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Global Mental Health: Focus on Latino Populations. Javier I Escobar MD Associate Dean for Global Health and Professor of Psychiatry and Family Medicine, UMDN-Robert Wood Johnson Medical School September 2011. Local Health International Health. Global Health. GLOBAL HEALTH.

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Global mental health focus on latino populations

Global Mental Health: Focus on Latino Populations

Javier I Escobar MD

Associate Dean for Global Health and Professor of Psychiatry and Family Medicine, UMDN-Robert Wood Johnson Medical School

September 2011

Local Health

International Health

Global Health


“Health problems, issues, and concerns transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.”The Institute of Medicine

Us commitment to global health
US Commitment to Global Health

  • The President asked congress to spend $ 63 billion

    over the next six years on a broader Global Health strategy that would reshape previous policy.

  • According to the President, this US global health investment is an important component of the national security “smart power strategy”, where the power of America’s development tools can build the capacity of government institutions and reduce the risk of conflict before it gathers strength.

  • It has been also recommended that Global Health should become the pillar of US Foreign Policy*

*Institute of Medicine report released on 12/22/2008

We are in a global age
We are in a Global Age

  • US Medical Schools are developing programs in Global Health (Harvard, Johns Hopkins, Michigan, NYU and

    many others)

  • NIH Institutes opening Global Health’s Offices.

  • Major Universities require significant time abroad for undergraduates (Harvard, Princeton, etc.).

  • “If you are going to come to Harvard College it would be very good to have a passport” William Kirby, Dean of the Faculty of Arts and Sciences (Guardian Unlimited, April 27, 2004)

Nih and global health

  • The new director of NIH,

    Francis Collins, listed Global Health

    as one of his top four priorities at

    the Institute

  • Collins plans to expand research efforts to include diseases endemic to developing nations and increase research collaboration with those countries, to alter the world’s view of the United States, “by emphasizing its role as a doctor rather than a soldier”

Nimh international activities


In 2004, there were 184 NIMH-funded research projects that included an international component, only a handful of these (5 or less) taking place in Latin America.

By 2009, the director reported that there were 200 projects with an international component.

In 2010, first RFA to create “International Hubs” (one of them in Latin America)

In 2011, second RFA for “International Hubs”*

*We are submitting application that includes UMDNJ and sites in Colombia, Mexico, Argentina and Peru.

Us medical schools and hospitals expanding overseas
US Medical Schools and Hospitals Expanding Overseas

  • Weill Cornell Medical Center: Cornell Medical

    School in Qatar

  • Duke University: Duke Medical School in Singapore

  • Johns Hopkins: Two Hospitals in the United Arab Emirates and one in Singapore

  • Cleveland Clinic: Hospital in Abu Dhabi

  • University of Pittsburgh (UPMC): Oncology centers in Greece, Turkey, Germany, South Korea

Latinos in new jersey
Latinos in New Jersey Zaragoza Spain?

Source : U.S. Census, 2000

Latinos in new brunswick 48 of all residents
Latinos in New Brunswick Zaragoza Spain?48% of all residents

Source: New Brunswick Community Health Survey,

Center for State Health Policy, 2004

Latinos in New Brunswick Zaragoza Spain?

Source: New Brunswick Community Health Survey,

Center for State Health Policy, 2004

Country Origin of Latino Patients Recruited in a Primary Care Study at Eric B. Chandler Clinic, in New Brunswick(Escobar J.I., et al Annals of Family Medicine, 2007)

Concentration of Foreign-born Immigrants in Zaragoza Care Study at Eric B. Chandler Clinic, in New Brunswick

Delicias, Casco Viejo

A. Fullaondo, P. Garcia,

Immigrants in zaragoza 2006
Immigrants in Zaragoza (2006) Care Study at Eric B. Chandler Clinic, in New Brunswick

Total Population =


Immigrants =


Immigrants in zaragoza spain
Immigrants in Zaragoza, Spain Care Study at Eric B. Chandler Clinic, in New Brunswick

  • Zaragoza = the smallest among Spanish Metropolis.

  • 2001 = 14,583 (2%)

  • 2005 = 53,492 (8%)

  • 2006 = 65,012 (10%)

  • 2008 = 92,491 (12%)

  • 2010 = 108,373 (>15%)

  • Immigrants account for >90 % of the demographic growth in the city.

  • More than one fourth of all immigrants come from Ecuador and Colombia. Other immigrant groups (Asians and other Europeans) have been on the increase recently.

