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
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
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
Americas 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

US Medical Schools are developing
programs in Global Health (Harvard,
Johns Hopkins, Michigan, NYU and
many others)
NIH Institutes opening Global Healths
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 worlds
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
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

Why Global Health in Places

Like New Jersey or Zaragoza
Spain?

Latinos in New Jersey

Source : U.S. Census, 2000

Latinos in New Brunswick

48% of all residents

Source: New Brunswick Community Health Survey,

Center for State Health Policy, 2004

Latinos in New Brunswick

Mexican

C/S
American

Dominican

Puerto Rican

Not US
citizen

84%

63%

62%

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

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)

Total Population =
660,895
Immigrants =
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 Nowadays
Communicable, 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
YEAR

610
644
900
1348
1495
1510
1546
1557
1567

DISEASE

Influenza
Leprosy
Smallpox
Plague
Syphilis
Scarlet Fever
Typhus
Malaria
Smallpox

History of Emerging Infections

1973
1977
1977
1981
1982
1983
1983
1991
1991
1994
1998
1999
2001
2003
2006

Rotavirus
Ebola Virus
Legionnaires Disease
Toxic Shock Syndrome
Lyme Disease
HIV-AIDS
Helicobacter Pylori
Multi Drug Resistant
(MDR) TB
Epidemic Cholera
Cryptosporidium
Hong-Kong Bird Flu
West Nile Virus
Anthrax
SARS
Extremely Drug Resistant (XDR) TB)

West Nile Virus in the US

AIDS Pandemic
AIDS undoubtedly was one of
the most devastating diseases
that emerged during the 20th century.
o

From 1981 to the end of 2004, about 25

million people world-wide have succumbed
to HIV infections.
o

The pandemic is expected to progress

well into the 21th century.
o

Influenza
An agent of great concern
globally is influenza virus.
Influenza virus is known to cause
epidemics as early as the 1500s, 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

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. ...

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.

WHOs SAFE
Surgery
Antibiotics
Facial Cleansing
Enhanced Hygiene

NCS in the Global Front

Most people nowadays die from noncommunicable 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

Leading Causes of Disability Around The World

(Cost in Billions of US Dollars)

World Health Organization, 1996

Obesity

Violence

Addiction

DALYs Lost Due to

High-Risk Drinking by
Disease Category and
Region (2001)
11.8

9.7

Millions of
DALYs

6.8
4.5

5.6
3.7

Notes: Numbers are rounded.

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

The WHO ranking of the worlds

health care systems

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

France
Italy
San Marino
Andorra
Malta
Singapore
Spain
Oman
Austria
Japan
Norway
Portugal
Monaco
Greece
Iceland
Luxembourg
Netherlands
United Kingdom

WHO Health Report, 2000

19. Ireland
20. Switzerland
21. Belgium
22.Colombia
23. Sweden
24. Cyprus
25. Germany
26. Saudi Arabia
27. United Arab Emirates
28. Israel
29. Morocco
30. Canada
31. Finland
32. Australia
33.Chile
34. Denmark
35. Dominica
36.United States of America

Total Health Expenditures as %

of GDP, 2002-2005
1. Marshall Islands (19%)
2. USA (>14%)
3. Niue
4. Timor-Leste
5. Micronesia
6. Kiribati
7. Maldives
8. Malawi
9. Switzerland
10. France (10%)
11. Germany (10%)

40.Spain (7-8%)
41. United Kingdom (78%)
60.Colombia (7-8%)

Source = WHO

Disability Adjusted Life

Expectancy at Birth
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Japan
Australia
France
Sweden
Spain
Italy
Greece
Switzerland
Monaco
Andorra
San Marino
Canada

Source, WHO, 1999

13. Netherlands
14. United Kingdom
15. Norway
16. Belgium
17. Austria
18. Luxembourg
19. Iceland
20. Finland
21. Malta
22. Germany
23. Israel
24. United States of
America

RWJMS Office of Global Health

Located at CAB Suite 7038
o Javier I Escobar MD,
Associate Dean for Global Health
o Aparna Kalbag MD, PhD, Post
Doctoral Fellow
o Rachel Werner, Administrative
Assistant
o 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 OHearn MS3, Minyoung
Yang MS3, Peter Murr MS-2, Rhea Itoop MS-2, Shazia
Mehmood MS-2

RWJMS Medical Students

Interest in Global Health
o

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:

COLOMBIA
--CES Medical School, Medelln
--Universidad de Antioquia, Medelln
--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 Autnoma del Estado de Puebla (UPAEP)
--Universidad de Oaxaca
PERU
--Universidad Cayetano Heredia, Lima
COSTA RICA
--International Health Central American Institute Foundation
, San Jos

