 Thank you, Dr. Une. It's been a long day for all of us already and I promise not to make it any longer. So I'm Nishant Arlupan and I worked in Yemen before and during the current conflict. However, I have two disclaimers. I have not worked in Hajjah and I don't have a background in mental health. The authors of the study couldn't be here today, so I'm doing this on their behalf. How does the context in Yemen influence mental health? A Wikipedia page for civil war in Yemen lists 13 conflicts starting from 1948 up to now. This clearly shows the high risk of conflict relapse in this country and the chronicity of the conflict can definitely predispose vulnerable populations to psychological problems. Yemen experienced its own version of the Arab Spring in 2012, following which a transitional government was installed. However, armed tribes from the north began to revolt against the government and they mobilized all the way down south. This opened up a lot of new front lines and also drew international actors into the conflict. And with a few exceptions, most of the front lines remain static and this in turn has influenced IDP movements inside the country. There were heavy airstrikes in two of the northern governments, which caused a massive influx of IDPs into the government called Hajjah. In addition to this, fighting along the western coast and also along the southern front line caused influx of IDPs into Hajjah. And right now Hajjah hosts almost half of the 2.7 million IDP population in Yemen. MSF currently works in eight of the governments. We have been working in Hajjah since August 2015. We are supporting Aljamuri Hospital in the ER, ICU, surgery, IPD, maternity and referrals. And just in 2016, we treated almost 3,400 war wounded and the survivors. How did mental health fare in Yemen before the war? The data is not very recent. In 2011, WHO observed that there was one psychiatrist for every 500,000 of the population. Now, compare this with high income countries where you have nine psychiatrists for every 100,000. And the stats on the psychologists and social workers are much less. And as of right now in Sana, there are about 40 psychiatrists and there are all the psychiatrists in Yemen itself. There are about four mental hospitals with a capacity of 850 beds and the resources in the private sector is not that great. There are four psychiatry departments and 11 psychology departments in all the various universities throughout Yemen. Now, the culture in Yemen closely links mental health illnesses with magic, witchcraft and sorcery. And because of this, there's a lot of social stigma towards mental health illnesses and this leads to neglect as well. And traditional fare healers are normally the first line of approach in these cases. In 2001, WHO estimated that there was about 20% of the population suffered from psychological or emotional disturbances, which was almost 4 million back then. And in 2006, approximately 30,000 patients frequented or sought mental health care. In terms of ranking, paranoia and schizophrenia came first, followed by depression and anxiety. And they also mentioned epilepsy, though it's strictly a neurological condition. What is MOH doing about this? Till date, there is no officially approved mental health policy. A mental health legislation doesn't exist and there is no data on the expenditure in mental health from MOH. As I said, HAJA hosts almost, and why is this stuff relevant in HAJA? As I said, HAJA hosts almost half of the current IDP population and there are absolutely no mental health specialists in HAJA. And the other local NGOs that were involved have closed shop due to problems with the budget. So we decided to intervene in November 2016. So this study collected data on all the patients who received individual psychological support between November 2016 and February 2017. And though the impact was interesting, there were some unique challenges that they faced. The first step was to train two MOH counselors in recognizing the reactions to traumatic events. They preferred to say reactions rather than symptoms so that the beneficiaries would not view their reactions as something abnormal or negative, given the pre-existing stigma of mental health in the culture. So the next step was to train the other MOH staff to seek for these reactions in the other patients in the other departments of the hospital. And in addition to this, our MSF staff were also trained in psychological first aid and psychological interventions in mass casualty events if MSF has to be acquitted. So the whole purpose of this was to streamline referrals to the mental health team. That's a training session in progress. And so the numbers, with the group intervention with the MOH counselors, there was about 2,224 beneficiaries and among them 209 beneficiaries received individual psychological support. And out of that, there were about 11 people who shared common traumatic experiences and group counseling was done with them. So in addition to the first consultations, there was about 289 follow-up consultations, sometimes even up to the seventh session, making it a total of 495 sessions. There was a default rate of about 21%, mostly because either the patients had moved to another place or they came from a very far away place, or some of them simply couldn't be traced. Now in terms of the demographics, males formed almost 57% and almost 80% of the males were more than 18 years of age. And the females too, this category was more than 80%. Now this slide, as you can see, in terms of the source of referrals, shows clearly the impact of the intervention as more than 40% of the referrals was from their psycho-education sessions done by the MOH counselors. And next came the sources from our MSF and our MOH staff. And finally, it says, come in by others or family members. What does this mean? Word spread around in the community that MSF is doing mental health interventions. Sometimes they do training sessions, I mean they were doing the sessions even in the hospital waiting rooms. So word got around and people brought in patients to the team. In terms of diagnosis, the big four was psychosis, depression, PTSD and anxiety. Though they did encounter patients with chronic mental conditions, following the first session, follow-up sessions were not done and these patients were managed by the MOH. In terms of precipitating factors, violence arguably was the largest component and combined with what you see in the green sector, 10% separation of loss due to the conflict. So 85% was directly related to the conflict. And there was other precipitating factors, almost 11% where people with chronic medical conditions like patients with renal failure, diabetics who couldn't access the dialysis centers or the dialysis centers had shut down or they couldn't get the insulin that was also a precipitating factor. What were the main challenges first? There was challenges on the pressure on the recruitment of the candidates for the team and there was also a significant stigma associated with gender-based violence and HIV. And the confidential nature of the counseling sessions was not very well-received. And some doctors refused to respect the guidelines for psychotropic prescriptions and refers to psychiatric hospitals in other areas was problematic because of problems in transport or difficulties of follow-up. However, the positive thing was that there was a very good acceptance from MOH and MOH said we'll keep the services on even if MSF decides to leave. What would be further be required would be baseline anthropological studies to better understand the cultural attitudes towards this and also to plan interventions for sensitive issues like gender-based violence. And I'd like to thank, I mean the first doctors would like to thank the staff and the patients of Yemen and I would like to thank the editorial team especially Safia and Ryan for the inputs on the stock. If you want the references, meet me after this. Thank you. Great presentation for a stand-in presenter. Great presentation for someone who's just stood in. Tremendous. Great. All right. Any quick questions that you may want to ask? I have the data with me so I don't know what to do. But because this is the last presentation on mental health that we have so if there are any questions that you have about the context or the program itself. Yeah, Alan? I mean, I still hear a bit in MSF that if we do mental health it's not the core, it's a bit of a soft topic for people like MSF. But we see it's a growing need and it's a need that's unaddressed in a lot of the world. Should we as MSF, and I'm opening it, should be doing more in mental health? This is for you, Dr. Lee. All right. I think the need has always been recognized. The problem has always been what to do about it. I mean, even in our own societies there are different approaches to deal with mental health. Compound that with, you know, different culture, different language. It makes it very difficult to implement a mental health program. And also you're right that we tend to hold, we have a higher rigor, scientific rigor for physical health programs than we have for mental health programs. But that I think has been changing in the last... Again, in a place like this, mental health, one of the challenges of providing mental health care is that people continue to live in the traumatizing conditions that cause the problems in the first place. And that is a problem. So psychological first aid is something that we talk about a lot, but we have to do more work to actually see how effective these programs are. And I think we are putting in more effort, but there's much more work to be done. That's it. You heard Meghli? No?