lack of mental health services in el salvador

[48] Karolina Kozik and Jean-Sbastien Spulchre, Disability Rights Bill Offers Hope in Congo, commentary, Human Rights Watch Dispatch, March 11, 2020, https://www.hrw.org/news/2020/03/11/disability-rights-bill-offers-hope-congo; Sophie Morgan, The country where disabled people are beaten and chained, BBC News Online, July 28, 2015, https://www.bbc.com/news/blogs-ouch-33523742 (accessed September 21, 2020); Shantha Rau Barriga (Human Rights Watch), Torture Comes in Many Forms, commentary,The Huffington Post, June 29, 2015, https://www.huffpost.com/entry/torture-comes-in-many-for_b_7691390?guccounter=1 (accessed September 16, 2020). [160] UNHRC, Report of the Special Rapporteur on torture, and other cruel, inhuman or degrading treatment or punishment, Juan E. Mndez, A/HRC/22/53, February 1, 2013, https://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf, para. Personal hygiene is a serious problem since people who are chained often do not have access to a toilet. [110] Human Rights Watch, Like A Death Sentence, https://www.hrw.org/sites/default/files/reports/ghana1012webwcover.pdf, p. 50. According to the U.S. Department of Health and Human Services, one in five American adults have experienced a mental health issue, and one in 20 Americans live with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression. [64] Mentally Ill Confined at Home Due to Lack of Resources and Public Education, Global Times, June 25, 2015, https://www.globaltimes.cn/content/928917.shtml (accessed July 28, 2020); Caged People, The Beijing News, July 11, 2013, http://www.bjnews.com.cn/feature/2013/07/11/272800.html (accessed July 28, 2020); Chinese Healthcare: The Rural Reality, Collective Responsibility, July 23, 2018, https://www.coresponsibility.com/chinese-healthcare-the-rural-reality/ (accessed May 2020); 26-year-old Mentally Disturbed Man in China Locked in Cage by His Parents, Hong Kong Free Press, January 15, 2016, https://www.hongkongfp.com/2016/01/15/26-year-old-mentally-disturbed-man-in-china-locked-in-cage-by-his-parents/ (accessed May 2020); A Mentally Ill Chinese Man Has Been Locked In A Cage By His Family For 11 Years, Business Insider, May 28, 2013, https://www.businessinsider.com/chinese-man-kept-in-cage-for-11-years-2013-5 (accessed July 28, 2020); Chinese Mentally Ill Woman, Chained in Room for Decades by Family, to Get Medical Treatment, South China Morning Post, undated, https://www.scmp.com/news/china/society/article/1815641/chinese-mentally-ill-woman-chained-room-decades-family-get (accessed July 28, 2020). WHO report highlights global shortfall in investment in mental health In other cases, people have to use a drain or an open toilet in the room. Individuals located in rural areas and of lower-income are less likely to say that mental health services are extremely accessible to them. In the same period this year, it has happened 37 times18 times in June alone.. While the pandemic has exacerbated underlying mental health issues for many Americans, barriers to receiving mental health care have existed for years. The stigma attached to psychosocial disabilities extends to the mental health profession, which often discourages doctors from specializing in psychiatry and causes many general physicians and other health care workers to resist mental health training. COMMENTARY: Redrawing the battle lines: Vote yes for mental health 15; CAT; ACHPR, art.5; ACHR, art. (2019, October 1). [150], The CRPD introduces a significant shift in approach to legal capacity, giving agency to people with disabilities and empowering them to make decisions and exercise rights on their own behalf. 58 (1982), entered into force October 21, 1986. Human Rights Watch research in 2013 in Cambodia found that people with real or perceived psychosocial disabilities are forcibly locked up and often chained in drug detention centers, or in sporadic crackdowns to clean the streets ahead of high-profile international meetings or visits by foreign dignitaries. Wyoming and Utah have the largest proportion of population living in mental health shortage areas, at 96.4% and 83.3%, respectively. [129] The Mental Healthcare Act, 2017, https://www.prsindia.org/uploads/media/Mental%20Health/Mental%20Healthcare%20Act,%202017.pdf (accessed September 22, 2020), art. While countries are increasingly starting to pay attention to the issue of mental health, the practice of shackling remains largely invisible. 