ABOUT 50 RWJMS MEDICAL

STUDENTS WENT ABROAD
IN 2008-2009
60% = MS-II
25% = MS-III
15% = MS-IV

COUNTRIES VISITED
ZAMBIA

DOMINICAN REPUBLIC

MYANMAR
COSTA RICA
GHANA

ARGENTINA
SPAIN
CHINA

SOUTH AFRICA
SWITZERLAND

TIBET
INDIA

GUATEMALA
MEXICO

ECUADOR
COLOMBIA
HIMALAYAS/NEPAL

RWJMS HAS GONE GLOBAL

OPPORTUNITIES AND
RESOURCES FOR
INTERNATIONAL MENTAL
HEALTH RESEARCH

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
Research Issues in Latino Mental Health
Schizophrenia Study in Argentina.

Critical

Outcome of Schizophrenia Across

Cultures (WHO Study-- Jablensky et al, 1992)
Best Outcome Worst Outcome

40

20
0

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%

AVAILABLE DATA SETS

World Mental Health Surveys

Participating Countries in the
Americas
Country
Brazil
Canada
Colombia
Costa Rica
Mexico
Peru
United States

Sample Size
5,000
30,000
5,000
5,000
5,000
5,000
25,000
52

World Mental Health Surveys

Participating Countries

Legend
Participating countries
Pending countries
No Data
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.
WHO 2003. All rights reserved

Use of Cannabis and Cocaine in

Several Countries

Medina Mora et al, 2005

HEALTH DISPARITIES

Diagnostic disparities
Lets 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)

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

Psychiatry, 60:637-644, 2003

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:
ADVANTAGE OR
DISDVANTAGE?

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?)

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

Epidemiological Studies in USA

Ethnic Groups

Study

Immigrants/
USA

Language

Advantages
Immigrants?

White vs Black vs.

Hispanics

NCSR

299/5124

English

YES

Non-Hispanic Whites

NESARC

1541/23,622

English/Spanish

YES

Mexican Origin

ECA

706/538

English/Spanish

YES

NCS

319/58

English

YES

1810/1202

English/Spanish

YES

NCS

227/2331
54/16

English/Spanish
English

NESARC

434/563

English/Spanish

NLAAS

1630/924

English/Spanish

MAPSS
NESARC
Puerto Rican
Hispanics

YES
NO
NO
NO?

12 Month Prevalence of Mood and Addictive

Disorders in Males (Vega et al, 1997)

12-month Substance Abuse/Dependence Rate by Nativity,

Age at Time of Entry into US,
and Present Age
Age 016 at Entry US
Age 25+ at Entry US

Age 1724 at Entry US

US born

20
15
% 10
5
0
10

20

30

40

50

60

Age (years)

U.S. born significantly different (p < 0.001) from each immigrant group
(controlling for sex and present age).
Immigrants Age 016 at Entry US vs Age 1724 at Entry US significantly
different (p = 0.02) for present age 1824.
Vega WA, et al. In press

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

Modified from Vega et al, 1993

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
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)

Table 1. Clinical Characteristics

NJ 1994-2007
Hospitalized AMI
n (%)

Hispanic
n=13,106
6.5%

Whites
n=190,142
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

PCI, n (%)
CABG, n (%)

Hispanic
n=13,106

Whites
n=190,142

21.21%

18.49%

8.42%

8.81%

Adjusted
OR/HR
(95% CI)

Adjusted
p value

0.94 (0.900.99)
0.98 (0.911.07)

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.

0.03
0.72

Table 2. Multivariable Adjusted Associations

(Mortality)
NJ 1994-2007
Hospitalized AMI

Hispanic
n=13,106

Whites
n=190,142

12%

14.7%

30 Day Death

13.6%

17.1%

1 Year Death

22.8%

27.6%

In-Hospital Death

Adjusted
OR/HR
(95% CI)

0.88 (0.830.93)
0.95 (0.900.99)
0.98 (0.941.01)

Adjusted
p value

<0.000
1
0.047
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 Results
Despite higher prevalence of risk
factors and lower rates of PCI in
Hispanics, the in-hospital and 30day 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)

Abraido-Lanza et al AJPH 1999

Potential Explanations for Mental

Health Advantages of Immigrants in
the US
Measurement Error?

Salmon Effect

misinterpretation of questions;
language & translation issues;

Selective Migration

cross-cultural equivalence

Healthier Habits

Kin networks and Family

Response Bias?
social desirability, social
approval, acquiescence

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

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
o

1960s: High prevalence of Schizophrenia

in Caribbean Immigrants to the UK (1)
1980s: 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)
1990s: 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)
2000s; 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
o

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
o
o
o
o
o

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
o
o

o
o
o
o
o

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.