Recycled plastics pollute food, and the value of water
Better awareness of the precious resource that is water, getting a grip on coastal ecosystems and the impact of pollution, why recycled plastics are a threat for food packaging and kitchen utensils, how we can help humans to step up in extreme environments, and the opportunity offered by "lived experience" when it comes to mental health all go under the microscope in this episode of the Cambridge Prisms Podcast.
In this episode
00:39 - Better awareness of water
Better awareness of water
Janez Susnik, IHE Delft Institute for Water Education
Water is arguably one of the most critical molecules we rely on for our existence. It’s not a coincidence that ancient towns, cities and fortifications were all built around sources or access to the stuff. In the modern era, though, technology and pipelines mean we’re often much less aware of the role that water plays, how much we use, and the danger of running out. We need to take this resource much more seriously because, not only does it make life itself possible, it’s involved in almost everything we do, as, speaking with Chris Smith, Janez Susnik, from the IHE Delft Institute for Water Education, explains…
Janez - We have these global resources of water, energy, and food that humans use every day. And, in my opinion, it's water that's central to enabling these systems to work. They link with each other, they depend on each other, but it's really water that's at the heart of making these other resources available to us. So water's used in the energy sector for hydro power and of course it's used in agriculture to water our crops that we then consume as food.
Chris - It's one of those resources which is so ubiquitous and so taken for granted that it's almost invisible to us and we don't notice how important it is until it's not there!
Janez - Yeah, exactly. It's similar to what I wrote about actually in the article, that we don't really notice water until it goes wrong, when it's not there, as you mentioned, so extreme droughts sit situations or when there's extreme floods. Pakistan 2020 is a good example. So is the recent events we've seen in Libya, for example. And there situations when we really notice that water is either there or not, but otherwise it's one of these resources that's very much in the background, and we do indeed quite often I think, take it for granted.
Chris - One thing that struck me, I remember listening to an interview that another science journalist did about 20 years ago and it really brought it home to me because you just don't see the water in everyday industry. When this person said, every time I make a house and I carpet it, it's like filling the house up with, with water several times over just to make the carpets. When I make a car, it's like filling the car hundreds of times in order to make the steel in order to get the coal that powered the iron works. And so there's all this invisible water in everything. Do we know how much water the human race gets through every day?
Janez - It's a lot and you're absolutely correct. Water is - we call it embodied - it's embodied in the resources we use and consume and produce every day. So in the raw energy we extract in terms of coal, gas, powering electrical power stations. So when you turn a light switch on, you're essentially turning a tap on. In terms of how much we get through, we think that approximately, well it's a big number about seven and a half thousand cubic kilometres of water is consumed every year in crop production. It's a massive amount of water. It is about 70% of the water we use in total globally every year is in crop production. So that's where most of our water goes. And then in terms of energy production, about 1,500 to 2000 cubic kilometres of water withdrawn from supplies every year for electricity generation and energy production.
Chris - Is the ubiquity of it, though, and the fact that previously you could just dig a hole in the ground and this stuff came out or you could trap some that was flowing down a river and use that. Has it been taken for granted to the extent that when we develop, when we build things, we just assume the water's going to be there; and now we're beginning to really stress the system, we need to really worry about this, but there isn't really a plan?
Janez - To some degree, yes, but I think it is becoming much more kind of on the radar now that water's not just something that is always there. So people are now realising it changes in terms of where it is in space and some places are dry or wetter than others. It changes when it is in time. So different times of the year are wetter or drier than others. And there's also other things that depend on water as well. So it's not just human activities, of course ecosystems, plant life, animal life also depend on a certain amount of water being available for their consumption, which also support our society as well. So I think people are starting to become more aware of this and realising you can't just tap a hole in the ground or dam a river and just take it.
Chris - If we take a small example, England; some countries are very, very good because they've had the, the fact that there's not enough water foisted on them for a long time. So they've become quite good at coping with that. But if you take England as an example, some parts of the country have seen enormous development of housing, but there haven't been any new reservoirs plumbed in for decades. And now people are, are actually in a position where developers are being told, well, you can't build more houses because there just isn't the water supply. Are we in a position or getting towards a position with water that we were in historically with, with almost like climate change and fossil fuels where we just dug stuff up and burned it because we could and we didn't really have any thoughts of the consequences. But actually now people are beginning to say, well, hang on a minute, we need to do something about this. And when we do build, why is it that we are still seeing houses springing up all over the place and there isn't a water tank in the basement collecting the rain water. We are putting pristine drinking water that you could put down your throat down the toilet. Why have we still got this ridiculous unjoin up policy around what is becoming a precious resource?
