Yale Psychiatry Grand Rounds: "Frontiers in Global Mental Health Research & Service Delivery"

Transcript

• 00:01Hi. Well, thank you very
• 00:02much, doctor Crystal. Oh, sorry.
• 00:05Well, thank you very much,
• 00:06doctor Crystal, for the generous
• 00:08introduction.
• 00:09So, you know, mental illnesses
• 00:11are the leading,
• 00:13leading cause of disability adjusted
• 00:15life years globally. So I
• 00:17think it's very appropriate that,
• 00:18you know, we're having a
• 00:20a grand rounds in global
• 00:21mental health. So before further
• 00:23ado, I wanna introduce,
• 00:25my colleague and co resident,
• 00:26Natje
• 00:27Basilica, who comes to this
• 00:29residency program with a lot
• 00:30of accomplishments.
• 00:32Before his career in medicine,
• 00:34he was the chief of
• 00:36staff for the president of
• 00:37the World Bank, Jim Jim
• 00:38Kim, chief of staff for
• 00:40Paul Farmer. And when I
• 00:41was an undergrad, I actually
• 00:42read a book that he
• 00:44wrote,
• 00:46for my introduction to global
• 00:47health course.
• 00:49And he got his MD
• 00:50PhD from Harvard in economics,
• 00:53and, is, is honored to
• 00:55have him as a colleague.
• 00:56He was also recently voted
• 00:57favorite professor at Harvard by
• 00:59class of twenty twenty five.
• 01:00So he somehow manages to,
• 01:02you know, keep,
• 01:04you know, his teaching responsibilities
• 01:06as well as, you know,
• 01:08being a being an outstanding
• 01:09clinician here. So, before further
• 01:11ado, here's Matt.
• 01:17Thanks so much, Jay. True
• 01:19honor to be up here
• 01:20to speak to every one
• 01:21of you.
• 01:22And, you know, thank you
• 01:23for making this forum where
• 01:24we can explore some, you
• 01:25know, key progress in in
• 01:26this field. So I'll just
• 01:28frame global mental health a
• 01:30little bit.
• 01:31The field,
• 01:32which is, like, a part
• 01:33of the the field of
• 01:34global health is all about
• 01:35inequity. Right? Inequity in, the
• 01:38burden of illness, as Jim
• 01:39mentioned, and equity
• 01:41in access to services.
• 01:42And so, I'm gonna focus
• 01:44a bit of my talk
• 01:45on some of these, on
• 01:46the social determinants of health,
• 01:47some of this unequal burden,
• 01:49but really wanna emphasize and
• 01:51and as as doctor Kristol
• 01:52mentioned that,
• 01:53you know, the the pioneers
• 01:55in our field, but we
• 01:55can say global health or
• 01:57global mental health, have this,
• 01:59you know, unique set of
• 02:00characteristics
• 02:01where they have worked in
• 02:02partnership often for decades and
• 02:04decades,
• 02:05with some, communities in, tremendous
• 02:08need of
• 02:11of, from a health care
• 02:11standpoint. And so I have
• 02:13Paul Farmer up here who's
• 02:14really sort of a pioneer
• 02:15who who works and built
• 02:17organizations in nine different countries.
• 02:18They're working very tightly with
• 02:20communities, and those lessons from
• 02:22on the ground delivery problems
• 02:24are then shared globally,
• 02:26through many political changes,
• 02:28like those that we're going
• 02:28through now and, you know,
• 02:29develop resilient health care delivery,
• 02:32infrastructure
• 02:33and lessons that can be,
• 02:34you know, learned through the,
• 02:36to the whole world. And
• 02:37so Vikram Patel, they're our
• 02:39good friends, but, you know,
• 02:40Vikram is probably the biggest
• 02:41name now in global mental
• 02:42health, was also a psychiatrist
• 02:44in his native
• 02:45India for over twenty years
• 02:46and then used those lessons
• 02:48to become one of the,
• 02:49you know, highest funded, researchers
• 02:50in this area and really
• 02:51a global thought leader bringing
• 02:53these lessons of equity. And
• 02:54I would just point out
• 02:54that I think our next
• 02:55two speakers, both Jay and
• 02:57Marco, has really kind of
• 02:58lived this archetypal model where
• 03:00you're looking for sustained,
• 03:02knowledge generation at the frontier,
• 03:05working with communities in partnership,
• 03:07and then asking how those
• 03:08lessons can translate to,
• 03:10improving, global mental health equity.