Most important global health problems nowadays
Most Important Global Health Problems Nowadays Care Study at Eric B. Chandler Clinic, in New Brunswick

  • Communicable, Maternal, Perinatal and Nutritional Conditions

  • Non-communicable Diseases

    (Chronic Diseases; Mental Disorders)

  • Injuries

  • Other (Obesity, Violence, etc.)

LIFE EXPECTANCY AND INCOME Care Study at Eric B. Chandler Clinic, in New Brunswick

THE WORLDWIDE BURDEN Care Study at Eric B. Chandler Clinic, in New Brunswick

History of emerging infections
HISTORY OF EMERGING INFECTIONS Care Study at Eric B. Chandler Clinic, in New Brunswick



  • 610 Influenza

  • 644 Leprosy

  • 900 Smallpox

  • 1348 Plague

  • 1495 Syphilis

  • 1510 Scarlet Fever

  • 1546 Typhus

  • 1557 Malaria

  • 1567 Smallpox

History of emerging infections1

1973 Rotavirus Care Study at Eric B. Chandler Clinic, in New Brunswick

1977 Ebola Virus

1977 Legionnaire’s Disease

1981 Toxic Shock Syndrome

1982 Lyme Disease


1983 Helicobacter Pylori

1991 Multi Drug Resistant


1991 Epidemic Cholera

1994 Cryptosporidium

1998 Hong-Kong Bird Flu

1999 West Nile Virus

2001 Anthrax

2003 SARS

2006 Extremely Drug Resistant (XDR) TB)

History of Emerging Infections

West Nile Virus in the US Care Study at Eric B. Chandler Clinic, in New Brunswick

Aids pandemic
AIDS Pandemic Care Study at Eric B. Chandler Clinic, in New Brunswick

  • AIDS undoubtedly was one of

    the most devastating diseases

    that emerged during the 20th century.

  • From 1981 to the end of 2004, about 25

    million people world-wide have succumbed

    to HIV infections.

  • The pandemic is expected to progress

    well into the 21th century.

Influenza Care Study at Eric B. Chandler Clinic, in New Brunswick

  • An agent of great concern

    globally is influenza virus.

  • Influenza virus is known to cause epidemics as early as the 1500’s, and pandemics have been described as early as 1889.

  • The most extensive pandemic ever known is the pandemic of influenza of 1918-1919, which killed more 20 million people.

Ref Business Week, April 14, 2003 Care Study at Eric B. Chandler Clinic, in New Brunswick

Malaria Care Study at Eric B. Chandler Clinic, in New Brunswick

Trachoma Care Study at Eric B. Chandler Clinic, in New Brunswick

  • Trachoma is an infectious eye

    disease. the result of infection

    of the eye with Chlamydia trachomatis.

  • Trachoma is the leading cause

    of blindness in the world (Africa, China, Thailand, Mexico,

    Brazil, Ecuador).

    In the USA = Native Americans and the

    Appalachian Region

  • Globally, 84 million people suffer from active infection and nearly 8 million people are visually impaired as a result of this disease. ...

Trachoma Care Study at Eric B. Chandler Clinic, in New Brunswick

  • Infection spreads from person to person, and is frequently passed from child to child and from child to mother, especially where there are shortages of water, numerous flies, and crowded living conditions.

  • Infection often begins during infancy or childhood and can become chronic. If left untreated, the infection eventually causes the eyelid to turn inwards, which in turn causes the eyelashes to rub on the eyeball, resulting in intense pain and scarring of the front of the eye. This ultimately leads to irreversible blindness, typically between 30and 40 years of age.




Facial Cleansing

Enhanced Hygiene

Ncs in the global front
NCS in the Global Front Care Study at Eric B. Chandler Clinic, in New Brunswick

  • Most people nowadays die from non-communicable diseases (NCS) once associated with wealth such as cancer, heart diseases, diabetes, etc.

  • In 2008, 36 million deaths or 63% of all deaths worldwide, were due to NCS.

  • In late September 2011 a high level summit of the United Nations will be addressing this problem

Complex global health problems mental disorders addiction obesity violence injuries

Complex Global Health Problems Care Study at Eric B. Chandler Clinic, in New Brunswick:

Mental Disorders





Leading causes of disability around the world cost in billions of us dollars
Leading Causes of Disability Around The World (Cost in Billions of US Dollars)

World Health Organization, 1996

Obesity Billions of US Dollars)

Violence Billions of US Dollars)

Addiction Billions of US Dollars)

Dalys lost due to high risk drinking by disease category and region 2001
DALYs Lost Due to High-Risk Billions of US Dollars)Drinking by Disease Category and Region (2001)





Millions of DALYs



Notes: Numbers are rounded.

Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 47.3

The who ranking of the world s health care systems

France Billions of US Dollars)


San Marino















United Kingdom








Saudi Arabia

United Arab Emirates









United States of America

The WHO ranking of the world’s health care systems

WHO Health Report, 2000

Total health expenditures as of gdp 2002 2005

Marshall Islands (19%) Billions of US Dollars)

USA (>14%)








France (10%)

Germany (10%)

Spain (7-8%)

41. United Kingdom (7-8%)

60.Colombia (7-8%)

Total Health Expenditures as % of GDP, 2002-2005

Source = WHO

Disability adjusted life expectancy at birth

Japan Billions of US Dollars)










San Marino



United Kingdom










United States of America

Disability Adjusted Life Expectancy at Birth

Source, WHO, 1999

Rwjms office of global health
RWJMS Office of Global Health Billions of US Dollars)

Located at CAB Suite 7038

  • Javier I Escobar MD,

    Associate Dean for Global Health

  • Aparna Kalbag MD, PhD, Post

    Doctoral Fellow

  • Rachel Werner, Administrative


  • Steering Committee:

    Sunanda Gaur MD (Pediatrics), Robert Like MD; Sonia

    Garcia-Lambauch MD; Karen Lin MD (Family Medicine),

    Charletta Ayers MD (OB & Gyn); Abel Moreyra MD

    (Medicine/Cardiology), Shannon O’Hearn MS3, Minyoung

    Yang MS3, Peter Murr MS-2, Rhea Itoop MS-2, Shazia

    Mehmood MS-2

Rwjms medical students interest in global health
RWJMS Medical Students’ Interest in Global Health Billions of US Dollars)

  • 21% of RWJMS 2012 Class Were Born Outside the United States

  • Over 20 students in the entering class have participated in international service activities prior to medical school on four different continents

  • Over 1/3 of first year medical students express interest in having an international experience during medical school

LATIN AMERICA: Billions of US Dollars)


--CES Medical School, Medellín

--Universidad de Antioquia, Medellín

--Universidad de los Andes, Bogota

(Dr. Javier I Escobar)


--Brazil, Cross Cultural project with Pediatrics (Dr. Moorthy);

--Universidad de Sao Paulo (Dr. Pat Williams, Pediatrics)


--Universidad de la Plata (Dr. Abel Moreyra Medicine/Cardiology)

--Universidad de Buenos Aires; Departamento de Salud, San Salvador de Jujuy


--Instituto Mexicano de Psiquiatria

--Universidad Popular Autónoma del Estado de Puebla (UPAEP)

--Universidad de Oaxaca


--Universidad Cayetano Heredia, Lima


--International Health Central American Institute Foundation

, San José

About 50 rwjms medical students went abroad in 2008 2009

60% = MS-II

25% = MS-III

15% = MS-IV

COUNTRIES VISITED Billions of US Dollars)


















Rwjms has gone global

“RWJMS HAS GONE GLOBAL” Billions of US Dollars)

Collaborations with latin america javier i escobar md
Collaborations with Latin America: RESEARCHJavier I Escobar MD

  • Addiction in the Americas (CICAD - OAS) Collaboration with Costa Rica, Mexico, Barbados, Uruguay, El Salvador, Chile, Colombia (UMDNJ-RWJMS as Coordinating Site)

  • NIMH/CIR/PAHO: Collaboration in Mental Health Services Research and Education (USA, Canada, Mexico, Colombia, Chile, Brazil, Peru, Jamaica)

  • NIMH-Funded Genetic Study: “Bipolar Endophenotypes in Population Isolates” – UCLA, Colombia, Costa Rica

  • NIMH R-13 Mentoring Grant “Critical Research Issues in Latino Mental Health”

  • Schizophrenia Study in Argentina.

