Global Mental Health: Focus on Latino Populations
Javier I Escobar MDAssociate Dean for Global Health and
Professor of Psychiatry and Family Medicine, UMDN-Robert Wood Johnson
Medical SchoolSeptember 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
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 AgeUS 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 ACTIVITIESIn 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
OverseasWeill 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
Why “Global Health” in Places Like New Jersey or
Zaragoza Spain?
Latinos in New Jersey
050,000
100,000150,000200,000250,000300,000350,000400,000
Source : U.S. Census, 2000
Latinos in New Brunswick48% of all residents
23
8 7 73
26
18
7
0
5
10
15
20
25
30
Source: New Brunswick Community Health Survey, Center for State Health Policy, 2004
Mexican C/S American
Dominican Puerto Rican
Not US citizen
84% 63% 62% 0
Spanish at home
99% 87% 94% 51%
Adult uninsured
70% 51% 39% 23%
Adult MH (fair/poor)
41% 23% 43% 25%
Anxiety symptoms
6% 11% 8% 10%
Depression symptoms
12% 13% 13% 22%
Source: New Brunswick Community Health Survey, Center for State Health Policy, 2004
Latinos in New Brunswick
1.2%1.2%12%2.4%3.5%4.7%4.8%5%
9%
13%
8%
44%
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
Delicias, Casco Viejo
A. Fullaondo, P. Garcia, www.enhr2007rotterdam.nl
Immigrants in Zaragoza (2006)
Rumania24%
Ecuador17%
Otros Varios36%
Marruecos8%
Colombia7%
China 4%
Argelia4%
Total Population =660,895Immigrants =65,012
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
NowadaysCommunicable, Maternal, Perinatal and Nutritional Conditions
Non-communicable Diseases (Chronic Diseases; Mental
Disorders)
Injuries
Other (Obesity, Violence, etc.)
LIFE EXPECTANCY AND INCOME
THE WORLDWIDE BURDEN
HISTORY OF EMERGING INFECTIONS
610 Influenza644 Leprosy900 Smallpox1348 Plague 1495 Syphilis1510 Scarlet Fever 1546 Typhus 1557 Malaria1567 Smallpox
YEAR DISEASE
History of Emerging Infections
1973 Rotavirus1977 Ebola Virus1977 Legionnaire’s Disease1981 Toxic Shock Syndrome1982 Lyme Disease1983 HIV-AIDS1983 Helicobacter Pylori1991 Multi Drug Resistant
(MDR) TB 1991 Epidemic Cholera1994 Cryptosporidium1998 Hong-Kong Bird Flu1999 West Nile Virus2001 Anthrax2003 SARS2006 Extremely Drug Resistant (XDR) TB)
WNV Activity 9/ 04 T=1386 Deaths 35
West Nile Virus in the US
AIDS Pandemico AIDS undoubtedly was one of the most devastating diseases that emerged during the 20th century.
o From 1981 to the end of 2004, about 25million people world-wide have succumbedto HIV infections.
o The pandemic is expected to progresswell into the 21th century.
InfluenzaAn 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
Malaria
TrachomaTrachoma 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. ...
TrachomaInfection 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
SurgeryAntibioticsFacial CleansingEnhanced Hygiene
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 DisordersAddictionObesityViolenceInjuries
Leading Causes of Disability Around The World (Cost in Billions of US Dollars)
DepressionAnemiaFalls
AlcoholCOPD
Bipolar
Congenital Defects
Arthritis
Schizophrenia
$0.00 $10.00 $20.00 $30.00 $40.00 $50.00World Health Organization, 1996
Obesity
Violence
Addiction
DALYs Lost Due to High-Risk Drinking by Disease Category and Region (2001)
6.5 5.32.8
10.3
3.2 4.5
3.11.5
1.7
1.5
1.10.5
0.0
4.0
8.0
12.0
Europe/ Central
Asia
Latin America/Caribbean
Sub-Saharan
Africa
E. Asia/ Pacific
South Asia
High-Income
Countries
InjuryChronic Disease
Mill
ions
of
DAL
Ys
Notes: Numbers are rounded.Source: Disease Control Priorities in Developing Countries, second edition, 2006, Table 47.3
9.7
6.8
4.5
11.8
3.75.6
The WHO ranking of the world’s health care systems
1. France2. Italy3. San Marino4. Andorra5. Malta6. Singapore7. Spain8. Oman9. Austria10.Japan11.Norway12.Portugal13.Monaco14.Greece15.Iceland16.Luxembourg17.Netherlands18.United Kingdom
19.Ireland20.Switzerland21.Belgium22.Colombia23.Sweden24.Cyprus25.Germany26.Saudi Arabia27.United Arab Emirates28.Israel29.Morocco30.Canada31.Finland32.Australia33.Chile34.Denmark35.Dominica36.United States of America
WHO Health Report, 2000
Total Health Expenditures as % of GDP, 2002-2005