• 03:12It's really, exciting to to
• 03:14have been to co resident
• 03:15with them, and and I
• 03:15can't wait to see where
• 03:17their work will go.
• 03:19I'll just talk a little
• 03:20bit about my,
• 03:22my work in economics right
• 03:23here,
• 03:24some interesting findings,
• 03:26from from tools that we
• 03:27use in our discipline that
• 03:29might, have relevance to the
• 03:30ways that we think about,
• 03:31the unequal distribution of mental
• 03:33health disorders globally.
• 03:35And, you know, so kind
• 03:36of to take a recent
• 03:37review, this is from, World
• 03:38Psychiatry in twenty twenty four,
• 03:40a great review, really emphasizing
• 03:42that we know that adverse,
• 03:44you know, social conditions, especially,
• 03:47from anywhere from in utero
• 03:48to, early childhood to adulthood,
• 03:51obviously,
• 03:53affect risk of a variety
• 03:54of mental health disorders.
• 03:57My teaching kind of straddles
• 03:59two fields. One is, development
• 04:01and global health, and the
• 04:02other, this is kind of
• 04:03the first lecture class of
• 04:05kind of devoted to mental
• 04:06health at a we think
• 04:07at a top Egon department,
• 04:08so trying to fuse these
• 04:10two disciplines together.
• 04:11And one of the kind
• 04:12of interesting things that we
• 04:13encounter is that
• 04:15unlike the rest
• 04:16of global health where we
• 04:17have what's called the Preston
• 04:18curve and health naturally gets
• 04:21or, you know, it tends
• 04:22to get better as country
• 04:23incomes improve, We have kind
• 04:25of the opposite,
• 04:27finding in,
• 04:29in, you know, subjective well-being.
• 04:31And you may have seen
• 04:32this on the front page
• 04:34New York Times obituary
• 04:35this month for Richard Easterlin,
• 04:37who
• 04:38found the very famous Easterlin
• 04:40paradox, which is that despite
• 04:41rapid growth in,
• 04:44many countries, we don't see
• 04:45a concomitant rise in well-being.
• 04:48And so this has been
• 04:50thought to be one of
• 04:50the biggest puzzles in macroeconomics.
• 04:52Why does why does economic
• 04:56increase in subjective well-being? And
• 04:57here's just a few examples
• 04:58of this of this chart.
• 04:59And as you you'll see
• 05:00my hypothesis that I'm trying
• 05:02to get at is that,
• 05:04there's a there's a lot
• 05:05going on here in the
• 05:06aggregate social changes happening. This
• 05:08is not just about income
• 05:09changes. It's about other changes
• 05:10in society,
• 05:11sometimes very subtle changes. And
• 05:13if we can better characterize
• 05:14those, especially on a quantitative
• 05:16level, it might help us
• 05:17better appreciate some of these
• 05:18other, social determinants of health.
• 05:20So my goals are to
• 05:22think about new ways of
• 05:23using quantitative measure to subtle
• 05:24social determinants of mental health,
• 05:26including transgenerational
• 05:27cultural persistence,
• 05:28an embodiment of these large
• 05:30scale forces of macroeconomic change,
• 05:32and then to leverage causal
• 05:33inference techniques from historical macroeconomics,
• 05:35economics,
• 05:36to hopefully begin to unlock,
• 05:38again, this hypothesis around the
• 05:40Eastland paradox and then identify
• 05:42particular risk and protective factors
• 05:45for particular mental health disorders.