Janez - Yeah. Well again, I think it links a bit back to my previous answer that a lot of, a lot of places, even though the idea is still there, but it's becoming scarce and we need to plan better, it's not really in the mainstream yet. And a lot of the policy and the push simply isn't there to build these systems in place. I mean, I completely agree that for a lot of new developments, especially the water stream should be separated out. I mean, you quite rightly say, you know, you shouldn't really be using fresh drinking water supplies for watering your garden or washing your car. You are not just inappropriately using the water. There's also an energy cost associated with that water as well. You've extracted it, moved it to a treatment station, you've treated it, you've then pumped it to your new development, and then people are flushing it down the toilet or washing the cars with the water. I mean, it, it doesn't make much sense. So I think there needs to be better building regulations essentially to, to encourage developers to put in different water streams, collecting rain water, recycling grey water, which is the water that flows from your shower or from your sink. The stuff that goes down the toilet is known as black water. So that's different that should be treated of course. But gray water especially can for non-drinking sort of purposes for your garden, for your car, for to go back into your toilet. I think that should be made use of more efficiently. Countries like Singapore, for example, are very good at this. Also, in the traditional supply networks, just reducing the amount of leaks is also important and just being more efficient with the resources that you have. And yeah, not assuming that it will always be there. And start to have that dialogue occur.
08:13 - Coastlines threatened by poor water quality
Coastlines threatened by poor water quality
Ama Wakwella, University of Queensland
Given the central role of water in our lives, you’d think we’d be highly cognisant of the impacts of poor water quality and the declining health of coastal ecosystems. But actually the data are quite sparse and were not coherently assembled. As she explains to Chris Smith, Ama Wakwella, at the University of Queensland, decided to try to change that…
Ama - A lot of different activities that humans are doing, different developments, so clearing, mining, other industries are impacting water quality; and that poor water quality is running off into coastal ecosystems - places like coral reefs, sea grasses and mangroves. And they were causing the loss of these ecosystems, which was raising a lot of alarm bells among scientists and conservationists, but also for a lot of people in public health. So this poor water quality also impacts us, and can contribute to waterborne disease, nutritional issues for people who are reliant on fisheries. So a couple of colleagues and I decided to put together this review to kind of synthesis what the impacts are from poor water quality onto human health and also ecosystem health in our coastal environments.
Chris - There seems to be quite a lot of denial and also an attitude of "out of sight, out of mind: it doesn't affect me and I flushed it down the loo. It's now the sea or the ocean's problem, so I'm not going to worry about it." This means it tends to be quite under-researched. So where did you get the data from in order to compile this?
Ama - There is a lot of limitations with the data that's available; missing information really. So it was a matter of compiling literature that different sectors had information from. So we had to get information from people on the ocean-side who were seeing these impacts onto coral reefs, finding, you know, increased levels of caffeine or lots of plastics or hormones; things on the sanitation side of things, for example. And then from the human health perspective, they were looking primarily at levels of pathogens or other things that are harmful for drinking water and human use.
Chris - And I suppose when there are commercial interests at play where it's say a mine or oil extraction or even farming runoff, sometimes the data there might not be available, because people may have taken steps not to release it because it could damage their industry?
Ama - Yes, it can be quite complicated when you've got competing interests depending on the scenario, the region, the particular case. We were finding that there would have to be different approaches to kind of tackle those. So it might have to be more of a policy intervention in that case, if you've got a really stubborn or adamant area that your pollution is being sourced from. And it can be especially complicated because some of these sources of pollution are so diffuse. So we might be able to identify, okay, our drinking water source is contaminated, but there might be many different areas that might be contributing to that contamination. And it's really hard to attribute responsibility as well. So even if an industry or sector might be willing to cooperate, it can be difficult to say, okay, you are contributing this much to the pollution.
Chris - So how did you pull all these data together and then synthesise out of that something that would be a good treatment? As in these are the problems that we've identified so that we can begin to think about some recommendations?
