How can we use art to address mental health stigma? Dr Alexei Sammut writes about the art book Living with Mental Illness and the accompanying exhibition, which are his contributions to strengthen the discourse on mental health in Malta.
Declining mental health is a global burden. Anxiety, depression, and substance abuse are on the increase. Current estimates from the World Health Organization report that one in every four of us will experience some form of mental health challenge during their lifetime. By 2020, these figures are expected to double. And while support services do exist, their accessibility can be difficult.
There is no one explanation for this. The issue is complex and multifaceted. A lack of information on such services is a major contributing factor, however, stigma continues to be the main reason people refrain from seeking support and advice. Just a decade ago, discussing depression, eating disorders, self-harm, and suicide in Maltese public fora was unimaginable. And while things have improved—social media provides plenty of evidence—we cannot become complacent.
As part of my PhD, I looked into the attitudes of Maltese nurses and midwives towards mental illness. As people working in caring professions within medical settings, they are on the front lines of community health, seeing people from all walks of life, day in day out.
What I found was that while local nurses and midwives hold a positive attitude towards individuals with a mental illness, continued education, public engagement, and mental health literacy promotion are imperative.
Nurses and midwives who followed specific mental health nursing training held the highest positive attitudinal scores. This finding highlights the important correlation between education and mental health literacy to the attitudes towards those with a mental health condition. Without adequate mental health literacy, stigmatising attitudes will prevail, and people will not receive the care they need.
With this knowledge in hand, I wanted to raise awareness around mental health. To do this, I combined my goal with my love for art, collaborating with local artist Anthony Calleja to explore the lived experiences of living with mental illness.
Calleja produced 18 works of art, all of them depicting mental illness based on first hand accounts from people living with the diseases. The idea was to increase awareness and generate discussion without the need for text. Visual art allows for nuanced personal interpretation, empowering the individual to reflect and absorb the messages within the art they are viewing. People use metaphors to relate to their life situations, especially when things become difficult to explain. Like metaphors, art can be used to express things that cannot be stated in words. Art can be a therapeutic medium that helps people reach out. But this was not all we planned to do with the initiative.
Calleja’s pieces were collocated into a book titled Living with Mental Illness. The publication was launched at an exhibition of the original works. On the night, I conducted a study through questionnaires investigating people’s own interpretations of the works and the emotions they conveyed.
Although data analysis is still at a preliminary stage, findings seem to agree with the national survey on health literacy carried out in 2014 by the Maltese National Statistics Office on behalf of the Office of the Commissioner of Mental Health. In 2014, research showed that 42.5% of the Maltese population have a problematic level of health literacy. This further highlights the importance of education and health promotion campaigns.
We’ve all heard someone around us say that mental health is as important as physical health, and we need to act on that adage. We cannot shy away from giving it the attention it deserves. Now is the time to speak out and collaborate as a collective. We need to listen closely to those among us who are struggling, especially to those who use our community’s mental health services. Only they can help us revamp and address the challenges that lie ahead.
You can’t watch Blue Planet and not feel a pang of guilt for the plastic straw in your drink. But what does it truly take to mobilise people and encourage more sustainable behaviour? Kirsty Callan talks to Dr Vincent Caruana.
We’re finally living in a world where environmentalism is a sexy topic. Everywhere you look, it’s vegan-this, plastic-free-that. And it’s wonderful. Public awareness of the impact we are having on our planet is on the rise, and yet, according to Eurostat, Malta still registered the European Union’s highest increase in carbon dioxide emissions from energy use in 2017.Researcher Dr Vincent Caruana (Centre for Environmental Education and Research, University of Malta [UM]), believes the crises we are facing can be summed up in one double challenge: the eradication of poverty and the preservation of the environment. By simplifying the issue, it is turned into a single problem rather than many overwhelming issues, highlighting the interconnectedness of the challenges we face, be they social, economic, or environmental.