• 05:46And again, I'll show you
• 05:47suggested evidence here. I'm not
• 05:48saying I'm I'm there by
• 05:49any means, but this is
• 05:50sort of where we're trying
• 05:51to go. So
• 05:54some of the motivation from
• 05:55this comes from, I think,
• 05:56a really interesting set of
• 05:58researching,
• 05:58cognitive psychology.
• 06:00Joe Henrich, who started as
• 06:01a trained as an anthropologist,
• 06:03taught in economics at University
• 06:04of British Columbia, is now
• 06:05the chair of psychology at
• 06:06Harvard,
• 06:07is famous for, you know,
• 06:09essentially finding instead of hypotheses
• 06:11around the weirdest people in
• 06:12the world. So WEIRD stands
• 06:14for Western, educated, industrialized,
• 06:16democratic.
• 06:17And essentially, it's a series
• 06:19of findings that says, hey,
• 06:20most of our cognitive,
• 06:22theories, and our even our
• 06:24our, neuroimaging evidence comes from
• 06:27fairly similar populations from a
• 06:28social learning perspective. And in
• 06:30fact, if you look at
• 06:31the ethnographic record, these societies
• 06:33are pretty unusual,
• 06:36in the following types of
• 06:38ways. So to focus on
• 06:39kinship for a second,
• 06:41having little or no marriage
• 06:43to cousins or other relatives.
• 06:44Most, you know,
• 06:46folks in what are called
• 06:47weird societies, we find this
• 06:48a little bit odd.
• 06:49Twenty five percent of societies
• 06:51share this property in the
• 06:52African African American, meaning, you
• 06:53know, seventy five percent don't.
• 06:55When we think about other
• 06:55things like monogamous marriage, nuclear
• 06:57families, and then you and
• 06:58local residents,
• 07:00you know, those of us
• 07:01that have ever thought about
• 07:02living with, relatives, etcetera, to
• 07:04save money, if there's some
• 07:06kind of taboo around that,
• 07:07again, it's pretty unusual that,
• 07:10the kind of social norm
• 07:11that,
• 07:12you know, new families, couples
• 07:14are are living outside the
• 07:15the household. So,
• 07:17if you add up,
• 07:18most,
• 07:19societies of the twelve hundred
• 07:20sixty five ethnographic atlas share
• 07:22zero of these five kinship
• 07:24features with,
• 07:25with weird societies, and almost
• 07:27none share all five.
• 07:30Henrik's hypothesis, which really extends
• 07:32work from the famous sociologist
• 07:33Max Weber, is, not only
• 07:36that the increasing market penetration
• 07:38has, you know, led to
• 07:39individualization,
• 07:40this is also sort of
• 07:41theory that Marx made famous.
• 07:43But that in particular, there
• 07:44are changes in the the
• 07:46middle ages that the, Catholic
• 07:48church and their institutions were
• 07:50somewhat intentionally trying to fracture
• 07:52kinship bonds into this particular
• 07:53package. So he goes through
• 07:54a whole theory about what
• 07:55their incentives were, why this
• 07:57happened, but does show pretty
• 07:58clear evidence that there was
• 07:59this structural change in kinship
• 08:02and that this has led
• 08:03us to a different,
• 08:05not just set of social
• 08:06norms this way, but, potentially
• 08:08could lead us to, interesting
• 08:11outcomes as I'll try to
• 08:11get to in a second.
• 08:12So
• 08:14that's where the framing the
• 08:15so the evidence comes from
• 08:16the ethnographic ATLAS and the,
• 08:18standard cross cultural survey, twelve
• 08:20hundred sixty five communities. And
• 08:22I'm gonna pull on the
• 08:23methodology of two very famous
• 08:25econ papers to, try to
• 08:27establish,
• 08:28these these results. So one,
• 08:29it's,
• 08:31written Jen Roles, Women in
• 08:32the Plow, which, these,
• 08:35leading development economists,
• 08:37are very interested in how,
• 08:39this you know, when when
• 08:40jobs are scarce, women
• 08:42men should have more right
• 08:43to a job than women.