217A(III), U.N. Doc. Because we currently lack the needed resources many of our. Please give now to support our work, Share this via Facebook And women and girls are not supported to manage their menstrual hygiene, for example through the provision of sanitary pads. In Nigeria, Human Rights Watch visited 28 state-run and private facilities between 2018 and 2019, across which a few hundred people were arbitrarily detained, and where people were regularly chained or shackled. More in This Topic Guide. Spike in suicides in El Paso County jail highlights shortfalls of Many interviewees appeared undernourished and complained of hunger. Most mental health professions require at least a bachelors degree, except for psychiatric nurses, and many require additional post-graduate education and certification. Res. The report also draws on Human Rights Watchs extensive research on stigma, mental health, and discrimination that people with psychosocial disabilities face around the world, including in Australia, Brazil, Cameroon, Croatia, India, Iran, Kazakhstan, Preventing institutionalization should be an important part of this plan. This is the case for Sodikin, a 34-year-old man with a psychosocial disability, who had been released from chains after over 8 years shackled in a shed outside his family home in Cianjur, West Java in Indonesia. In some instances, people are provided with a small bucket to urinate and defecate in, but these are emptied only once a day leaving a putrid smell in the room for most of the day. Clinical psychologists usually need a Doctor of Philosophy in psychology (PhD) or a Doctor of Psychology (PsyD) degree. [49], A volunteer from an organization providing services to people with disabilities in Cameroon said: People in Cameroon have negative perceptions about disability. [12] The World Health Organization (WHO) reports that one in five of the worlds children and adolescents have a mental health condition. [176] The right to be free from non-consensual medical treatment and experimentation is guaranteed under the ICESCR. The El Salvador-based nonprofit has mobilized over 100,000 volunteers, like Emanuel, and trained frontline workers across Central America and Mexico, reaching more than 2 million children and adults. This is in part due to a lack of government support and monitoring. [23] Consequently, instead of walking a short distance to a primary health center, families may have to give up a days work to travel to reach a psychiatric hospital. Strengthening Health Care in El Salvador - SaportaReport This report includes field research and testimonies collected by 16 Human Rights Watch researchers working in their own countries, including Afghanistan, Burkina Faso, Cambodia, Ghana, Indonesia, Kenya, Liberia, Mexico, Mozambique, Nigeria, Sierra Leone, Palestine, Russia, the self-declared independent state of Somaliland, South Sudan, and Yemen. It focuses on raising awareness about mental health and pasung, integrating mental health into primary health services, providing mental health medication at the 9,909 community health centers, training health staff to identify and diagnose basic mental health conditions, and creating community mental health teams called Tim Penggerak Kesehatan Jiwa Masyarakat (TPKJM) that act as a coordination mechanism between the department of health and others departments at the provincial and district levels to monitor and facilitate the release of people from pasung. [33] The World Bank, Mental Health, https://www.worldbank.org/en/topic/mental-health; WHO, Mental Health, https://www.who.int/news-room/facts-in-pictures/detail/mental-health; WHO, Mental Health in the Workplace, https://www.who.int/mental_health/in_the_workplace/en/. I was fearful that someone would attack me during the nights, without being able to defend myself because of being shackled.[89], People end up living shackled in institutions for long periods because their relatives do not take them home and the institution has nowhere to send them. Emergency workers struggle to get mental health services in El Salvador The WHOs World Mental Health Survey found that only 1 in 5 people with depression receive minimally adequate mental health services in high-income countries and it falls to 1 in 27 in low and middle-income countries. The government identifies shortage areas so it can address them with proper resources. Institutions: Refers to state-run (unless specified otherwise) psychiatric hospitals, government social care or nongovernmental organization-run residential facilities. I am not free to walk about. As a result of this initiative, according to the WHO, 1,700 people were freed from chains in Somalia between 2007 and 2010. Those workshops address teen marriage and pregnancy, suicidality, behavioral problems and drug and alcohol misuse in an effort to improve educational and professional outcomes for rural populations. It is typically an administrative process and does not contain any provisions for judicial oversight. [101] Ghana: Faith Healers Defy Ban on Chaining, Human Rights Watch news release, November 27, 