Taking Nepal and Bangladesh as examples, both have suffered devastating floods. Some point to large-scale deforestation by logging companies and agricultural businesses, as well as locals using the forests’ resources. Some environmentalists point to the population and blame them, saying that the increasing use of the forest by locals places burdens on the region’s resources, suggesting that their activities are the current major source of environmental problems. But that creates a scenario where the victims of poverty are blamed for trying to alleviate their own poverty. Meanwhile, the reality is that the wealthiest one-fifth of humanity consumes so much more than the rest of the world, leaving the rest hungry.
Who is most to blame for these problems? International institutions such as the United Nations, national governments, transnational corporations, or consumers?
In his classes, Caruana runs his students through a similar thought experiment. Who is most to blame for these problems? International institutions such as the United Nations, national governments, transnational corporations, or consumers? Some argue that it is greedy transnational corporations, out to make a quick buck while ignoring environmental impacts. Some retort, saying that corporations are bound by economy to maximise profits. Others would point their fingers at the consumers who choose to buy from dirty companies instead of the most ethically sourced. ‘Of course, there is no correct answer,’ Caruana states. ‘There is no single solution. We need thousands of solutions working in parallel. Literally. The interconnectedness of it all requires both governments and civil society to commit time and effort.’
GETTING TO THE CRUX
Caruana’s doctoral research identifies the influences that lead people to engage in responsible sustainable behaviour and hones in on ways to sensitise and mobilise sustained civic action.
Caruana is quick to note that there are a plethora of barriers—social, economic, and political—which prevent people moving towards sustainability. What surprised him was that more personal barriers, such as frustration, hopelessness, and dealing with disappointments, also pose a problem. ‘This is a significant point, considering that environmental circles are oft en concerned with reaching out towards the unconverted rather than supporting the converted,’ he explains. In other words, we have to continue to motivate those who are already on the right path to ensure they don’t become demoralised.
Looking to understand how people can take control of processes that affect their lives, Caruana conducted four case studies. Among them were an intentional community in Malta and a Fair-Trade network in Egypt. ‘The power of case studies lies in their ability to reframe and critically challenge core beliefs that are now taken for granted, like how a municipality, church organisation, and a trade organisation ought to act,’ he says.
Caruana believes that education on sustainable development (ESD) lies at the heart of it all—and he is not alone. In 2015, representatives from 193 countries gathered in New York to sign off on the 2030 Agenda for Sustainable Development. At the opening ceremony of the summit, Ban Ki-moon referred to the the Agenda outlined as ‘a to-do list for people and planet’. One goal focuses on education, which includes the aim to ‘ensure all learners acquire knowledge and skills needed to promote sustainable development by 2030.’
In Malta, ESD is established as a cross-curricular theme within the National Curriculum Framework. However, ‘in practice, it is still in the process of being concretely translated across schools and within subjects,’ Caruana notes. He also highlights the need for adults to be educated too, so that this cultural shift can truly happen; however, he is quick to follow up the notion with its own weakness. For years, adult ESD has remained ‘locked within ideologies which have caused many of our contemporary environmental problems.’ We need a complete overhaul of our outlook. Increased emphasis on recycling is a positive; however, what would be better is if we could reduce the amount of waste we are creating in the first place. This is but one example. ‘As long as ESD remains stuck within the same thinking that is creating the double challenge, there can be little progress,’ says Caruana.
CLEARING THE SLATE
Back in 2001, Caruana co-founded Malta’s Fair-Trade movement. ‘Faced with the continuous realisation of an unfair world trade system, and seeing first hand through my voluntary work how such a system creates poverty, my friends and I wanted to be proactive and part of a solution,’ he states. ‘The path forward was not chartered for us. We started off passionately, then with each step, we finally arrived to setting up a fair trade shop and an ongoing educational programme. Rather than complain, we have within us the power to create new solutions.’
