An Expert Discussion on Autism in Adulthood in Low- and Middle-Income Countries

Introduction

Globally, >80% of the population live in low- and middle-income countries,^1,2,* 95% of all <5 years of age with developmental disabilities including autism live in low- and middle-income countries,³ and 75of ∼120 countries in which an autism-specific organization has been established are low- and middle-income countries.⁴ However, most autism research is based in high-income countries and despite an increase in autism research, a vast majority of individuals on the autism spectrum continue to be unrepresented in autism research.^2,5,6

We wanted to know more about the lives of autistic adults living in socioculturally diverse and low-resource environments, where improving the lives of the “unseen” and “unheard of” adults on the autism spectrum may be a lesser societal priority than issues such as child mortality, access to drinking water, poverty, and malnutrition, and where dignity of human life is dwarfed by the sheer number of people within the country.

To share their perspectives, we have brought together seven panelists from five different low- and middle-income countries from South Asia, Africa, and Latin America. With a population of ∼1.9 billion, South Asia is home to about one-fourth of the world's population. Another 17% resides in Africa and 8.5% in Latin America. Between them they represent ∼45%* of the total population of the world.

Given their contribution toward furthering the autism movement in their country, our panelists are considered as front-runners in their region. They bring with them years of experience and a great deal of understanding to address the diversity within their country.

Following is a transcript of our discussion with edits for clarity.

Dr. Nidhi Singhal: Today we have seven panelists, three of whom are autistic themselves. We have two representatives each from Argentina and Kenya and one each from Bangladesh, India, and Pakistan. Thank you everybody for joining in this discussion today. I request each of you to briefly introduce yourselves.

Mr. Tomás Corrons: I am from Argentina and was diagnosed with autism a couple of years ago as a young adult. During my teen years I endured bullying that is very common to us all. I have been able to overcome that page, and have set a new course in my life, and I am pretty optimistic about the future. I am a member of an organization that also aims at raising awareness about what autism means. Currently, I am also pursuing a degree in environmental engineering, and aim at becoming a diplomat.

Dr. Alexia Ratazzi: I am a child and adolescent psychiatrist trained in Buenos Aires, Argentina. In 2012, I was one of the founding members of PANAACEA (Argentine Program for Children, Adolescents and Adults with Autism Spectrum Conditions) wherein we try to improve quality of life of individuals on the spectrum and their families. And since then I have been dedicated to autism spectrum awareness, training, research, intervention, incidence, and everything that has to do with the autism spectrum in Argentina and other countries in Latin America.

Ms. Karen Muriuki: I am from Nairobi, Kenya. I was diagnosed autistic when I was 3 years, in 1985, when autism was not commonly known in Kenya. I am an activist and involved in a lot of autism advocacy. I believe the power of activism helps to create many of opportunities for adults in Kenya. I am a trainee at Anapendeza, an organization that helps to seek job opportunities for adults with developmental disabilities and also working with an NGO, GeneTrans. I am also an alumni of project Autism Tech Training at Strathmore University.

Ms. Pooja Panesar: I am a board-certified behavior analyst based in Kenya. I am also the founder and director of Kaizora, a center for individuals with autism and related disabilities in Kenya and Tanzania that provides multidisciplinary services. We serve children from as young as we can get them, and our oldest client at the moment is 24 years, so our work starts from early intervention and progress all the way to vocational training and job placements. Given the need, I also founded Autism Awareness Kenya in 2010 to create awareness on autism and provide networking and support for those who need it.

Mr. Qazi Fazli Azeem: I am from Karachi, Pakistan. I was diagnosed on the spectrum in 2006 when I was 25 years. I am Pakistan's first and the only national and regional self-advocate for the autism spectrum. I have presented at various national and international conferences and events including the UN on Autism Awareness Day in 2013. I have trained pediatricians, educators, scientists, and researchers. I have contributed to the global self-advocacy movement by having my writings published in a book called Been There. Done That. Try This!: An Aspie's Guide to Life on Earth.⁷ A lot of my work is all nonprofit, and I use my own experiences to help wherever I can. I am a graphic designer and design educator and did my MFA from Mass Art Boston and the MIT Media Lab through the Fulbright scholarship.