• 08:44The variation was from three
• 08:45point six percent in Iceland
• 08:47and ninety nine percent Egypt.
• 08:49And they wanted to show
• 08:50that, some of these features
• 08:52of
• 08:53societies in ethnographical record could
• 08:55actually be predicted, in fact,
• 08:56show historical persistence in predicting
• 08:58these modern day social norms.
• 09:00So their approach is to
• 09:02link that data to the,
• 09:05Ethnologue Language Atlas, which is
• 09:07a Language Atlas of the
• 09:08world, can be linked to
• 09:09those different societies. And so
• 09:11here you can see how
• 09:11they link,
• 09:14societies at the plow versus
• 09:15those that didn't have the
• 09:16plow. The hypothesis in their
• 09:17paper was essentially,
• 09:18was goes to anthropologist Esther
• 09:20Boseroff, is that societies at
• 09:22the plow favored,
• 09:24upper body muscular strength and
• 09:25would lead to a higher
• 09:27level of gender segregation in
• 09:29economic roles. And so you
• 09:30see that both in the
• 09:31ethnographic atlas and then using
• 09:33this mapping, they're able to
• 09:34show that indeed a higher
• 09:36fraction of ancestry from traditional
• 09:37plow use communities is associated
• 09:40with higher labour force participation
• 09:42between
• 09:43two thousand, actually, sorry, more
• 09:45plow use is less, and
• 09:47then, other really key outcomes
• 09:49when we think about gender
• 09:49inequality, including share of women
• 09:51in political positions and pretty
• 09:53large average effect sizes.
• 09:54Sizes. And, again, so the
• 09:56economics focus a lot on
• 09:57is how to use causal
• 09:58inference when you can't randomize.
• 09:59Right? So obviously, it's a
• 10:01large scale historical process. So
• 10:02we use something called instrumental
• 10:04variables, which is really not
• 10:05it's a can do, you
• 10:06know, random assignment in in
• 10:07a randomized controlled trial, but
• 10:09we need some other,
• 10:11instrument. So here they use
• 10:14a geological instrument saying there's
• 10:16an environment that could lead
• 10:17to one crop versus another
• 10:19to to create this IV.
• 10:20So I'm just showing that
• 10:20I pull in this methodology
• 10:22and then another very famous
• 10:24experiment.
• 10:26This is one of my
• 10:28thesis advisors and
• 10:30recommenders, and these charts are
• 10:32from a very famous paper,
• 10:34which shows that the,
• 10:36what we want to consider
• 10:37this process of
• 10:38historical institutional change, which are
• 10:40very interested in sort of
• 10:41Westernization.
• 10:42These
• 10:44scholars showed that the death
• 10:46rate of colonial settlers
• 10:48related to the likelihood of,
• 10:52extractive institutions. That's the higher
• 10:53the death rate, the more
• 10:54likely extractive institutions were to
• 10:57be set up in, in
• 10:58European colonies, and then that
• 11:00also,
• 11:01predicts,
• 11:03income today. So it's called
• 11:04an instrumental variable, that log
• 11:05of settler mortality,
• 11:07that's how many,
• 11:09colonial social are dying, they're
• 11:10more more likely to set
• 11:11up these terribly extractive institutions.
• 11:13Obviously, intuition there, but this
• 11:15paper and these,
• 11:17like I showed this in
• 11:17the RTC seminar, these were
• 11:19the only two,
• 11:20graphs shown in the twenty
• 11:22twenty four Nobel Prize in
• 11:23Economics for exactly this work,
• 11:24which went to these three
• 11:25authors,
• 11:26since since that presentation. So
• 11:28I'm trying to extend essentially
• 11:29those two key econ papers
• 11:31into how we think about
• 11:32the global burden of mental
• 11:34health disorders. So I'm gonna
• 11:35look at, these,
• 11:37a set of controls that
• 11:38comes from the ethnographic record
• 11:39as well.