Ama - The approach that was taken was actually compiling data sets of literature reports and case studies. It was through compiling all of those pieces of information, essentially, and screening through them to identify what the impacts to coastal ecosystems were. So we focused on coral reefs and then with some of our colleagues who are from the public health sector or from sanitation - so looking at like wastewater and different aspects of human health - we looked at those impacts. And then, secondarily, after that we were looking at how humans are not only directly impacted from declines in water quality because we need water to drink and to bathe in or to swim in, but also how loss of ecosystems can go on to impact humans indirectly as well.
Chris - Can you take us through briefly some of the recommendations that you've made as a result of doing this?
Ama - Yeah, absolutely. One of the main recommendations was the need for resource mobilisation. Basically trying to accumulate funding or information that we need to improve water quality. So sometimes this can take enormous funding, so you might need to improve sewage treatment across a large area, for example, which can be enormously expensive; or trying to prevent erosion, so have soil management practices and things like that. One of the problems that was identified there was a lack of sustainability in the funding. So some of these programmes might take years or decades, not just to implement but also to see the results from. Also the importance of, as a lot of researchers recommend, always monitoring: so being able to actually assess what are the contributors to pollution in your area. And strong coordination of course - so the need for bringing everyone to the table, making sure that you've got your key stakeholders involved. Otherwise, as you were saying, you can have some stubborn groups, particularly if they are a source of pollution, ensuring that everyone is there to be a part of the conversation. So there is buy-in.
Chris - And when you went through it all, were there any things that leapt out at you, and you think, my goodness, I hadn't thought about that, but that really is quite surprising and shocking.
Ama - Absolutely. I think we intrinsically kind of know that water is, you know, at the centre of life; we need it desperately to live, and so do our ecosystems and our fellow organisms. But I think just how widespread some of the impacts of poor water quality are was a bit shocking. So it can be a huge driver of infectious disease burdens, so like water related disease from the water we drink, but just the sheer cost of poor water quality in terms of just recreation - so our access into oceans, people swimming in our oceans - if that water quality is poor, then that can contribute to severe health burden. So it can cost billions of dollars in terms of the kind of health burdens it causes and also the impacts from contaminated seafood. Lots of people who depend on fisheries, it could be a huge impact from the loss of that source of food.
15:14 - Chemical contaminants from recycled plastic
Chemical contaminants from recycled plastic
Birgit Geueke, Food Packaging Forum Foundation
The “5 Rs” of sustainable waste management are refuse - don’t buy it in the first place - reduce, reuse, repurpose, and… recycle. But when it comes to the last one, and when that involves plastic, there can be a sting in the tail. Because many plastics come into close contact with humans and our food supply. We use plastic packaging, plastic utensils, plastic plates, plastic bowls, plastic cups and plastic bottles. And although the rules say those should only be made using plastics regarded as safe, there’s evidence that, through the recycling process, unsafe plastics, and therefore a suite of potentially harmful chemicals that go with them, are ending up in food-related materials, where they should be a total no-go. Speaking with Chris Smith, Birgit Geueke, is with the Food Packaging Forum Foundation…
Birgit - We wanted to find out which kind of chemicals are found in packaging that is made out of recycled material and also which chemicals were found in plastics that is used in the kitchen several times, such as bowls or containers, or kitchen utensils.
Chris - Is this a legitimate health concern?
Birgit - We think so because the amount of chemicals that are used in these items is huge, more than hundreds, and it's always difficult to predict which kind of chemicals.
Chris - And is the industry currently un- or under-regulated in the sense the point you're making is, well, there's stuff being made from recycled things and we don't necessarily know the chemical provenance of that. And so therefore there could be all sorts of things in what we are using and, and it's coming into close contact with humans and human food stuffs?
Birgit - When looking at the European regulation, there is quite a bit in place, but there are weaknesses, let's call it like this. So for example, if you look at repeat use articles as we call them, so the containers, the kitchen utensils, they're only tested three times. But if you use them over a long time, they may degrade and then they release chemicals you don't find during the testing. That's for sure. One of the weaknesses.
Chris - And the origins of these chemicals would be presumably that because we mix lots of different plastics, which may have themselves had different compositions or different things in contact with them, in the recycling bin, a whole mixed bag of stuff ends up in recycled plastic products together with its cargo of chemicals?
Birgit - No, it shouldn't be like this. So if you use the recycled plastic in food packaging for example, again the source should be pretty clean. PT bottles should only be recycled into new PT bottles or other containers. However, there are cases where you find residue of your old TV, or food packaging or similar materials, and that's for sure not intended and shouldn't be like this according to the law.