Ms. Saima Wazed Hossain: I am a clinical and school psychologist trained and licensed in the United States, and have been working in Bangladesh since 2010. I serve as chair on a National Advisory Committee under the Ministry of Health of Bangladesh. I also have a not-for-profit organization called Shuchona. We do advocacy with policymakers and have been instrumental in developing a national strategy in Bangladesh on issues that would assist those on the autism spectrum. We work with various ministries and provide consultancy in building supportive programs and training opportunities.

Dr. Shubhangi Vaidya: I am a sociologist, with research interests in disability studies. I have authored books and published research articles in the areas of autism, family, and gender. As a parent to a 22-year-old young man with autism, I have also been associated with Action For Autism, a leading nongovernmental organization in India and South Asia for the past 20 years, and have been involved in advocacy activities to build awareness and promote rights-based approaches in India.

Dr. Singhal: I would like to start with a brief introduction on the understanding of autism in your country. We would especially like to hear about the common beliefs and perceptions surrounding autistic adults in your country.

Mr. Corrons: Unfortunately, there is still a lot of prejudice in Argentina, and a large part of the society still believes that we are sick with some unknown illness that turns us into dangerous individuals. I believe it is right to say that unfortunately a large part of the society still believes that. And that could not be further away from reality. So, even though substantial progress has been made throughout the past years in terms of raising awareness about what autism means, we still have to work a lot on raising awareness, particularly making people understand that we are just different and that we have our own abilities. Another big barrier here is that we have a lot of inequality. Unfortunately, the poverty rate has gone up and when you do not have resources, it is much tougher to have access to both health care and medicine. I know India has the same problem. So that is what kind of draws the line between the more developed countries and the underdeveloped world.

Dr. Ratazzi: I totally agree with Tomás. There is still a lack of knowledge and there is a lot of ignorance surrounding autism in adulthood in Argentina and the region. I think a common belief is that autism is related to childhood, and that there are no adults with autism. It is always related to children. Nobody thinks about those children growing up and becoming adults. And in contrast, the people who do think about adults almost always relate autism with a deficit model of disability, and the idea that adults with autism cannot study in university or work like anyone else, and that they will probably depend on their families for the rest of their lives.

Ms. Hossain: In Bangladesh, autism was not a word that was familiar or understood when we started in 2010. It was not even considered to be a medical condition. There were many of misconceptions, superstitions, and fears—for example that a spirit has taken over. We worked really hard in these past 10 years to educate the public on a large scale that autism is a neurological condition. Part of the reason we had to talk about it as a medical condition was to engage families to seek interventions. Because of social stigma, families hide the family members from others. Even until 2 years ago, the topic was very much focused on children. The oldest diagnosed person on the spectrum we know of in Bangladesh is probably in their 20s. There were children who had gone to school until about 16 years and after that have been at home because they have nowhere to go. Of course, they did not want to go back to children's school and families always have to struggle with that. Most do not even get opportunities to learn how to function outside their home. People still tend to use autism as synonymous with somebody with a disability. The word is interchangeable. And disability in Bangladesh has been conceptualized as somebody who cannot really function in “normal” society. The attitude in the past 10 years has significantly changed. People are much more open-minded about it. There are opportunities, but not quite to the extent that we would like. But we still have some core issues as how can somebody on the spectrum work or could be going to university? And as long as we do not have good examples, then the misconceptions will continue to stay.

Dr. Vaidya: In India, autism as a category does not have much salience outside of certain very specific restricted urban circles. And the important thing is that the difficulties in obtaining diagnosis, the difficulties even in understanding what this condition is all about, have meant that persons with autism have not been visible. Because their autism was never recognized or acknowledged, as adults, too, they remain invisible. So it is almost as if they have fallen through the cracks, and it is only now that the fact that they exist at all is being acknowledged, but in a very limited way and among limited sections of society.