• 11:42To give just some preliminary
• 11:43evidence and suggestive, I think,
• 11:45of of this hypothesis,
• 11:48well-being and hunter gatherer interest
• 11:50rates. So the first thing
• 11:50to look at is societies
• 11:52that seem the least affected
• 11:53by these processes of cultural
• 11:55change. And,
• 11:56I think the first to
• 11:57report, and this was accepted
• 11:59as a single author
• 12:01poster at the APA for
• 12:02the summer,
• 12:03that
• 12:04a fraction of gathering predominant
• 12:06ancestry significantly, policy, predicts country
• 12:08level happiness,
• 12:10and that's robust to country
• 12:12level controls in a variety
• 12:14of historical controls as well.
• 12:16And, find someone looking at
• 12:18hunter hunting or gathering, predominant.
• 12:20Again, these are actually, like,
• 12:21quite strong effect sizes, especially
• 12:23when we map them up
• 12:23to, what we typically think
• 12:25about,
• 12:26GDP or or other predictors.
• 12:30I'm now gonna focus on
• 12:31a couple of disorders. I
• 12:32I don't find strong effects,
• 12:34first of all, in bipolar
• 12:35psychotic disorders, which might be,
• 12:37you could say a bit
• 12:38a bit more expected, but,
• 12:39part of the hypothesis here
• 12:40is that some of the
• 12:41changes in constricts rupture have
• 12:42led to increase in
• 12:44guilt based or internalizing disorders.
• 12:46So I'm gonna focus on
• 12:47substance use disorders and, self
• 12:50harm and suicide.
• 12:52So using the, Ace Moble
• 12:54Johnson and Robinson instrument from
• 12:55this, paper that just won
• 12:57the the Nobel, I find,
• 12:59that
• 13:01the expropriation risk, that's the
• 13:03stronger the democratic institutions, actually,
• 13:05the light more likely these,
• 13:07these, eusasors are. And then
• 13:09using their instrument of log
• 13:10settled mortality, I also find,
• 13:13in in the IV,
• 13:15that the higher the death
• 13:16rate of the coin, the
• 13:17slower the, lower the contemporary
• 13:20prevalence rate of of these
• 13:21disorders. The outcome, by the
• 13:22way, is the twenty nineteen
• 13:23global burden disease to sort
• 13:25of take out the effects
• 13:25of COVID.
• 13:28Also, again, suggesting that there's
• 13:30a strong cultural influence here
• 13:32is is that
• 13:34the colon colonizer style also
• 13:36really matters for the,
• 13:38prevalence of disorders.
• 13:39Conversely, if you look at
• 13:41some, you know, predictors of
• 13:42kinship in the ethnographic atlas,
• 13:44we can find different effects.
• 13:45So cousin marriage, again, a
• 13:46pretty strong,
• 13:48predictor of non weird kinship
• 13:50structure,
• 13:51is associated with lower rates
• 13:53of alcohol use disorders,
• 13:55versus monogamous marriage, which is
• 13:56assigned with with higher rates.
• 13:58I find very similar results
• 14:00when, looking at drug use
• 14:01disorders,
• 14:03both for institutions,
• 14:04you know, these, colonial institutions,
• 14:06again, increasing the the risk,
• 14:09and then, aggregate kinship score,
• 14:11again, a higher,
• 14:13average kinship score of
• 14:15ancestral
• 14:17groups in any country is
• 14:19associated with a lower level
• 14:20of substance use disorders today.
• 14:23And, again, a similar set
• 14:25of findings with opioid use
• 14:26disorder.
