Global Mental Health: Focus on Latino Populations

1. 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

2. Local Health International Health Global Health

3. 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

4. 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

5. 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)

6. 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”

7. 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.

8. 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

9. Why “Global Health” in Places Like New Jersey or Zaragoza Spain?

10. Latinos in New Jersey Source : U.S. Census, 2000

11. Latinos in New Brunswick48% of all residents Source: New Brunswick Community Health Survey, Center for State Health Policy, 2004

12. Latinos in New Brunswick Source: New Brunswick Community Health Survey, Center for State Health Policy, 2004

13. 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)

14. Concentration of Foreign-born Immigrants in Zaragoza Delicias, Casco Viejo A. Fullaondo, P. Garcia, www.enhr2007rotterdam.nl

15. Immigrants in Zaragoza (2006) Total Population = 660,895 Immigrants = 65,012

16. 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.

17. Most Important Global Health Problems Nowadays • Communicable, Maternal, Perinatal and Nutritional Conditions • Non-communicable Diseases (Chronic Diseases; Mental Disorders) • Injuries • Other (Obesity, Violence, etc.)

18. LIFE EXPECTANCY AND INCOME

19. THE WORLDWIDE BURDEN

20. 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

21. 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

23. West Nile Virus in the US

24. 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.

25. 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.

26. Ref Business Week, April 14, 2003

27. Malaria

28. 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. ...

29. 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

30. 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

31. Complex Global Health Problems: Mental Disorders Addiction Obesity Violence Injuries

32. Leading Causes of Disability Around The World (Cost in Billions of US Dollars) World Health Organization, 1996

33. Obesity

34. Violence

35. Addiction

36. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. ABOUT 50 RWJMS MEDICAL STUDENTS WENT ABROAD IN 2008-2009 60% = MS-II 25% = MS-III 15% = MS-IV

45. COUNTRIES VISITED ZAMBIA DOMINICAN REPUBLIC MYANMAR GUATEMALA ARGENTINA SPAIN COSTA RICA SOUTH AFRICA MEXICO GHANA SWITZERLAND CHINA TIBET ECUADOR COLOMBIA INDIA HIMALAYAS/NEPAL

46. “RWJMS HAS GONE GLOBAL”

47. OPPORTUNITIES AND RESOURCES FOR INTERNATIONAL MENTAL HEALTH RESEARCH

48. 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.

49. Outcome of Schizophrenia Across Cultures (WHO Study-- Jablensky et al, 1992)

50. 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%