Mr. Azeem: In Pakistan the situation is very similar to that in Bangladesh and India. We are basically not as far ahead in terms of available services and government support as our neighboring countries. I think one of the reasons is that diagnosis is still a problem in Pakistan. There is practically no adult diagnosis that has ever happened here. Doctors even refuse to diagnose adults because they are afraid that they might not be qualified enough. And there are very few adults who come forward because of the social stigma and also because of the lack of awareness particularly toward adults who are higher on the spectrum. As far as the children go, their diagnosis is not much better than it was about 10 years ago, and the younger teachers and doctors and pediatricians are sort of partially aware. But as far as the understanding for adults go, it is a serious problem because of the lack of awareness, and also because there are not enough people coming forward. I am a self-advocate and I talk about autism. My interviews are on television, the Internet, YouTube™, and so on. One year ago, another self-advocate, Ahmad Siddiqui, has also come forward. But that is it. And you are looking at a country of ∼200 million people. So that is a lot of people, and a lot of people who were never diagnosed or misdiagnosed and are falling through the cracks. And that itself is a problem, because once you have a critical mass of people who were diagnosed later in life, then the self-advocates would be there to help in the training process to help advise people. And that is missing. I believe what we need in a South Asian context are more self-advocates. Having lived in the West for a few years, I have seen the incredible change that self-advocates bring to society. And that is missing in Pakistan and in all of South Asia. We need more people to come forward. And for that to happen, social perceptions will have to change. I have seen excellent Indian television series such as Aap Ki Antara⁸ and movies such as My Name is Khan and Barfi that address autism. With leading actors, they gain the much-needed popularity and significantly impact perceptions. More of that needs to happen.

Ms. Muriuki: My major concern with autistic adults in Kenya is that there is still a lot of unemployment and nothing available for the transition to adulthood. So, once an adult with autism reaches the age of 20–21 years, they are hidden at home. Once they have cleared school, there are no opportunities for them. And parents have the misconception that there is nothing that autistic children can do once they reach adulthood. There are not enough services for autistic adults in Kenya, not even adult diagnostic services, because all services are aimed at children. There is still a lot of unemployment and zero opportunities of job placement. There is a little bit of improvement in terms of job training, but there are no long-term services for autistic adults at this point.

Ms. Panesar: The understanding of autism in Kenya and Tanzania actually depends on where in the country you are—urban or rural. In cities, there is somewhat higher level of awareness and understanding on what autism is, but there is still no understanding of interventions. Ten years ago, when I first said to somebody, “I work with autistic children,” they said, “Oh, you work for the artistic children. How lovely.” And we have come a long way from that and what I get now is “Okay, I have kind of read about it, but what is it exactly?” So, although it has definitely improved, it is not great. Doctors are not always very aware about autism, so you have to go to a few specialist doctors to be able to get any diagnosis. Diagnosis in adults hardly happens, and when it does happen, it is often delayed. There is also a lot of misdiagnosis.

In rural areas, you see a lot of “the person is possessed”; “it is witchcraft”; “the mother is cursed”; “mother's dowry has not been paid”; “it is bad parenting. Control your child.” So there is a lot of stigma around these things. They also think autism can be spread, so a lot of distance is created. Rather than trying to help, there is a lot of wariness and this distance created and we get a lot “What if my child gets infected?” More severely affected adults in the rural areas are called “mental” or “crazy.” They are hidden from society because it brings stigma to the whole family. Even in the cities, there is the perception that if somebody has autism, they are not going to be useful in the workplace. They are considered more of a burden like they would not have any contribution in a work environment. It is challenging even to get internships in different organizations. One of my students was denied an internship, because “They will make the customers uncomfortable.”

Dr. Singhal: What in your opinion have been some of the significant developments that have positively impacted the lives of adults with autism in your country?

Mr. Corrons: A national law was passed in Argentina in December 2014 (Act 27043—”Comprehensive and interdisciplinary approach to persons with autistic spectrum disorders”). It was a landmark piece of legislation in the sense that it expanded the rights of persons with autism in Argentina. A year later, Congress passed another bill declaring the National Day of Autism. So, from a political point of view, that would be the most significant progress made.