This philosophy is at the core of what Caruana is doing now. ‘The current model needs to be challenged, and we do have the power within us to create new ways of thinking. We need a shift from thinking in terms of economic growth to growth in wellbeing,’ he says. Referring to the United Nations Conference on Environment and Development in 1992, Caruana says they had it right. ‘A country’s ability to develop more sustainably depends on the capacity of its people and institutions to understand complex environmental choices.’ We need real leaders, not token ones, who inspire, embrace and support citizens in their actions, and create new spaces for dialogue. ‘Both Civil Society Organisations and local institutions can be a positive force towards sustainable solutions at a local level.’
This mission is a beastly mountain. The reality is that there are major hurdles standing in the way of a paradigm shift that would see Malta’s people acting more sustainably. Beyond personal barriers, Caruana’s research reveals the vulnerability of local processes: ‘In Malta, a change in government results in a change in priorities (and support).’ Every five years, the system is shaken by an election that brings with it new agendas and philosophies. ‘Stability in environmental issues and processes is essential,’ he notes. Caruana also points out the fragility of civil societies’ human resources.
The solution, Caruana suggests, is ‘to create stronger links between governments, politicians, organisations, and citizens, both for research and to build a network of adult educators.’ This was highlighted in his Fair Trade case study where success was highly dependent on the level and consistency of engagement at both a local level with producers and with their partners in the west.
It is clear that good leadership is key. To help address this issue, he has created an Erasmus+ project called PEERMENT with the aim of coming up with a new model of mentoring and peer-mentoring for ESD. It involves about 20 education specialists as teacher trainers and senior mentors and about 50 teacher mentees.
‘We have to invest in leadership,’ says Caruana. ‘We need to focus on social learning and empowering institutions and organisations to work together and become innovative co-creators of new ways of thinking. In an ever-changing world, this is a challenge for educators to embrace with passion and urgency.’
Circling back to the double challenge, it is clear that no one project will be able to comprehensively solve the issues we are facing as a global society. But ‘we have to stop waiting for permission,’ says Caruana. ‘The beauty of the emerging paradigm lies in the reality that we don’t need permission to change outmoded mind-sets that no longer serve us.’ And this will be crucial in the road ahead.
In the challenge of keeping our seas clean, plastics FAIL. And yet, during the last decade, we produced more of it than in the last 100 years combined. Dr Adam Gauciwrites about his team’s eﬀorts to categorise the microplastics from Malta’s beaches and how those eﬀorts will contribute towards the war on plastic.
Sharks are a vital part of marine ecology, keeping everything beneath them in the food chain in check. But they’re being caught and consumed at an alarming rate, and people aren’t even realising it. Randel Kreitsberg writes about Sharklab Malta founder Greg Nowell’s work in raising awareness and preserving these fantastic creatures.
I’ll pick you up at 2.45,’ Greg says casually. ‘AM?’ ‘Yes,’ he smiles.
There is a one hour gap, between three and four in the morning, before the Pixkerija (fish market) in Marsa opens to the public. This is the time when fishermen arrive with their catch, but their clients, chefs and managers of Maltese restaurants, have yet to appear.
It is also when Greg Nowell, founder of the Sharklab Malta elasmobranch conservation group, and a small crowd of volunteers inspect the shelves and boxes of fresh catch. They’re looking for two local catshark species—nursehounds and lesser spotted catsharks—so they can cut them open and save the viable eggs still inside the females in the hopes of releasing them back into the wild.
AN ENGLISHMAN’S LIVING ROOM
Greg Nowell is a diver whose ‘regular’ job involves electronics quality auditing and building renovation works. In 2011, while at a local fish market, Greg noticed something unusual. One of the catsharks on sale had an egg protruding from it. ‘I took it out, and it looked intact. I could see there was something inside,’ he says. He decided to put the egg in an aquarium to see what would happen, and while the shark pup inside developed successfully over the course of a few weeks, it eventually died before the two month mark. Looking back, Nowell can confidently say now that it had everything to do with temperature.