Chris - But your argument would be that it's nevertheless happening, albeit by accident. It's happening from time to time. Do you know to what extent then it's happening?
Birgit - That's difficult to answer. I think. I cannot give you any numbers.
Chris - So how have you approached this then? What have you actually done to gain more insight into what's going on?
Birgit - Some years ago we compiled a big database where we really checked all the available studies. So we have more than a thousand studies from all different labs all over the world, which addressed these questions. We looked at all the chemicals coming from all different food packaging materials and this database is a great source to address specific questions. For example, what chemicals are found in PT bottles or which chemicals are found in the melamine bowls you're using for small kids in the kitchen.
Chris - And so what is your main concern here then? We know about these chemicals, there are laws in place that mean they shouldn't be there. Is your chief concern that although they shouldn't be there, they nevertheless are there?
Birgit - There are several concerns. We don't know that these chemicals exist in these products. That's what I meant before. And then additionally of course many of these chemicals have been tested and shouldn't be there. For example, there are carcinogens that cause cancer that interact with the hormone system. These chemicals shouldn't be there.
Chris - And so what would your recommendations be? The law says they shouldn't be there. They on the whole aren't there, but occasionally are. So there is an exposure and you are raising a legitimate health concern. What can we do about the small risk then?
Birgit - Those chemicals which are known to be toxic, they should be banned. The law shouldn't allow them in food packaging. Then we may need to change the way we test our food packaging and really look at the bottle which is sold in the end, not in the chemicals we put into the bottle in the beginning when we make it. Think about the way we are using our food packaging. That probably a question addressing the whole society. So if we want to to change away from plastics and paper packaging, for example, we may get rid of many of these chemicals.
Chris - Would you be more comfortable than if we didn't use recycled plastic in human contact type activity at all food and so on? Just use fresh?
Birgit - From a chemicals perspective, this is for sure the safer alternative and from a waste perspective, of course it, it would increase the amount of waste. But recycling can only be done for a certain number of cycles anyway. So we, we may need to find better solutions.
Chris - Yes. So would a saner safer approach be to say, well we want to bear down on and reduce plastic overall anyway, but we'll ringfence some aspects of plastic production for some applications and say that we won't use recycled plastics in those applications for the very reasons you've outlined?
Birgit - Yes. I think we really have to be very careful where we can use recycled plastics and where we shouldn't use it.
Chris - So are people actually having a conversation about this? Because what's alarming to me is that until I read your paper, I hadn't really thought about it and I suspect that policymakers who are even more remote from the science than I am may well find themselves in the same position...
Birgit - Yeah, that's something we're working on: that these two areas - the waste and the chemical safety - talk to each other. It's needed that we reduce the amount of waste and recycling is one measure. And on the other hand, we have to take care of the chemicals which we keep in the loop when we do recycling.
22:01 - Human performance in extreme environments
Human performance in extreme environments
Michael Schmidt, Sovaris Aerospace
Humans have always striven to push boundaries: to go higher, further, faster, deeper and especially where no man - or woman - has been before. And that often includes into space. In other words, into unnatural environments that humans have not evolved to accommodate. On the one hand this presents an opportunity to study human physiology at the extremes, and learn how to better manage more mundane situations and conditions back here on Earth. But on the other hand, keeping people fit, healthy and safe when they’re operating under these pressures is also a major priority. And, speaking with Chris Smith, this is what Michael Schmidt - CEO and Chief Scientific Officer at Solaris Aerospace - does for a living…
Michael - So one of the things unique to our field is we work in extreme environments. Everything from the space flight environment to military special forces or to sports where the environment is not harsh, but where the training, the competition, the physical loading, the psychological loading is very dynamic. And so they have higher risk and they have a higher demand for high performance. So any decrements and performance really can impact their ability to do their work safely and even survive. Any improvements that we can make in their ability to perform can be very important for their success in those environments. If you're operating in an extreme environment like a spacewalk and you've lost 10% of your metabolic activity, that could be very serious. And so we as precision medicine to enter that world, basically ask the question, if we measure these 500 biochemical markers that give us a picture of the landscape, what can that tell us about a way to optimise your performance? So it's like going into a forest and instead of choosing just a couple of trees to understand the health of the forest, we're gonna measure a thousand trees. We're gonna get the best possible picture, and from that, then we can prescribe what the forest needs.