Dr. Ratazzi: There has been quite a rise in the number of advocacy organizations: self-advocacy and parental, family advocacy organizations that have led to the rise in awareness in the past 10 years in Argentina and in the region. Because of activism and advocacy activities done by all these organizations through talks, networking, participation in media, awareness campaigns, TV, and radio, everybody is talking a bit more about autism. And this is a key point in positive developments in and society knowing about autism in adulthood. I think this kind of thing can be easily translated to other places.

Ms. Hossain: In Bangladesh, attitudes have changed in the past 10 years with our awareness-building activities. In the past 2 years, many young adults have received opportunities to showcase their skills, participate in various discussions, and now companies and organizations are becoming interested in hiring autistic adults. There are opportunities though not quite to the extent that we would like. We have also worked on our legislation and advocated and assisted in updating many of our policies so that individuals with autism have better opportunities to go to schools and complete their education, successfully attend examinations, and have a shot at getting employed.

Mr. Azeem: In Pakistan things are a little bit better than they were about 10 years ago. The younger teachers and doctors and pediatricians are now sort of partially aware. We find that the government hospitals are also stepping up and being trained.

Dr. Vaidya: Awareness and activism around disability and disability rights are growing in India, and autism is not as unfamiliar as before. Family-driven organizations and NGOs are doing great work in building awareness and creating services. The new law—The Rights of Persons with Disabilities Act (2016)—includes autism in the list of disabilities and this will surely have an impact on opportunities in education and employment for persons with autism. Social media has also played a big role in mobilizing people across the country and the world, helping them to share experiences and build solidarities.

Ms. Panesar: One of the most significant developments happened in 2010 when the Kenyan constitution stated that there be a fair representation of persons with disabilities in the country and brought into legality the acceptance of disabilities. Multiple autism organizations and more importantly self-advocates are now involved in creating awareness of autism in the country. One of them conducts various walks all over the country (in rural areas as well) with her camels to spread awareness on the disorder, another one is currently writing a book, and a third one is an advocate. We need to hear more voices and I am sure we will be seeing great developments emerge with time.

Dr. Singhal: If you could select one or two priority areas that your country should focus on right now, what would those be and why?

Ms. Muriuki: The most important thing in Kenya is having diagnostic and counseling services for undiagnosed autistic adults. Training needs to be done for clinical officers and psychiatrists so they can also understand autism from autistic standpoints. Another area is organizing for job training. There are companies that do not understand and could be better informed about autism. They need training about autism from scratch, led by autistic people who know what it means to be autistic.

Ms. Panesar: One of the things we need is early intervention because it is the children who grow up into adults. If we start the childhood right and provide for what is needed, people transition into successful adults. We also need awareness and advocacy. Our constitution calls for a fair representation. Adults with autism should have a voice in every major organization in this country.

Mr. Corrons: I believe that in Argentina, we have to focus on what happens during childhood. It is critical that we ensure that young kids with autism are integrated. In the past, there was not any kind of framework or policy to ensure that kids with autism are integrated from a young age. I suffered from bullying when I was in high school. That is probably because teachers were not trained. There was not much awareness about what autism means. It is important that we ensure that kids live a happy and healthy childhood, so it is critical that we share resources, do research, and train our teachers so they are better prepared. We have to spread more awareness and demolish preconceptions about autism. Let people know that people with autism have their own abilities and may even be better than the average individual in some aspects, and that we may struggle to socialize not because we want to but because we find it difficult. It is crucial that our society understands that we can make a difference, and that we can propose growth and progress in the same way we have always done in history. And we have many examples of autistic people who have made significant contributions. That will get people to embrace the idea of being diagnosed as autistic instead of fearing it. This can provide them with more tools and more chances to face life instead of transforming their lives into an uphill race. Unfortunately, people used to be scared of being diagnosed with autism or Asperger's and that needs to change more. We have to work toward making sure that autistic people are given the same chance to get a job as the average individual. And although it is true that there is legislation or laws that were approved in the past couple of years, they are not enforced, either because politicians do not pay attention to them or because we lack resources.