1. Marshall Islands (19%)
2. USA (>14%)3. Niue 4. Timor-Leste5. Micronesia6. Kiribati7. Maldives 8. Malawi9. Switzerland10.France (10%)11.Germany (10%)
40.Spain (7-8%)41. United Kingdom
(7-8%)60.Colombia (7-8%)
Source = WHO
Disability Adjusted Life Expectancy at Birth
1. Japan2. Australia3. France4. Sweden5. Spain6. Italy7. Greece8. Switzerland9. Monaco10. Andorra11. San Marino12. Canada
13. Netherlands14. United Kingdom15. Norway16. Belgium17. Austria18. Luxembourg19. Iceland20. Finland21. Malta 22. Germany23. Israel24.United States of
America
Source, WHO, 1999
RWJMS Office of Global Health
Located at CAB Suite 7038o Javier I Escobar MD, Associate Dean for Global Healtho Aparna Kalbag MD, PhD, Post Doctoral Fellowo Rachel Werner, AdministrativeAssistanto 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 Healtho 21% of RWJMS 2012 Class Were Born Outside
the United States
o Over 20 students in the entering class have participated in international service activities prior to medical school on four different continents
o Over 1/3 of first year medical students express interest in having an international experience during medical school
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 JujuyMEXICO--Instituto Mexicano de Psiquiatria--Universidad Popular Autónoma del Estado de Puebla (UPAEP)--Universidad de OaxacaPERU--Universidad Cayetano Heredia, LimaCOSTA RICA--International Health Central American Institute Foundation, San José
ABOUT 50 RWJMS MEDICAL STUDENTS WENT ABROAD
IN 2008-200960% = MS-II
25% = MS-III
15% = MS-IV
COUNTRIES VISITEDCOUNTRIES VISITED
ARGENTINA
COLOMBIACOLOMBIA
COSTA RICA
ECUADOR
GHANA
INDIA
MYANMAR
MEXICO
HIMALAYAS/NEPAL
SOUTH AFRICA
TIBET
DOMINICAN REPUBLIC
GUATEMALA
ZAMBIA
SPAIN
SWITZERLANDCHINA
“RWJMS HAS GONE GLOBAL”
OPPORTUNITIES AND RESOURCES FOR
INTERNATIONAL MENTAL HEALTH RESEARCH
Collaborations with Latin America:
Javier I Escobar MDAddiction 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)
0
20
40Best Outcome Worst Outcome
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% 0
100
200
300
400
500
600
Low EE High EE
relapsed did not relapse
AVAILABLE DATA SETS
52
World Mental Health SurveysParticipating Countries in the
AmericasCountry Sample Size
Brazil 5,000Canada 30,000Colombia 5,000Costa Rica 5,000Mexico 5,000Peru 5,000United States 25,000
World Mental Health Surveys Participating Countries
LegendParticipating countriesPending countriesNo Data
WHO 2003. All rights reserved
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
Use of Cannabis and Cocaine in Several
Countries
0
2
4
6
8
10
Marihuana Cocaine
USA Canada Mexico South America Asia
Medina Mora et al, 2005
HEALTH 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!--
Diagnostic disparities
UBHC STUDY (N=19,219)Percent With Serious Mental Illness
(Dementia, Schizophrenia, MDD, Bipolar)
05
101520253035404550
Latinos Blacks Whites
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
Percent Diagnosed as Schizophrenia
(N=19,219)
0
2
4
6
8
10
12
14
Latinos (N=1531) Blacks (N= 6,475) Whites (N=10,339
Minsky S, Vega W, Miskimen T, Gara M, Escobar JI, Arch Gen Psychiatry, 60:637-644, 2003
IMMIGRATION: ADVANTAGE OR DISDVANTAGE?
Vega WA, et al. 1998; Alderete E, et al. 2000
ImmigrationAbout 50% of Latinos in the US are ImmigrantsHispanics born or living in the US appear to be at a greater risk for mental disorders than counterparts born or living in their native countriesStress of trying to integrate into US society, feelings of alienation and discrimination may increases risk for some disordersLonger time of residence in US and younger age at entry increase risk for immigrantsProtective effects of strong cultural and familial ties may weaken when living in the USLonger residence in US and younger age at immigration increase risk (vulnerable period?)
White vs Black vs. Hispanics
NCSR 299/5124 English
Non-Hispanic Whites
NESARC 1541/23,622
English/Spanish
Mexican Origin ECANCSMAPSSNESARC
706/538319/581810/1202227/2331
English/SpanishEnglishEnglish/SpanishEnglish/Spanish
Puerto Rican NCSNESARC
54/16434/563
EnglishEnglish/Spanish
Hispanics NLAAS 1630/924 English/Spanish
Ethnic Groups Study Immigrants/USA
Language
YES
YES
YES YES YES YES NO NO NO?