‘Originally, we didn’t know all the parameters we needed to develop the eggs. Temperature was the big eureka moment. Most of the eggs collected during the year’s early months started to develop nicely, but after some time most of them simply stopped – until we installed the cooling system! Now if we have an egg that starts to develop, it has a 95% chance of making back into the sea,’ Nowell says proudly.
It took two years to successfully release the first market-sourced shark pup. Nowell released the baby himself. ‘I don’t know if it was saltwater in my mask or tears—it was beautiful!’ More than 280 shark babies have been released into our seas since then.
Today, a lot has changed. The Sharklab team and volunteers proactively check all the egglaying shark species in fish markets before they’re sold. The shark pup aquariums have also moved out of Nowell’s living room and into tanks in the Malta National Aquarium, where citizens can learn and foster an appreciation for them.
While the initial plan for our interview was to go to the fish market and save the eggs still alive in the female sharks, a storm put an end to those plans. The fishermen couldn’t go out to sea, so we made our way to the Malta National Aquarium instead.
The aquarium looks different from others I have visited over the years. Yes, there are some tropical species and colourful Japanese Koi Carps, but the majority of species there are local. This includes 20 to 30 cm nursehound pups and their empty egg-cases. It immediately strikes me that the focus of the aquarium is conservation and education, rather than the display of pretty fish.
Sharklab science officer Lydia Koehler praises the national aquarium for their support. She emphasises that with the help of the national aquarium, other countries are following suit and scavenging viable eggs from caught female sharks. Currently, there is a Sharklab in Bosnia Herzegovina, founded with Sharklab Malta, as well as activities in Spain and Greece, which are making strides. ‘In Spain they have a lot of Blackmouth Catsharks,’ Koehler says. ‘They had their first release couple of weeks ago.’
WHAT CAN WE DO?
‘A major part of what Sharklab Malta does is raise awareness and educate people,’ Koehler says. ‘And we have seen a change amongst younger people, appreciating the animals for what they are.’ But there are challenges too. ‘There is a generational gap,’ she notes. ‘Some older people don’t go into the water because there could be sharks in it. They are still very afraid of them.’
At the same time, shark is still a popular menu item with locals and tourists, which is why populations are heavily exploited in Malta. Koehler says that the volume of catches is astounding. ‘The first few times you go to the fish market, you don’t actually realise how many sharks they bring back. That was one thing that really shocked me. Especially for the small spotted catsharks. They come in boxes of 40 to 60 individual sharks. Once we saw them bring in 40 boxes in one day.’
Koehler says that most people don’t even know they are consuming shark. ‘Traditional Maltese fish soup, aljotta, often has several different species of shark in it,’ she says. ‘The issue is people don’t call them sharks—they call it fish soup. If you ask people whether or not they eat shark, their reply is: no, we don’t. But if you ask: do you eat mazzola? The reply is yes. They don’t know sharks are used in it,’ Koehler says, joking then that we should give up mazzola for good.
But there is more to Sharklab than the sharks themselves, Nowell notes. Towards the end of our trip to the aquarium, he highlights the need for better ecosystem management. ‘The animals, as fascinating as they are, live in an environment,’ he says. That itself deserves attention.
‘Plastic is a major issue for all marine life, and if you start affecting any part of it, you’re affecting sharks,’ Nowell says. ‘We also need to be knowledgeable about the species we’re consuming. Overexploitation of fish species because we like to eat them has a direct impact on sharks, because they can get caught accidentally as bycatch.’ Being apex predators, sharks have a critical role in maintaining the species below them in the food chain. They remove the weak and sick individuals, all while keeping competitors balanced to ensure species diversity. Sharks are essential for ocean health, and they have to be protected.
There is much to be done. And there are lots of opportunities to get started, as Nowell and his volunteers have clearly shown by empowering themselves and taking action. But as with every environmental issue, larger numbers make the loudest noise. And so it always boils down to a very simple question: Do we care enough to add our voices to the call?