Dr. Ratazzi: In Argentina, there is a lot of prejudice, bias, preconceptions, myths, and ignorance that is related to adults getting a diagnosis. Even professionals who dedicate themselves to adults know very little about autism. Often professionals like me from child and adolescent field diagnose adults, because adult psychiatrists do not know much about autism. So, as in many countries, it is very difficult for adults with autism to get a diagnosis. Even for those who received diagnosis as a child, it is very hard.

Then there is inadequate legislation. For example, the law provides access to employment. So, all state agencies and dependencies are required to fill in 4% of total vacancies by people with disabilities. However, this does not make public employment accessible and does not provide opportunity for people with developmental and intellectual disabilities that has resulted in >80% unemployment.⁹ In Argentina, we still have a segregated education paradigm instead of the inclusive education paradigm as recommended by the Convention of Rights of People with Disabilities.¹⁰ If we could have inclusive education in the first years, that would certainly follow through into adulthood. For example, many times a requisite to get a job is to have a formal secondary education. So, if you were in special education as a child or a teenager, you cannot access a normal job because you do not meet the prerequisite accredited education. So, an inclusive educational paradigm would favor inclusion in all aspects in adulthood.

Mr. Azeem: I think the foremost for Pakistan that I would really like to see is an epidemiological study so that we have better understanding of the number of the people impacted, both children and adults on the spectrum. The reason I say this is because recently a survey was done on 1800 people who went to psychiatrists and it was found that ∼12.5% had symptoms of Asperger syndrome or higher functioning autism.¹¹ They were not diagnosed, but my point is that this is a very high number. The number of people on the spectrum cited in Pakistani media are based on projections extrapolated from Western studies as no epidemiological Autism study has yet been conducted in the country. The epidemiological studies done in India and Bangladesh have probably helped the process of sensitizing the public to how crucial and how important it is to do something about this, how it is affecting many people. And in Pakistan, we still do not know how many people exactly are on the autism spectrum. Sadly, because of the current economic situation in the country, the government has all kinds of other pressures and may not be paying much attention to this area as they should.

Ms. Hossain: To showcase that autistic adults are quite capable of being very successful, you need demonstrable evidence. If the opportunities are not provided—because of the prejudices, stigmas, and preconceived notions—we will never be able to change mindsets. So, we have to bring out individuals and showcase their specific talents. Last year was the first time that in a national celebration on television people saw a performance by a mixed group of singers. And it was very good in the sense that they were not just persons with disabilities, but they were actually a group of young adults who love to sing—and some were typically developing and some were on the spectrum. We need more opportunities to create ambassadors who can break down many of these pre-existing barriers that exist in the minds. This cultural change makes a significant impact and changes their core belief of what it is to be an autistic adult.

Simultaneously, to continue having long-term impact, you have to start really young. So, the easiest group is the very early childhood group in primary schools. We have to start building relationships with children so they are comfortable with another child and different ways of communication and interactions. That can make a big shift in what happens in our country. Children are much more open-minded and do not have firm beliefs. We also have these very young youth groups who can be involved. So, we have got to create more of such opportunities, giving children an opportunity to interact with one another, as well as, at the same time, to create a few ambassadors who can break down many of these pre-existing barriers that exist in the minds.

Dr. Vaidya: Everybody has covered most of the areas that are of great concern—correct diagnosis, inclusion in the educational system, awareness, and so on. I would also like to add that in some contexts, autism has become a kind of an industry wherein many private players, unverified theories, and money making in the name of therapy have become a huge cause of concern. And although we do feel the need for more accurate diagnosis, epidemiology, as Fazli said, so that we actually can assess the number of persons with autism, there is also this parallel medicalization that is taking place. The person with autism is just regarded as a medical issue or medical problem, and the therapy industry sort of weighs in and takes agency out of the hands of the individual and the people around the individual. So, I think this is kind of a conflict. On one hand, you do want more specialists and more practitioners to engage with the issue. On the other hand, this leads to robbing of agency. How does one reconcile these things, and speak the language of rights and neurodiversity?