2019, https://www.hrw.org/news/2019/11/27/ghana-faith-healers-defy-ban-chaining. [45] Human Rights Watch interview with Dr. Kafayah Ogunsola, psychiatrist, Lagos, September 26, 2018; Karoon, What is the state of mental health in Thailand?, post to Pacific Prime Thailand (blog),June 24, 2019, https://www.pacificprime.co.th/blog/state-of-mental-health-in-thailand/(accessed March 23, 2020); Melinda Benjamin, The Promotion of Mental Health Awareness in Cambodia, Borgen Magazine,August 1, 2019,https://www.borgenmagazine.com/mental-health-awareness-in-cambodia/(accessed March 19, 2020); Nivendra Uduman, Mental Health and Stigma in Sri Lanka, post to Ground Views (blog), February 19, 2018, https://groundviews.org/2018/02/19/mental-health-and-stigma-in-sri-lanka/ (accessed March 23, 2020); Mark Tilly,TV series to fight mental health stigma, Khmer Times, August 25, 2017,https://www.khmertimeskh.com/79742/tv-series-fight-mental-health-stigma/(accessed March 19, 2020); Human Rights Watch, We Are Also Dying of AIDS, https://www.hrw.org/sites/default/files/reports/zambia0714_ForUpload_1.pdf, p.16; A. Allen,andE.Green,Discrimination and Stigmatization of People with Epilepsy in Zambia: The Need for Integration of Social, Healthcare, and Policy Reform, Southern African Institutefor Policy and Research,August 19, 2013, http://saipar.org/wp-content/uploads/2013/09/Allen-and-Green_Discrimination-and-Stigmitisation_Final-DraftCorrected.pdf (accessed April 2, 2020); Jane Chung,Disabled South Koreans Protect Inhumane Benefits System, Reuters, October25, 2012, https://www.reuters.com/article/us-korea-disabled/disabled-south-koreans-protest-inhumane-benefits-system-idUSBRE89O05X20121025 (accessed March 23, 2020); International Federation for Human Rights and Taiwan Association for Human Rights,The Hidden Face of Taiwan: Lessons learnt from the ICCPR/ICESCR review process,April2013,https://www.refworld.org/pdfid/51e799594.pdf(accessed March 23, 2020); M. Bari Qasem Saleh and A. Mohamed Makki,Mental Health in Yemen: Obstacles and Challenges, International Psychiatry,5.4(2008),https://www.cambridge.org/core/services/aop-cambridge-core/content/view/2F6080907180CF8B9BE1296B6C9D0360/S1749367600002277a.pdf/div-class-title-mental-health-in-yemen-obstacles-and-challenges-div.pdf(accessed March 18, 2020), pp. 15 April 2022. Ensure these programs are gender-sensitive. Malakis story helped shape his community to be more inclusive and accepting. [158] UN General Assembly, Interim Report of the Special Rapporteur on torture and cruel, inhuman or degrading treatment or punishment, Manfred Nowak, A/63/175, July 28, 2008, https://undocs.org/A/63/175(accessed September 23, 2020), para. 24; CEDAW, art 12; CRPD, art. The deadline was extended to 2019. 1, U.N. Doc. [49] Human Rights Watch interview with Benjamin Ballal, survivor of shackling and secretary general for cultivation at Cultivation for Users Hope, Nairobi, February 15, 2020. In many countries around the world, there is a widespread belief that mental health conditions are the result of possession by evil spirits or the devil, having sinned, displaying immoral behavior, or having a lack of faith. [135] By 2012, the program had unlocked 271 people who had been shackled for periods ranging from 2 weeks to 28 years across 26 provinces. Its very challenging to navigate domains where we may be told we dont belong, he says. MSF has continued to operate non-COVID-19 healthcare activities in the two most populated cities, Soyapango and San Salvador, which are now epicenters of the outbreak. Addressing the escalating psychiatrist shortage | AAMC In one case, a person died while tied up and locked in one of the bathrooms, which was used as an isolation room. [78] Despite being shackled for most of her life, her case was never counted or included in government data because its a practice that remains invisible and hidden, even from neighbors, the local community, and the authorities. 108(e); United Nations Educational, Scientific, and Cultural Organization (UNESCO), Universal Declaration on Bioethics and Human Rights, adopted October 2005, SHS/EST/05/CONF.204/3 REV, arts. The ACRWC has been ratified by Benin, Burkina Faso, Cte dIvoire, Egypt, Ethiopia, Ghana, Kenya, Liberia, Mozambique , Nigeria, Senegal, Sierra Leone, South Africa, Sudan, Tanzania, Togo, Uganda, and Zimbabwe. Poor mental health, an obstacle to development in Latin - World Bank In several cases, the ambulance was called when patients were already in critical condition. Students and Human Rights Watch researchers also conducted phone interviews with activists, representatives of local NGOs, mental health professionals, and journalists. Of the 60 countries where Human Rights Watch found evidence of shackling, only a handful have laws, policies or strategies in place