• 14:28Self harm, again,
• 14:30not as robust of results,
• 14:32but this is a a
• 14:33global burden disease aggregate of
• 14:35suicide and self injurious behavior
• 14:37and, again, democratic institutions, and
• 14:39this is and long term
• 14:40mortality,
• 14:41predicting
• 14:42in the expected directions that
• 14:44this sort of Westernization
• 14:46is leading, you know, is
• 14:47associated with, and if you
• 14:48take this as suggestive causal
• 14:50evidence,
• 14:51higher levels of these disorders.
• 14:56So that's sort of shifting,
• 14:57you know, and the hypothesis
• 14:59is, you know, maybe the,
• 15:02as these institutions came through,
• 15:03the fracturing of kinship networks
• 15:06and,
• 15:07the individualization
• 15:08that we see under,
• 15:10the kind of structures of
• 15:12of modern capitalism.
• 15:13They might be weeding the
• 15:14higher incomes but also putting
• 15:16us at risk of certain,
• 15:17disorders, both those that we
• 15:18can measure easily like this
• 15:20and other features, and the
• 15:21combination of those two factors
• 15:23is why we might see
• 15:24the
• 15:25Eastland paradox. But, again, I
• 15:26have a lot more due
• 15:27to work to do to
• 15:28get there.
• 15:29I'll just take one final
• 15:31bit to show how this
• 15:32methodology could be used to
• 15:33maybe better appreciate
• 15:35particular social risk factors for,
• 15:40for particular mental health disorders.
• 15:41So this is,
• 15:43been with my senior thesis
• 15:45advisor, Lal Caplan.
• 15:46The hypothesis here is that
• 15:48anorexia
• 15:49nervosa,
• 15:50might have lower rates of
• 15:52prevalence in matrilineal societies, which
• 15:54are societies in which,
• 15:56kin based lineages based on
• 15:57the mother's family, not the
• 15:58father's. They're typically associated with
• 16:00more political power in the
• 16:01hands of, of women and
• 16:03of female households. And, the
• 16:05the hypothesis essentially that, you
• 16:07know, there's been ethnographic evidence
• 16:08of less object
• 16:10divisation of female bodies, and
• 16:12that might lead to lower
• 16:13rates of prevalence.
• 16:15So indeed, we find that
• 16:18ancestral fraction of matrimonial kinship
• 16:20is associated with lower rates
• 16:22of eating disorders in both
• 16:24sexes and females as well.
• 16:25And then there's a very
• 16:27nice instrument
• 16:28in the economics literature, which
• 16:29is coral reef formation.
• 16:31There's a ethnographic work on
• 16:33the,
• 16:34density of coral reefs being,
• 16:36more likely to create, fishing
• 16:38communities, and we also know
• 16:39that fishing communities are more
• 16:40likely to be matrilineal. There's
• 16:42a sense of, when some
• 16:43folks are going out into
• 16:44the water, others are able
• 16:46to maintain more,
• 16:47control over the land,
• 16:49and and associations are important
• 16:50for politics, and that's increased
• 16:52the likelihood of formation of
• 16:54of matrilineal
• 16:55versus patrilineal societies. And so
• 16:57using that instrument,
• 16:59and if you take the
• 17:01exclusion restriction that the only
• 17:02way that this is affecting
• 17:04modern day eating disorders is
• 17:05through this channel, then that's
• 17:07gonna be an instrumental variable
• 17:08for,
• 17:10the effect of maternal kinship
• 17:11on
• 17:13modern eating disorders. Again, we
• 17:14find
• 17:15similarly sized effects that maternal
• 17:17kinship
• 17:18is is associated with
• 17:20lower prevalence of eating disorders
• 17:22in countries today. So,
• 17:25hopefully, you know, trying to
• 17:26establish some interesting findings on,
• 17:29using these techniques,
• 17:32of long duration history, to
• 17:34explain some of the prevalence
• 17:35of these mental health disorders,
• 17:36and,
• 17:37hopefully one day to
• 17:39actually identify
• 17:44so thank you very much
• 17:45for listening to this portion
• 17:47of the talk. And, again,
• 17:48I'm
• 17:48really just honored to, introduce
• 17:50one of my colleagues, Jay.