I think the one thing that is crucial is advocacy and the need for self-advocates in the South Asian context, because there are very, very few of them. And the reason, like I mentioned earlier, is that so few people have been diagnosed. I also think larger cross-disability interaction is important, because autism tends to be this outlier category. Nobody really knows much about it, so it does not figure prominently in discussions in our country. So, there is a need for self-advocacy—not just by parent advocates, because there has been a lot of parent-led advocacy, but also by autistic adults—to put them up front and center in the larger disability discourses, and rights-driven discourses that are gaining currency in South Asia.

Dr. Singhal: I request Christina who has been listening quietly but closely to share her thoughts and summarize the discussion. I think it will be very useful to hear Christina's perspective with her experiences from higher income countries.

Dr. Christina Nicolaidis: I have been listening to this conversation with the ears of an outsider and have been learning so much from all of you. I hear many commonalities across the various countries represented today. And some of them feel a bit familiar, even for those of us living in the United States or other higher income countries.

• First, I am hearing about many challenges related to the public's basic understanding of autism. We heard about the existence of superstitions, especially in rural areas, where people might believe that somebody on the spectrum has been possessed or cursed or where there might be concerns about contagion or other such things. And then we are also hearing about some of the same problems we have all over the world in terms of stigma, bullying, ableism, stereotyping, and general prejudice against people on the autism spectrum.

• I am also hearing a familiar tension between the medical and social model of disability, but this tension may even be a bit trickier in this context. Saima makes an argument in favor of medicalizing autism so that people see it as a neurological condition, and thus move away from believing that an autistic person is possessed or cursed. In contrast, as Shubhangi points out, there is still a potential downside to using a medical model in that it may decrease agency, perpetuate stigma, encourage potentially harmful interventions, or decrease acceptance. It will be interesting to see whether and how one can change attitudes about autism being a curse without introducing some of the problems the medical model of autism has caused in higher income countries.^12,13 It would also be interesting to learn more about the diversity of traditional conceptualizations of autism around the world, and to explore culturally sensitive ways to inform strength-based models of autism.

• Similarly, I am hearing a familiar tension around how best to focus on strengths. It sounds like there has been some real progress in helping the public understand that autistic adults have strengths and can be productive, successful, or “useful.” At the same time, there is a danger of accidentally devaluing the lives of people who might face more significant disabilities. As we discussed in another recent round table discussion,¹⁴ this is a struggle that the advocacy movement is dealing with all over the world. It is indeed possible to recognize a wide range of strengths—not just those that lead to stereotypical “success stories”—and to focus on strengths without ignoring challenges.

• We heard a lot about the importance of inclusion, both in education and in society, and the value of including autistic children in regular education. Personally, I particularly like Pooja's idea of making sure that neurotypical children—who might be more open-minded than neurotypical adults—get exposed early to ideas related to inclusion and acceptance.

• Yet, as in higher income countries,¹⁵ autism programs are already largely focused on children. I am used to hearing that people are not even thinking about autism in adults, but I have to say it was striking for me to hear Saima say that the oldest diagnosed person in Bangladesh may be in their 20s or to hear Fazli describe himself and one other person as the only widely visible self-advocates in a country of 200 million people.

• And then we heard about the extreme lack of clinicians who can diagnose autism in adults, as well as the lack of counseling, vocational, or support services for autistic adults. Again, the lack of adult services is a huge problem in higher income countries,^16–18 but we may underappreciate how magnified it is in low- and middle-income countries. Several people pointed to additional barriers and challenges when there are great social inequalities and to the importance of trying to make sure that advocacy programs and services reach everyone, including people who might have lower socioeconomic status and people in rural areas.