that explicitly ban or aim to end shackling of people with mental health conditions. Over 400 million people worldwide lack access to essential health services typically delivered through primary healthcare. Human Rights Watch research found that in institutions and healing centers visited, people with psychosocial disabilities often live in severely overcrowded and unhygienic conditions. [70] Nigeria: People With Mental Health Conditions Chained, Abused, Human Rights Watch news release, November 11, 2019, https://www.hrw.org/news/2019/11/11/nigeria-people-mental-health-conditions-chained-abused. In many institutions in Indonesia, people with psychosocial disabilities were fed meals devoid of proper nutrition such as instant noodles for most meals.[113]. Between October 2018 and February 2019, nearly 260,000 people left the Northern Triangle region (El Salvador, Guatemala and Honduras)about double the number who left during the same period the previous year, according to an analysis of U.S. Customs and Border Protection (CBP) and other data by migration researchers at the Lawfare Institute, a nonprofit educational organization based in Washington, D.C. (Leutert, S., & Spalding, S., Lawfare, Mar. About 80 percent of people with disabilities, including people with psychosocial disabilities, live in middle or low-income countries where it is often challenging to access healthcare,. The impoverished often live in overcrowded areas. Last Updated: 04/22/2022. This system effectively gives mental health the same importance as all other indicators and ensures that community health workers provide immediate and ongoing mental health services to meet their target of 100 percent coverage. [122] However, Human Rights Watch research found that people with psychosocial disabilities were forcibly treated, even in non-life threatening situations. "The lack of community-based mental health solutions, the lack of civil beds, the lack of walk-in centers and crises centers all of that has resulted in the last resort: the emergency. Access to mental health care in El Salvador: a case study of - PubMed [82] In another case, a woman with a psychosocial disability was chained for 24 years (since she was 10 years old) in Egypt.[83]. In Tanzania, Malaki, a boy with an intellectual disability was chained to a pole by his family to ensure he remained safe in his home in Nyarugusu refugee camp in Kigoma province in Tanzania in 2017. But through this program, we are working to create a culture of prevention., Other psychologists have turned their attention to a frequently overlooked populationthose who have been deported from the United States, known as retornados.. [40] Human Rights Watch interview with Ridha, family member, September 2020 (full name and details withheld). Stark Disparities in Accessibility at State and Income Levels. [133] WHO, Building Back Better: Sustainable Mental Health Care after Emergencies, 2013, https://apps.who.int/iris/bitstream/handle/10665/85377/9789241564571_eng.pdf?sequence=1 (accessed August 17, 2020), pp. Res. Participants were 383 high school students (50.9% boys) aged 11-18 years (M = 14.12, SD = 1.91) in El Salvador. A 2019 evaluation conducted by the Institute of Mental Health, University of Nottingham found that people who completed the QualityRights e-training course showed significant improvements in attitudes and practices towards a human rights based approach to mental health, including the need to end force and coercion in mental health services and to provide information and choice as well as respect peoples decisions concerning treatment. [153] CRPD Committee, General Comment No. In some healing centers, people were allowed to bathe once a day using a hose in their rooms. 24-64; Treated Worse Than Animals: Abuses against Women and Girls with Psychosocial or Intellectual Disabilities in Institutions in India, December 2014, https://www.hrw.org/sites/default/files/report_pdf/india1214.pdf, p. 34; We Are Also Dying of AIDS: Barriers to HIV Services and Treatment for Persons with Disabilities in Zambia, July 2014, https://www.hrw.org/report/2014/07/15/we-are-also-dying-aids/barriers-hiv-services-and-treatment-persons-disabilities; Like A Death Sentence: Abuses against Persons with Mental Disabilities in Ghana, October 2012, https://www.hrw.org/sites/default/files/reports/ghana1012webwcover.pdf, pp. [102] Disability Rights International, No Justice: Torture, Trafficking and Segregation in Mexico, July 22, 2015, https://www.driadvocacy.org/wp-content/uploads/Sin-Justicia-MexRep_21_Abr_english-1.pdf (accessed September 21, 2020). [7] In Indonesia, traditional healers who are versed in magic or dealing with spirits are usually referred to as paranormal or dukun, while Islamic faith healers who use Quranic recitations