect and humane treatment, and receive mental healthcare based on internationally accepted ethical standards. Moreover, mental health facilities should be appropriately and practically structured and resourced, and an impartial review body should, in view of consulting with mental health practitioners, review the cases of involuntary patients 16.

Over the past decade, international migration has been increasingly weaponized as “a political tool” to undermine democracy 14 and inclusive municipal engagement, aiming to divide communities on the issue of migration, demoralizing the significant benefits that enriched migration brings to the communities and ignoring our worldwide migration histories. Amongst countries whose statistics are overwhelmed by the rise of refugees, tensions are running high and feelings of ambivalence had created a dichotomy amongst the community, where the majority of the locals feel that their own values and cultures are being erased 17. The perceived discrimination and negative outcomes and forceful exclusion is strongly associated with poor mental and physical wellbeing, inflicting their migrants’ human rights to recover from trauma and the loss of “purpose of life” as result international differences of governments.

Being an asylum seeker or a refugee is not necessarily linked to having a mental disorder. In fact, the rates of psychosis and depression may not be disparate to those of host populations 18. However pre-, peri and post-migration risk factors, such as exposure to war and conflict, material deprivation, trauma and torture, and bereavements of people and place, can altogether contribute to an increase risk of PTSD (post-traumatic stress disorder) that have been reported in both children and adults. Children may be vulnerable to powerful emotions associated with trauma, injustice and loss events 19,20. Opportunities for employment and having adequate material resources (housing, income, food and safety) play an important part in protecting the mental health of vulnerable individuals and groups. Geographical mobility remains an issue despite after migration, especially when it is forced 21. The experience of those in receiving countries is often that mental health is the priority, more than the provision of formal mental health services after the individual has developed a mental disorder 22.

By marginalization and stigmatizing asylum seeker and refugees, who seeks inclusive status as a “sense of belonging”, this further ostracizes them from basic needs, such as education, employment and rightful healthcare, and exposes them to discrimination, abuse and violence. In addition to fear of being deported, their experiences of loss and potential culture shock, and facing further discrimination if they are diagnosed with a mental disorder, altogether impacts their willingness to seek and accept mental healthcare services 14.

Recommendations

What should governments do?

Governments should seek scientific based measures in order to adequate their own mental health services to the new and adapting situations like the COVID-19 pandemic, as well to the cultural background and structural stigma that their own societies could have in order to offer real mental health resources to their populations 23.

What should aid donors do (World Bank, etc)? What should regional organizations do? CARICOM, ECLAC, OHCHR, World Bank in Latin America, The Organization of American States, The Central American Integration System (SICA).

Funders should recognise reliable groups that have served to encourage local mental wellbeing. Such state and non-governmental agencies play an essential part in connecting individuals with psychiatric illnesses with psycho-social services. Historically, as a result of Basaglia's impact on politics and politicians, Latin America has moved from an asylum-centric to a community-based structure 24. The mobilisation of society in favour of the gradual deactivation of asylums was motivated by this reform 25. There is a growing number of Psychosocial Treatment Centers (CAPS) as an outstanding example of the group paradigm as the focal point of Brazil's mental health care structure and delivery of care 26. These outpatient treatment units have been built to facilitate intensive care, including alcohol and drug abuse, for individuals with serious psychiatric illnesses 27. There could be some crucial problems with ensuring sufficient funds for the creation of those community programs and the participation of Latin America's community and culture. The asylum dissolution process should be accelerated, and mental health facilities should be included in general hospitals for brief hospitalisations (up to 15 days). This will prevent psychiatric emergency care from overcrowding and could also lead to a decline in stigma and a greater understanding of mental illness and people with mental illness.

What should Psychiatry do? Who will do what? How will CAPE VI-LAC be presented and shared?

There is no question that the availability of community mental health services contributes to greater inclusion and elimination of mentally ill people's isolation and shame 28. While single persons are affected by mental illness, the family and society linked to the patients are heavily involved 29. To target clinical strategies and recovery services, the family and society need to be engaged to consider the context of patients, including their psychological, cultural, economic and clinical needs. It is well established that the efficacy of such approaches in the community is even greater than it is in the organisational structure 30. In the context of the bio-psycho-social model, the Community Mental Health Service should target health care services based on social, cultural and economic considerations 31. In addition, community service should promote fair access to the pathways of psychiatric treatment for patients belonging to all legal, ethnic and economic classes of society: contemporary psychiatry should be motivated by social justice 29. Mental health clinics can monitor the actions of patients and accurately include treatment modalities, but cannot customise interventions depending on the characteristics of patients. Psycho-social care should also be offered on the basis of psychological, cultural, and economic norms and should educate patients on socially required skills 32,33 and, in the context of the current COVID-19 pandemic, address the additional mental health problems that are emerging in the population of LAC and worldwide 34.

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Received: January 21, 2021; Accepted: March 03, 2021

Autor correspondiente: Dr. Albert Persaud. Centro para la Investigación Aplicada y Evaluación-Fundación Internacional CAREIF. Maidstone, United Kingdom. E-mail: albert.persaud@geopsychiatry.com

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