• Not surprisingly, given what a huge priority employment is to autistic adults around the world,¹⁹ today's discussion had a big focus on employment. I was very excited to hear about panelists' existing programs and new ideas to increase employment, be it through legislation, campaigns to change how corporations think about autism, or training of both employers and employees.

• Finally, and probably most importantly, we heard about the importance of self-advocates. An added challenge with so few adults being diagnosed in low- and middle-income countries is that fewer adults may be comfortable being open about their diagnoses. We heard a lot of enthusiasm about including self-advocates as they may promote societal acceptance of autism; help other adults embrace the idea of a diagnosis instead of fearing it; and better advocate around human rights and disability rights, fair representation, and being able to have a say in how things are done. And that is, I think, extremely important all over the world.

Dr. Singhal: We all agree that many concerns seem to be common for the low- and middle-income countries represented today. Were there things you found interesting or useful in today's discussion? And do you have any thoughts or suggestions on issues that could be addressed as a group or things that you think could be incorporated in your work?

Dr. Vaidya: Yes, something that I think all of us need to take on board is that all the countries we represent have huge diversity. Speaking of my own country, India, we have a billion-plus population, and many different languages, communities, ethnicities, and cultures. So, to actually have a one-size-fits-all understanding of what works does not seem very appropriate to me. I mean, inclusion for a person living in a far-flung rural village is very different from what would work for a person living in a metropolitan city, because the contexts are so different. And so, we need to always keep in mind the context within which the individual with autism finds himself or herself. I think that is something we should try not to lose sight of.

Mr. Azeem: Yes, Shubhangi's point is very valid. I want to add a couple of additional points. First, I believe that there is a lack of academic literature and research regarding developing-world issues and how we address them. For example, if you just look at the concept of shared communal spaces or communal living or rural living, there is not a lot of documentation about it. And that is generally what happens in the developing world—families are living together most of the time, even generations are living together. But not a lot of research and publication has been done. I also believe that there are pretty good examples within the region, and so much to learn from each other, but we are not communicating that much even within the region or learning from each other as we should be. I think the problem is that there is no regional effort, perhaps because of political or other reasons, but there is no concerted effort. We are all individually trying to do things the best we can, within our challenges. But our challenges are so similar, particularly in these developing countries. And many of the developing countries are simply not talking to each other, and they should.

Ms. Hossain: In most countries, there is a lot of great advocacy, and there are many great programs that are in place. However, those programs operate in silos, and not necessarily at a more national/governmental level. I know it may be a bit of a struggle, but if we really want to see a difference, we need to advocate for change in the governmental level, because that is the largest system in place, reaching the most number of people. So, it is key to work through the government system to create various opportunities including employment.

Ms. Panesar: I loved this discussion today because it is bringing people from all around the world together. I found it very interesting listening to the perspectives from Tomás, Fazli, and Karen as well, because for us who are on the other side we think that we and trying to make a difference and do something good. But it is always different and important to hear it from the other perspective. Like Fazli was saying, we need to all be able to hear each other's stories as well, because that is how we will move forward. You feel heard and you also know that you are not the only one who has been through this. There are people all over the world who have the same struggles. And, just brainstorming together like this, it kind of clears your mind and helps you work your way forward, as well.

Mr. Corrons: To be honest, I was able to anticipate that there were going to be many things in common. I am in favor of globalization. I like this cosmopolitan idea. Well, as I said, I believe that what brings us together is this fight against preconceptions and prejudice. I believe that is a reality that is found everywhere. But what drew my attention the most is what Pooja said about what is happening in rural Kenya. I mean, how difficult it is to work under those conditions. So probably that is something we could learn from. I mean, we also have rural areas here in Argentina where there is a lot of inequality. So that is something that we could use—I mean, follow her example there. But above all, all interactions were particularly interesting. And I truly learned a lot, so thanks, a big thanks to all of you.

Dr. Singhal: Thank you, everyone for making the time for the discussion today. It was very interesting to know more about the different cultures and hear everyone's journey. Despite the geographical distances, challenges across the globe have been similar and there is much for all of us to learn from each other in this respect.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this roundtable discussion.