as a treatment method are known as ustad or kiai. Of the Americans that have not sought mental health treatment, more than half, or 53%, were in low-income households. [107] When the city of Taizz, Yemen, was attacked in mid-2017, Jalila al-Saleh Ali fled with her two sons, and in her distress left behind her husband with a psychosocial disability in chains. Human Rights Watchs research into mental health settings in at least 25 countries has found that people with mental health conditions can face a range of abuses when sent to a psychiatric hospital, such as arbitrary detention, involuntary treatment, including electroconvulsive therapy, forced seclusion as well as physical and sexual violence. [125] Nigeria: People With Mental Health Conditions Chained, Abused," Human Rights Watch news release, https://www.hrw.org/news/2019/11/11/nigeria-people-mental-health-conditions-chained-abused. 2 (1); ACHPR, arts. [55] Shackling is also used in church-affiliated prayer camps, traditional or religious healing centers as well as in state-run or private social care institutions as a form of restraint, punishment, or treatment.[56]. [136] The program demonstrated that accessible community-based mental health services were key to ensuring people remained free from chains and proved to be an example of how non-healthcare workers could be mobilized to deliver services in rural and low-resource settings. 90% of our funding comes from individual donors. [72] In Morocco, the government in 2015 released over 700 people chained in one shrine alone, about 50 kilometers from Marrakesh in the southwestern part of the country. American Psychological Association. [68] In the Greater Accra Region, there are an estimated 70 prayer camps. 37. In a privately-run social care institution in Russia, staff regularly brought people with psychosocial disabilities to the dining hall chained to each other and forced them to eat in handcuffs. In a few countries, government efforts at the national level to eradicate shackling have had some success in creating a roadmap to ending the practice. As of 2018, more than two-thirds of all countries did not cover reimbursement for mental health services in national health insurance schemes. Mental health services in the U.S. are insufficient despite more than half of Americans (56%) seeking help. Liberation psychology, for example, established in the 1970s by Jesuit priest Ignacio Martn-Bar, PhD, calls on psychologists to redefine their role as sociopolitical and to support oppressed communities. Although faith healing centers can be registered with a government department or religious authority, they are not always regulated or monitored. They dont want to socialize with me because my mental health condition brings shame on them. Human Rights Watch interviews with Benjamin Ballal, February 15, 2020; Archbishop Danokech, February 18, 2020; and Fiera [not her real name], November 20, 2019. Education is crucial to help people understand more about life in the United States as a migrant, says Maria Elena Humphrey, PhD, former executive secretary for Mexico, Central America and the Caribbean at the Interamerican Society of Psychology. 1. While many countries are increasingly starting to pay attention to the issue of mental health, the practice of shackling remains largely invisible. [109] "Indonesia: Shackling Reduced, But Persists," Human Rights Watch news release, October 2, 2018, https://www.hrw.org/news/2018/10/02/indonesia-shackling-reduced-persists. Even when mental health services are free or subsidized, the distance and transport costs are a significant barrier. [180] UN General Assembly, Report of the Special Rapporteur on the rights of persons with disabilities, A/73/161, July 16, 2018, https://undocs.org/en/A/73/161 (accessed September 17, 2020), para. 16; ACRWC, art. In state-run or private institutions, as well as traditional or religious healing centers, they are often forced to fast, take medications or herbal concoctions, and face physical and sexual violence. [137] There is no publicly available current data on whether the people released by the 686 initiative remain free or whether they have access to ongoing support in the community. 11, 69-71; sjcintern and Zoya Aleem, Chaining the Mentally Ill, post to The Upstream Journal (blog), January 2012, https://www.upstreamjournal.org/chaining-the-mentally-ill/ (accessed August 17, 2020). A doctor working at a psychiatric hospital in southern Nigeria said: We have to use chains in some cases.