• 17:51You already heard from from
• 17:52doctor Crystal,
• 17:54this, you know, decade plus
• 17:56commitment to a place on
• 17:57the ground.
• 17:58Paul Farmer wrote one of
• 18:00his letters for, medical school.
• 18:01He was a mentor of
• 18:02mine. I know, you know,
• 18:03felt very highly about him
• 18:04and his work and where
• 18:05he would go, and he's
• 18:06been using these lessons,
• 18:09to to generate new understandings
• 18:10about mental health stigma in
• 18:12addition to being the chief
• 18:12resident in RTP. So,
• 18:15really happy to be a
• 18:16co resident with Jay and
• 18:17can't wait to hear what
• 18:18what he's gonna say.
• 18:25Alright.
• 18:26Thank you, Matt, for, the
• 18:28broad overview,
• 18:29and thanks for the introduction
• 18:31to,
• 18:32Jeff. Oh, yeah.
• 18:35So, today, I'm gonna be
• 18:36talking about, my work, in
• 18:39Uganda. And as, you know,
• 18:40Matt said, I've been working
• 18:41there for, ten years now.
• 18:43So I thought I'd start
• 18:45by, you know, talking a
• 18:46little bit about my personal
• 18:47story of, like, what brings
• 18:48me to this work.
• 18:50So the arrows on the
• 18:51map point to all the
• 18:51areas, all all the places
• 18:53that that I've lived in
• 18:54my life. So I've lived
• 18:55in, like, a lot of
• 18:55places.
• 18:56I was born in Seoul,
• 18:57South Korea. I lived there
• 18:59until I was nine. And
• 19:00then, I moved around a
• 19:01lot, like Hawaii, South Florida,
• 19:03Appalachia, parts of the deep
• 19:04south.
• 19:06And in a lot of
• 19:06the places that I grew
• 19:07up, I was the only
• 19:08Asian person.
• 19:10And,
• 19:11you know, and it's quite
• 19:13a peculiar thing being the
• 19:15only person that looks like
• 19:16you in a in a
• 19:18place, and it makes people,
• 19:19I feel like, kinda label
• 19:20you as that. And it's
• 19:22very difficult to get past
• 19:23that, in terms of, like,
• 19:24people, like, recognizing your identity,
• 19:27recognizing who you are, like,
• 19:28beyond your race. Right?
• 19:30So I I didn't really
• 19:31feel feel, like, accepted into
• 19:33the American community. I didn't
• 19:34really feel accepted into Korean
• 19:36community anymore because, you know,
• 19:37I was
• 19:38pretty acculturated in America as
• 19:40well. So,
• 19:42in some ways that my
• 19:43high school self couldn't articulate
• 19:45at the at the time,
• 19:46I felt
• 19:47like I didn't quite develop
• 19:48in the way that I
• 19:49wanted to in terms of
• 19:50my identity, in high school.
• 19:51So I wanted to take
• 19:53a year off before going
• 19:54to college to figure myself
• 19:56out,
• 19:56to see, you know, like,
• 19:58what's important to me of
• 19:59who I am, you know,
• 20:00all these kind of existential,
• 20:02types of questions.
• 20:04So, you know, I thought
• 20:05I knew eastern culture and
• 20:06western culture having lived in
• 20:07Korea and having lived in
• 20:09the US, but I wanted
• 20:10to go somewhere as different
• 20:11as possible to figure out,
• 20:13you know, my identity and
• 20:14what I wanted to do.
• 20:15So I thought, Africa was
• 20:17very different, and I looked
• 20:18for some English speaking countries
• 20:20in Africa. I and Ghana,
• 20:22seems to be, you know,
• 20:23the the place that, that
• 20:25that made sense. So I
• 20:26used money that I saved
• 20:27from high school. I wrote
• 20:28to my university to defer
• 20:29to a year.
