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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

slide2

Local Health

International Health

Global Health

slide3

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
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

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

Source : U.S. Census, 2000

latinos in new brunswick 48 of all residents
Latinos in New Brunswick48% of all residents

Source: New Brunswick Community Health Survey,

Center for State Health Policy, 2004

slide12

Latinos in New Brunswick

Source: New Brunswick Community Health Survey,

Center for State Health Policy, 2004

slide13

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)

slide14

Concentration of Foreign-born Immigrants in Zaragoza

Delicias, Casco Viejo

A. Fullaondo, P. Garcia, www.enhr2007rotterdam.nl

immigrants in zaragoza 2006
Immigrants in Zaragoza (2006)

Total Population =

660,895

Immigrants =

65,012

immigrants in zaragoza spain
Immigrants in Zaragoza, Spain
  • 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
  • Communicable, Maternal, Perinatal and Nutritional Conditions
  • Non-communicable Diseases

(Chronic Diseases; Mental Disorders)

  • Injuries
  • Other (Obesity, Violence, etc.)
history of emerging infections
HISTORY OF EMERGING INFECTIONS

YEAR

DISEASE

  • 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

1977 Ebola Virus

1977 Legionnaire’s Disease

1981 Toxic Shock Syndrome

1982 Lyme Disease

1983 HIV-AIDS

1983 Helicobacter Pylori

1991 Multi Drug Resistant

(MDR) TB

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
aids pandemic
AIDS Pandemic
  • 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
Influenza
  • 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.
trachoma
Trachoma
  • 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. ...
trachoma1
Trachoma
  • 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.

WHO’s SAFE

Surgery

Antibiotics

Facial Cleansing

Enhanced Hygiene

ncs in the global front
NCS in the Global Front
  • 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:

Mental Disorders

Addiction

Obesity

Violence

Injuries

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

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

11.8

9.7

6.8

5.6

Millions of DALYs

4.5

3.7

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

Italy

San Marino

Andorra

Malta

Singapore

Spain

Oman

Austria

Japan

Norway

Portugal

Monaco

Greece

Iceland

Luxembourg

Netherlands

United Kingdom

Ireland

Switzerland

Belgium

Colombia

Sweden

Cyprus

Germany

Saudi Arabia

United Arab Emirates

Israel

Morocco

Canada

Finland

Australia

Chile

Denmark

Dominica

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%)

USA (>14%)

Niue

Timor-Leste

Micronesia

Kiribati

Maldives

Malawi

Switzerland

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

Australia

France

Sweden

Spain

Italy

Greece

Switzerland

Monaco

Andorra

San Marino

Canada

Netherlands

United Kingdom

Norway

Belgium

Austria

Luxembourg

Iceland

Finland

Malta

Germany

Israel

United States of America

Disability Adjusted Life Expectancy at Birth

Source, WHO, 1999

rwjms office of global health
RWJMS Office of Global Health

Located at CAB Suite 7038

  • Javier I Escobar MD,

Associate Dean for Global Health

  • Aparna Kalbag MD, PhD, Post

Doctoral Fellow

  • Rachel Werner, Administrative

Assistant

  • 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
  • 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
slide43

LATIN AMERICA:

COLOMBIA

--CES Medical School, Medellín

--Universidad de Antioquia, Medellín

--Universidad de los Andes, Bogota

(Dr. Javier I Escobar)

BRAZIL

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

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

ARGENTINA

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

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

MEXICO

--Instituto Mexicano de Psiquiatria

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

--Universidad de Oaxaca

PERU

--Universidad Cayetano Heredia, Lima

COSTA RICA

--International Health Central American Institute Foundation

, San José

slide45

COUNTRIES VISITED

ZAMBIA

DOMINICAN REPUBLIC

MYANMAR

GUATEMALA

ARGENTINA

SPAIN

COSTA RICA

SOUTH AFRICA

MEXICO

GHANA

SWITZERLAND

CHINA

TIBET

ECUADOR

COLOMBIA

INDIA

HIMALAYAS/NEPAL

collaborations with latin america javier i escobar md
Collaborations with Latin America:Javier 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.
familial expressed emotion and relapse of schizophrenia
Familial Expressed Emotion and Relapse of Schizophrenia
  • 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 SurveysParticipating 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
slide56

Diagnostic disparities

  • 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)Percent 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(N=19,219)

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

60:637-644, 2003

immigration
About 50% of Latinos in the US are Immigrants

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?)

Immigration

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

epidemiological studies in usa
Epidemiological Studies in USA

Advantages

Immigrants?

Immigrants/

USA

Ethnic Groups

Language

Study

slide63

U.S. born significantly different (p < 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)*

P<.0001

*Garcia-Campayo et al, 2011

unhealthy habits in pregnant women
Unhealthy Habits in Pregnant Women

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

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(Moreyra et al, presented at GHEC, Cuernavaca, Mexico, Abril 2010)
table 1 clinical characteristics
Table 1. Clinical Characteristics
  • 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)
  • 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)
  • 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

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 (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?misinterpretation 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
  • 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: The 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
  • 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
  • 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.
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