[59] In eastern Indonesia, Human Rights Watch witnessed a woman being tied around the waist with a twisted cloth and restrained to her Ensure coordination between mental health professionals and staff at prayer camps to offer mental health services based on free and informed consent. L.J. A young woman raised by her grandmother in Honduras leaves to reunite with her parents after more than a decade. Your gift helps us provide medical humanitarian aid for hundreds of thousands of people each year. There is a mental health crisis in America. Res. It was like my mind had gone blank on account of the fright, she said. For example, in 2015 chaining was widespread in psychiatric as well as in mental health wards of general hospitals in Somaliland. [67], In countries where people believe mental health is a spiritual issue and robust mental health services are lacking, private institutions and faith-healing facilities flourish. They feel youre possessed and put liquid down your nose to drive out the devil. More than two-thirds of countries do not cover reimbursement for mental health services in national health insurance schemes. res. The fight was just beginning. A central issue is the lack of mental health care professionals. As a result, documenting shackling cases is extremely challenging. Comprehensively investigate state and private institutions in which people with mental health conditions live, with the goal of stopping chaining and ending other abuses. [90] Human Rights Watch interviews with Badini Ousseini, country director of CBM Burkina Faso, Ouagadougou, January 22, 2020. Marylin Beckley, a licensed professional counselor and doctoral student in the international psychology program at the Chicago School of Professional Psychology in Washington, D.C., works with IJM in Guatemala, El Salvador and other Latin American countries. In Kenya, which launched in November 2019, almost 3,260 people have enrolled and around 732 have completed the training. Cohen Veterans Network and National Council for Mental Wellbeing partnered with Ketchum Analytics who conducted an online survey among 5,000 Americans, representative of the U.S. population based on age, gender, region, household income and race/ethnicity. Im never invited to happy occasions, weddings or birthdays with my family. Shackling is practiced across socio-economic classes. In Nigeria, boys as young as 10 were chained together in rooms with adult men, leaving them at risk of abuse. The study offers a comprehensive analysis of the state of mental health care in the U.S. 1. For example, in 2017 India passed a landmark mental health care bill that explicitly prohibited people with mental health conditions from being chained in any manner or form whatsoever.[129] While the provision has proven challenging to implement, it enabled a lawyer to challenge in court cases of people shackled in homes and faith-based institutions in the state of Uttar Pradesh, India. There is a shortage of bilingual or Spanish speaking mental health professionals. Federal tax ID#: 13-3433452, Mdecins Sans Frontires 2022 [79] Human Rights Watch interview with Aisha [not her real name], family member, Gaza, February 15, 2020. Adults Who Needed Substance Use and Mental Health Care Did Not Get Treatment, National Council will Honor Five Distinguished Recipients with Awards of Excellence During NatCon22, Statement from National Council for Mental Wellbeing President and CEO Chuck Ingoglia on the Senate Finance Committees Hearing on February 8. [74] In Togo, prophets can lock up and chain up to 150 people in a single prayer camp. On average, countries spend less than 2 percent of their health budgets on mental health. (No. 56). 1, Equal recognition before the law, U.N. Doc. Fight for mental health services personal to Brazoria County sheriff All of our clients from all of our programs are eligible to make appointments. [74] Why Pakistans Poor Seek Mental Health Cure at Shrine, BBC News Online, September 29, 2016, https://www.bbc.com/news/world-asia-37495538 (accessed March 23, 2020). 58-60; Once You Enter, You Never Leave: Deinstitutionalization of Persons with Intellectual or Mental Disabilities in Croatia, September 2010, https://www.hrw.org/report/2010/09/23/once-you-enter-you-never-leave/deinstitutionalization-persons-intellectual-or. Associations between racism and mental health are stronger than those between racism and general medical health ( 2 ). 5 Barriers to Mental Health Treatment and Access to Care - Social Solutions [134] WHO, Building Back Better Sustainable Mental Health Care after Emergencies, https://apps.who.int/iris/bitstream/handle/10665/85377/9789241564571_eng.pdf?sequence=1, p. 73. A number of factors fuel the shortage, including a greater awareness of mental health problems that has spurred people to seek treatment. Even people who are released from chains or confined spaces often go back to being shackled as there is little access to support or mental health services, and stigma and bias persists.

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