Outcome of schizophrenia across cultures who study jablensky et al 1992
Outcome of Schizophrenia Across Cultures RESEARCH(WHO Study-- Jablensky et al, 1992)

Familial expressed emotion and relapse of schizophrenia
Familial Expressed Emotion and Relapse of Schizophrenia RESEARCH

  • 26 Studies in Several Countries (England, USA, Spain, Germany, Eastern Europe, Japan, Mexico)

  • Percent Relapsing: Low EE -- 22% High EE -- 50%

World mental health surveys participating countries in the americas
World Mental Health Surveys RESEARCHParticipating Countries in the Americas

CountrySample Size

  • Brazil 5,000

  • Canada 30,000

  • Colombia 5,000

  • Costa Rica 5,000

  • Mexico 5,000

  • Peru 5,000

  • United States 25,000

World Mental Health Surveys RESEARCH Participating Countries

Use of cannabis and cocaine in several countries
Use of Cannabis and Cocaine in Several Countries RESEARCH

Medina Mora et al, 2005

Diagnostic disparities RESEARCH

  • Let’s remember the old USA/UK Study inspired by the Schizophrenias that “were cured just by crossing the Atlantic” (From the US to England)!

  • --This led to structured instruments and diagnoses to diminish bias --

  • --However, diagnostic bias is here to stay!--

Ubhc study n 19 219 percent with serious mental illness dementia schizophrenia mdd bipolar
UBHC STUDY (N=19,219) RESEARCHPercent With Serious Mental Illness (Dementia, Schizophrenia, MDD, Bipolar)

Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003

Percent diagnosed as schizophrenia n 19 219
Percent Diagnosed as Schizophrenia RESEARCH(N=19,219)

Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry,

60:637-644, 2003


About 50% of Latinos in the US are Immigrants RESEARCH

Hispanics born or living in the US appear to be at a greater risk for mental disorders than counterparts born or living in their native countries

Stress of trying to integrate into US society, feelings of alienation and discrimination may increases risk for some disorders

Longer time of residence in US and younger age at entry increase risk for immigrants

Protective effects of strong cultural and familial ties may weaken when living in the US

Longer residence in US and younger age at immigration increase risk (vulnerable period?)


Vega WA, et al. 1998; Alderete E, et al. 2000

Epidemiological studies in usa
Epidemiological Studies in USA RESEARCH





Ethnic Groups



  • U.S. born significantly different ( RESEARCHp < 0.001) from each immigrant group (controlling for sex and present age).

  • Immigrants Age 0–16 at Entry US vs Age 17–24 at Entry US significantly different (p = 0.02) for present age 18–24.

Vega WA, et al. In press

Prevalence of current diagnoses in immigrants and native born in spain n 1500 each
Prevalence of Current Diagnoses in Immigrants and Native Born in Spain (N=1500 each)*


*Garcia-Campayo et al, 2011

Unhealthy habits in pregnant women
Unhealthy Habits in Pregnant Women Born in Spain

Modified from Vega et al, 1993

10 year age education adjusted coronary heart disease mortality risk for mexican american adults
10 Year Age-Education Adjusted Coronary Heart Disease Mortality Risk for Mexican-American Adults

Sundquist & Winkleby Am J Public Health, 89:723-730, 1999

Cultural gradient and blood pressure
Cultural Gradient and Blood Pressure Mortality Risk for Mexican-American Adults

Average Systolic Blood Pressure

Socioeconomic Status

Steffen PR, Journal of Behavioral Medicine, 29: 501-510, 2006

Cardiovascular paradox in new jersey moreyra et al presented at ghec cuernavaca mexico abril 2010
Cardiovascular Paradox in New Jersey Mortality Risk for Mexican-American Adults(Moreyra et al, presented at GHEC, Cuernavaca, Mexico, Abril 2010)

Table 1 clinical characteristics
Table 1. Clinical Characteristics Mortality Risk for Mexican-American Adults

  • Hispanics were younger (67 years vs. 71 years),

  • more likely to have

    • hypertension (70% vs. 64%),

    • and diabetes (39% vs. 29%),

      • all differences significant, p<0.0001.

Table 2 multivariable adjusted associations interventions
Table 2. Multivariable Adjusted Associations (Interventions) Mortality Risk for Mexican-American Adults

  • Hispanics had lower adjusted rates of percutaneous interventions:

    • (PCI) (OR 0.94, CI 0.90-0.99, p=0.03),

  • but similar rates of revascularization:

    • by CABG (OR 098, CI 0.91-1.07, p=0.72.

Table 2 multivariable adjusted associations mortality
Table 2. Multivariable Adjusted Associations (Mortality) Mortality Risk for Mexican-American Adults

  • Hispanics had lower:

  • In-hospital (HR 0.88, CI 0.83-0.93, p<0.001) and

  • 30-day mortality (HR 0.95, CI 0.90-0.99, p=0.047),

  • But at one year the survival difference was no longer significant (HR 0.98, CI 0.94-1.01, p=0.23).