Advantages Immigrants?
Epidemiological Studies in USA
12 Month Prevalence of Mood and Addictive Disorders in Males (Vega et al,
1997)
USA MEXI CO0
5
10
Depression
Dysthymia
Mania
Alcohol
Drugs
12-month Substance Abuse/Dependence Rate by Nativity, Age at Time of Entry into US,
and Present Age
0
5
10
15
20
10 20 30 40 50 60Age (years)
%
Age 0–16 at Entry US Age 17–24 at Entry USAge 25+ at Entry US US born
•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)*
*Garcia-Campayo et al, 2011
P<.0001
Unhealthy Habits in Pregnant Women
05
1015202530354045
LatinWomen
White,US- born
Positive for Drugs Positive for Alcohol Smokers
Modified from Vega et al, 1993
10 Year Age-Education Adjusted Coronary Heart Disease Mortality Risk for Mexican-American Adults
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
MALES FEMALES
US-born Spanish US-born English Mexico-born
Sundquist & Winkleby Am J Public Health, 89:723-730, 1999
Cultural Gradient and Blood Pressure
95
100
105
110
115
120
125
Low Middle High
Whites Latin Immigrants
Socioeconomic StatusSteffen PR, Journal of Behavioral Medicine, 29: 501-510, 2006
Average Systolic Blood Pressure
Cardiovascular Paradox in New Jersey
(Moreyra et al, presented at GHEC, Cuernavaca, Mexico, Abril 2010)
Table 1. Clinical Characteristics NJ 1994-2007 Hospitalized AMI
Hispanicn=13,106
Whitesn=190,142
n (%) 6.5% 93.6%Age, y 67 + 15* 71 + 14
Hypertension, n (%) 69.7%* 63.7%Diabetes Mellitus, n (%) 39.2%* 29.1%
Renal Disease, n (%) 11.3%* 11.5%
• 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)
NJ 1994-2007 Hospitalized AMI
Hispanicn=13,106
Whitesn=190,142
AdjustedOR/HR
(95% CI)
Adjusted
p valuePCI, n (%) 21.21% 18.49% 0.94 (0.90-
0.99)0.03
CABG, n (%) 8.42% 8.81% 0.98 (0.91-1.07)
0.72
• 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)
NJ 1994-2007 Hospitalized AMI
Hispanicn=13,106
Whitesn=190,142
AdjustedOR/HR
(95% CI)
Adjusted
p valueIn-Hospital
Death 12% 14.7% 0.88 (0.83-
0.93)<0.00
0130 Day Death 13.6% 17.1% 0.95 (0.90-
0.99)0.047
1 Year Death 22.8% 27.6% 0.98 (0.94-1.01)
0.23
• 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 ResultsDespite 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)
0
0.2
0.4
0.6
0.8
1
Males FemalesMexican Puerto Rican CubanCentral/South Amer. Non-Latino Whites
Abraido-Lanza et al AJPH 1999Abraido-Lanza et al AJPH 1999
Potential Explanations for Mental Health “Advantages” of
Immigrants in the US Measurement Error?
misinterpretation of questions; language & translation issues; cross-cultural equivalence
Response Bias? social desirability, social approval, acquiescence
“Salmon” Effect
Selective Migration
Healthier Habits
Kin networks and Family
Support?
Advantages of Bilingualism
o Bilingual people (French/English) obtain better results in execution tests, have better cognitive flexibility, better ability to negotiate abstract concepts than monolingual people1
o 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
o 1960’s: “High prevalence of Schizophrenia in Caribbean Immigrants to the UK” (1) o 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)
o 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)
o 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
o Disadvantages and travails of Black people and ethnic minorities in England.
o 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.
o “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
Migrationo There is ethnic variation in the presentation of
psychotic symptoms 1
o Documented bias in the diagnosis pf certain ethnic groups (African Americans in USA) 2
o The diagnosis of Afro-Caribbeans in England is possibly due to a similar bias.
o Studies of Afro-Caribbeans in Jamaica do not show an excess of psychotic disorders. 3
o 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, 60:637-6443-Hickling FW, Sorel E (eds), Images of Psychiatry: The Caribbean, Stephenson Litho Press, Jamaica, 2005
Reflexions on Immigration and Psychopathology
o Immigration is a risk factor with a high level of variability. o It is related to motivations for migrating, social
conditions, language, culture, acceptance of the immigrant in the new environment, employment, etc.
o Unfortunately, color of the skin continues to play a significant role (racism).
o Language is a critical factoro Resilience, personality, social support, are protective
factors.o Immigration may have an impact on certain psychiatric
disorders but not in others. o Epidemiological vs. Clinical Studies.