For the first time in Malta, a cardiac screening programme for young people aims to identify who among them are most at risk of sudden cardiac death. Here, Laura Bonnici chats with Dr Mark Abela to learn more about the Beat It project and the impact it is having on young lives across Malta.
There are times in life when death haunts us all. It is most tragic when it strikes down our youth. This year, Italian footballer Davide Astori and Belgian cyclist Michael Goolaerts made headlines after they died unexpectedly. Also making headlines was sudden cardiac death (SCD).
Ischaemic heart disease is the most common cause of cardiac deaths, its likelihood increasing with age. A blockage in one of the arteries supplying the heart starves it of oxygen and nutrients, leading to heart attacks, sometimes resulting in cardiac arrest, in which there is sudden and unexpected loss of electrical heart function. But SCD in young people is very different from cardiac death later in life.
Much like Astori and Goolaerts, SCD victims are generally presumed to be in good health. Early symptoms are often incorrectly attributed to other issues or life changes. The result is a horrendous loss for the sufferer and their family and friends, who also have to weather biological, psychological, and social repercussions. Seeing these events unfold, specialist trainee in Cardiology Dr Mark Abela felt the time was right to offer an SCD screening programme to young people in Malta. He called the project Beat It.
The idea behind Beat It was inspired by the UK-based NGO Cardiac Risk in the Young [CRY], Abela notes. ‘CRY offers screening to young people between 14 and 35 to identify those who might be prone to heart disease. They then give follow-up advice, support, and evaluations accordingly. I realised that a similar programme would be very beneficial to young people here in Malta,’ says Abela.
In Malta, the Beat It project has focused mainly on fifth form students between the ages of 14 and 16. The cardiac screenings attempt to identify those who may be susceptible to SCD, with those prone to it referred to hospital for further tests to catch the condition before it can strike.
‘Because athletes are believed to be at a higher risk for SCD, we need to have routine screening across all sporting disciplines,’ says Abela. ‘Sport has shown the medical community that young individuals who are susceptible to genetic heart disease are still at risk of SCD. Screening helps decrease this burden. Current evidence also supports that this risk is present for non-athletic youths—so why neglect these youngsters?’
Launched officially in October 2017, the Beat It project saw nine doctors, accompanied by a team of technicians and nurses, going into schools and running screenings. Students filled in a simple questionnaire and took an Electrocardiogram (ECG) test on the spot. ‘We analysed the results in the hope of identifying heart disease in the early stages, then advised the young people if they should consider some lifestyle changes,’ says Abela. This included advice ranging from easing up on tennis, to which career choices might be most appropriate for the student based on their health. The team also advised further medical treatment and organised follow-up appointments with specialists Dr Mark Sammut, Dr Tiziana Felice, and Dr Melanie Burg in some instances. In the end, the project screened 2,700 of the 4,300 eligible fifth form students across Maltese schools, all with the support of the school administrators and teachers, who ensured that everything ran smoothly.
The significance of this project could also reach well beyond the lives of the young people themselves. ‘Since the country is so small and families are often inter-connected, genetic diseases in Malta tend to be more prominent,’ Abela emphasised. ‘The discovery of susceptibility to hereditary cardiac disease in any young person therefore also suggests that their parents or siblings may be at risk of SCD. With appropriate testing, the ripple effect of Beat It could preempt problems in entire families, maybe even saving someone’s life in the process.’
The project boosted awareness of cardiac disease and SCD for Maltese young people, their parents, and their teachers. UK data reports that eight out of 10 young deaths do not report symptoms beforehand. There is also a tendency for symptoms to be downplayed by educators who are not aware of potential problems. With this in mind, Beat It will also act as a learning platform. Since young people with cardiac abnormalities are at higher risk for exercise-related symptoms, physical education teachers are now more aware about potential red flags.
Celebrating the completion of the Beat It project, Abela expressed his gratitude for the team who made it possible. ‘The incredible dedication and teamwork of everyone involved has helped Beat It to effect positive change in young people’s lives, potentially saving some in the process.’