Summary of results
Summary of Results Mortality Risk for Mexican-American Adults

Despite higher prevalence of risk factors and lower rates of PCI in Hispanics, the in-hospital and 30-day post AMI mortality is lower, but the difference fades at 1-year.

The latino paradox mortality hazard ratios latinos vs non latino whites in the us nlms data
The Latino Paradox: Mortality Risk for Mexican-American AdultsMortality (Hazard Ratios) Latinos vs. Non Latino Whites in the US (NLMS Data)

Abraido-Lanza et al AJPH 1999

Potential explanations for mental health advantages of immigrants in the us

Measurement Error? Mortality Risk for Mexican-American Adultsmisinterpretation ofquestions; language & translation issues; cross-cultural equivalence

Response Bias?social desirability, social approval, acquiescence

“Salmon” Effect

Selective Migration

Healthier Habits

Kin networks and Family Support?

Potential Explanations for Mental Health “Advantages” of Immigrants in the US

Advantages of bilingualism
Advantages of Bilingualism Mortality Risk for Mexican-American Adults

  • Bilingual people (French/English) obtain better results in execution tests, have better cognitive flexibility, better ability to negotiate abstract concepts than monolingual people1

  • Similar results have been observed in the case of Hispanic origin people in the United States 2,3

1-Peal and Lambert, 1962 2-Rumbaut and Ima 1988 3-Portes 1997)

Immigration and psychosis the experience in england
Immigration and Psychosis: Mortality Risk for Mexican-American AdultsThe Experience in England

  • 1960’s: “High prevalence of Schizophrenia

    in Caribbean Immigrants to the UK” (1)

  • 1980’s: “Schizophrenia is 14 times higher among Caribbean immigrants than in the general UK population (2) and this also applies to the second generation born in England (3)

  • 1990’s: Studies with more methodological sophistication also showed an excess of schizophrenia (4) and mania (5) among Caribbean immigrants. However, other studies showed slight or no differences (6)

  • 2000’s; The AESOP study calls immigration “a risk factor for psychosis (7)

1-Sharpley et al, 2001; 2- Harrison et al, 1988; 3-Harrison et al, 1997; 4-Wessely et al, 1991 5- Van Os et al, 1996; 6-Bughra et al 1997; 7- AESOPStudy Group 2002

Social aspects of the caribbean migration to the united kingdom
Social Aspects of the Caribbean Migration to the United Kingdom

  • Disadvantages and travails of Black people and ethnic minorities in England.

  • Afro-Caribbeans are more likely to be arrested or be transported by the police, to be admitted to psychiatric services against their will and to be locked or confined.

  • “Diagnoses of psychosis made by White psychiatrists on Afro-Caribbeans are based on the notion that the person is strange, undesirable, bizarre, aggressive and dangerous”

Raleigh and Almond 1995; Fernando 1998; Hickling FW, Robertson-Hickling H,

Hutchinson G, Migration and Mental Health, in Hickling FW, Sorel E (eds), Images of

Psychiatry: The Caribbean, Stephenson Litho Press, Jamaica, 2005 (pages 153-177

Comments on studies associating psychosis with migration
Comments on Studies Associating Psychosis with Migration Kingdom

  • There is ethnic variation in the presentation of psychotic symptoms 1

  • Documented bias in the diagnosis pf certain ethnic groups (African Americans in USA) 2

  • The diagnosis of Afro-Caribbeans in England is possibly due to a similar bias.

  • Studies of Afro-Caribbeans in Jamaica do not show an excess of psychotic disorders. 3

  • The results of the old north American studies and the more recent European studies relating migration and psychosis may be due to these biases.

1-Vega WA, Lewis-Fernandez R, Current Psychiatric Reports, 2008, 10:223-228

2-Minsky S, Vega W, Miskimen T et al, Arch Gen Psychiatry, 2003, 60:637-644

3-Hickling FW, Sorel E (eds), Images of Psychiatry: The Caribbean, Stephenson Litho Press, Jamaica, 2005

Reflexions on immigration and psychopathology
Reflexions on Immigration and Psychopathology Kingdom

  • Immigration is a risk factor with a high level of variability.

  • It is related to motivations for migrating, social conditions, language, culture, acceptance of the immigrant in the new environment, employment, etc.

  • Unfortunately, color of the skin continues to play a significant role (racism).

  • Language is a critical factor

  • Resilience, personality, social support, are protective factors.

  • Immigration may have an impact on certain psychiatric disorders but not in others.

  • Epidemiological vs. Clinical Studies.