Chris - Isn't one of the challenges confronting you, and people working in this sort of setting, a data problem in the sense that when you've got millions of people that you can study, doing everyday things that everyday people do, you've got plenty of data to iron out the noise. When you've got extreme circumstances with just a handful of people, there's gonna be huge amounts of noise differences between individuals, differences between the individual settings. And does that not make this much more difficult to do meaningfully?
Michael - It does in one respect, which is why we, we do it in high performance environments, as I mentioned, from space flight to NFL football, to soccer, to military special forces, et cetera. So we're constantly testing that and we're constantly measuring that. We're asking the questions in those extreme environments, you know, is what we're doing, we're detecting these changes, and then we're developing a precise intervention for them. Is it having an impact on our performance, which is constantly being measured in all kinds of ways in these different environments anyway, so we get relatively rapid feedback on what we're doing. Has it made a difference in individual and in group performance? And so you're right, there's a lot of data that comes out of that. But we broke it down also into essential inputs into a system. So if you were flying a Saturn five rocket - and we'll use the old days! - The engineers would've built that and they know what goes into it, right? All the inputs. They know well how the processes work, because they engineered those, and they know what the output is; they know what's supposed to happen. And it's that way with all engineered systems. And the human system's already been built. It's very complicated, as you know, we're trying to simplify that equation into, well, what are the essential inputs? What are the things that the body must have in order to function? Number two, what are the conditionally essential ones? What are those intermediate ones where the body normally makes them because of various circumstances, it's no longer making them sufficiently. And then what are the non-essential inputs like drugs and environmental exposures, the things that are not needed? So what of these three tiers that are going into the system are themselves creating these perturbations? I'll use one example if I may. There was a study looking at the effect of inflammation on what's called psychomotor speed. This is the speed of processing and reaction time. And if somebody throws a baseball at you, how quickly can you react to that? What they found is that the higher the levels of inflammation, the slower the reaction time. But what was interesting is that they asked the different question than of the data, and they said, well, what if we break it down, not based on age, but based on the levels of these inflammatory markers. And what they found out was, regardless of age, those with the higher levels of inflammatory chemicals had the slower reaction times, meaning that you could be in your thirties, but if your inflammatory markers were high, you might have the slower reaction time of someone who's in their seventies. So this is where understandings that some of the molecular processes that affect critical capabilities like reaction time, can help us develop a molecular map. And so across these different molecular processes, there's a wide range of things that impact things critical to performance, like reaction time. NASA did a similar study in their Hera experiment, where they simply changed the diet and they gave a regular space station diet over 45 days, and then an enhanced diet, which had a range of different nutrients, and they looked at psychomotor vigilance tasks; and those with the enhanced diet had a better psychomotor vigilance. So those are the increments that we're trying to look for.
Chris - We often find that when we look at performance in extreme circumstances, it can be extremely informative about the more mundane or the more pedestrian circumstance. Scientists went to the top of Everest and took blood from mountaineers in order to learn better how to manage people with low blood oxygen in the intensive care unit, for example. So I suppose that by having clear examples of how things operate at the extreme, you nevertheless learn quite a bit about how you can do things for the man and woman and child on the street?
Michael - Exactly. And there's three examples that could quickly go over. So one is the bone loss and muscle loss in space flights. So that's a, there's a very diligent efforts to try and reverse that, and that's informed us a great deal about bone and muscle muscle loss on earth. There's another problem called space associated neuro-ocular syndrome, which essentially because when you go in space, the fluid all floats up towards your head and you get pressure inside the cranium and inside the eyes, and you develop visual problems. Probably happens with 25 to 40% of the astronauts who are up there for four months or longer. So we're looking extensively at what are the molecular underpinnings of that? There's genetic markers that seem to make that subgroup more susceptible, and now we have a target to intervene upon. And then a new phenomenon related to that is called jugular vein stasis. So the, the large veins in the neck that are supposed to drain blood out of the cranium, out of the brain, it gets stagnant there. And then in a handful of astronauts, there's been some clotting there. So that can inform us about related phenomenon on earth.
30:14 - Lived experience should guide mental health policy
Lived experience should guide mental health policy
Claudia Sartor, Global Mental Health Peer Network
In previous episodes of this programme, we’ve heard worrying statistics about the growing prevalence of mental ill-health across the world. But are we overlooking a potential gold-mine of information that could help us to better address the issue and reduce the likelihood of mental illness manifesting in the first place? As she explains to Chris Smith, Claudia Sartor, from the Global Mental Health Peer Network, is a staunch advocate for the importance of hearing from people with “lived experience” when drawing up policies and treatment plans…
Claudia - We continue putting forth an argument to include people with lived experience of mental health conditions into discussions that are happening globally and get their perspectives and recommendations on what they think should change and what should be in place to better those practices.
Chris - Is that not happening already? It boggles my mind to think that we would make rules, regulations, and policies for people without asking them first!
Claudia - Yeah. It is mind boggling. We've been advocating for this sort of inclusivity and improved quality care for a number of years and there is slow progress, but still very tokenistic. In other words, we still have psychiatrists and policy-makers sort of making decisions that are not including the people that are being affected by these processes. So we as an organisation, because we are run by people with lived experience, we are able to provide those insights. So the best way to tackle this is for us to bring our voices to collectively make this argument.
Chris - Do you think this is a legacy of presumed lack of capacity or lack of insight on the part of some patients and this has led to the view that the expert knows best? Or is there some other reason why the key people who are being impacted haven't been made more central to policy decisions and so on?
Claudia - Good question. The answer will vary dependent on context, right? So if we're looking at countries within the African continent, or perhaps southeast Asia, we're looking at individuals who already have limited access to quality healthcare. Certain African countries only have a handful of psychiatrists available. Then what happens is the immediate response is that the clinician is of a higher power than the patient. In Africa, there is a very big issue with power imbalance, stigma. So the very first thing that comes to mind is that this person I'm going to go see knows more than me. I need to listen to them. I don't have a say as to my treatment. I must listen, accept and move on.
Chris - But expertise matters, doesn't it? We can't devalue the experts because otherwise there's a danger we erode professions and professionalism, and that may actually be counterproductive. We do need experts...
Claudia - Absolutely, with no doubt. So we follow a process that is non-textbook. My experience, when I went to go see a psychiatrist, I went through the process, that mental health services process. So I, based on my experience, can give you valuable insight that somebody else cannot. So we can't exclude the voices of people. We know what works for us and what doesn't, and we should have a seat at the table.
Chris - One thing that jumped out at me when I read your manuscript was one of the things you're advocating for is paying people to come and share their expertise in that respect. I was a little uncomfortable with that, in the sense that do you not think there's a danger if you do this you almost create an industry and, and it might bias thinking because the wrong sort of people might come forward?
Claudia - There's always gonna be a risk. But stakeholders, companies, whatever it may be that are looking to improve wellness strategies within the workplace, if you have somebody that has had specific experience in the workplace where they were discriminated against, they lost their job, they were told they were never gonna be able to work again, you need those type of people helping companies go, "let's create processes that's going to create a safer environment." So, by paying these individuals, you are valuing their expertise. I spent four to five years where I was helping big international organisations and I would spend hours and hours and hours looking at reports, giving in my input and recommendation and I didn't get paid for it. And I really felt that that was an injustice. It shouldn't just be seen as volunteers. These people have knowledge that others do not.
Chris - So what sorts of things have you been able to bring to the fore and exact positive change thanks to your intervention?
Claudia - For example, we worked with a very big pharmaceutical company and they took the initiative and they looked at their policies and they said, "you know what, this isn't good enough at this stage." And we went in and revised their entire policies and helped with consulting and making those changes. And we basically received this recommendation to say thank you so much because we're now implementing these changes and it seems to be working. Staff morale has increased, there's more knowledge about mental health.
Chris - Why do you think this is needed though Claudia? I don't dispute the fact that you're doing a good job, but why have we ended up in a position with a world that needs this to happen when you didn't exist historically, were we all just terribly miserable and didn't talk about it? Or has something fundamentally changed that means that suddenly this is a much more serious issue, it's much more prevalent and we need these sorts of interventions and if so, what is it that's driving this?
Claudia - There was not much talk about it. It's an invisible illness. People don't see it. Therefore you're okay. There's also a lot of stigma. Covid is what actually really brought out mental health, because people now started seeing how being in isolation makes you sad or depressed. Having no contact with people ,feeling lonely. That's why there's now this sudden surge of inquiries about how can we better improve the status quo.
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