• 20:31And then I told my
• 20:32parents that I'm not gonna
• 20:34go to college
• 20:36immediately, and they were very
• 20:37thrilled about that, obviously.
• 20:40And then, and then I
• 20:41went to Ghana.
• 20:43And,
• 20:44living in Ghana, you know,
• 20:45I stayed in this, like,
• 20:46small town. I traveled around
• 20:48for a bit, and then
• 20:48I stayed in this, like,
• 20:49small town. I tried to
• 20:50make a routine for myself.
• 20:51And I just tried to
• 20:52wanted to live like a
• 20:53normal person,
• 20:55you know, in this society,
• 20:57as much as that is
• 20:58possible. Right? So I ran
• 20:59in, like, a room. I
• 21:00had, like, mattress in the
• 21:01floor. And my friends were,
• 21:02you know, Ghanaian guys from,
• 21:04like, sixteen to twenty four
• 21:05years old. We, like, play
• 21:06barefoot soccer. We would like
• 21:07to wrestling contests.
• 21:09And we we would just
• 21:10hang out. Right? As, you
• 21:11know, you'd want and they
• 21:13were friends. And and I
• 21:15guess, say, in this process,
• 21:17it is also very striking
• 21:18the disparity in opportunity, disparity
• 21:20in health care.
• 21:22You know, multiple of my
• 21:23friends had family members died
• 21:24from preventable illnesses,
• 21:26and it just seems so
• 21:27unfair. Right? Like, the price
• 21:29of Starbucks coffee in the
• 21:31US in the right hands
• 21:32at the right time could
• 21:33literally save somebody's life.
• 21:36So I I thought this
• 21:37is so compelling,
• 21:39that
• 21:40and I thought the disparity
• 21:41in global
• 21:42I thought the global disparity
• 21:44was a global emergency.
• 21:47And, in the process of
• 21:48living in a different place,
• 21:49I also thought more about
• 21:50my identity, like, what that
• 21:52means. Like, do I have
• 21:52to be Korean? Do I
• 21:53have to be American? What
• 21:55does that mean to be
• 21:55American, or what does that
• 21:56mean to be Korean?
• 21:58So I embrace, like, more
• 21:59of an identity as a
• 22:00global citizen. And to me,
• 22:02that means that I care
• 22:03about all people regardless of
• 22:04where they're from, regardless of
• 22:06their race, and, regard and
• 22:08regardless of their background, that
• 22:09everybody deserves to be treated
• 22:11with the utmost dignity and
• 22:12respect.
• 22:14So in college, at Washington
• 22:16University, I I looked for
• 22:18opportunities
• 22:19to, to, you know, further
• 22:21my experience and further my
• 22:22skills.
• 22:23So,
• 22:24in college,
• 22:25so in my travels, you
• 22:26know, I saw that a
• 22:27lot of people use traditional
• 22:28medicines to treat different
• 22:30illnesses. And I thought this
• 22:31is very interesting because, malaria
• 22:33medication, artemisinin, was discovered from
• 22:35Chinese traditional medications. So I
• 22:37was wondering if, you know,
• 22:39ever anybody had studied African
• 22:40traditional
• 22:41traditional medications in the same
• 22:43way. So I emailed around
• 22:44in college, and, after about
• 22:46twenty cold emails, I found
• 22:47somebody at Oxford, in the
• 22:49UK that does some some
• 22:50research in traditional medicine, and
• 22:52he referred me to, some
• 22:54of some of his colleagues
• 22:55in Uganda.
• 22:55And then I went to
• 22:56Uganda.
• 22:58In in Uganda,
• 23:00during the course of the
• 23:01research analysis and journalism then,
• 23:03I just formed a lot
• 23:04of, like, really great relationships
• 23:05that still maintain today. So,
• 23:08the picture on the right
• 23:09is Peter Weiswe.
• 23:10You know, he's my, good
• 23:12mentor. He's,
• 23:14he he's on the the
• 23:15WHO advisory board from maternal
• 23:17health,
• 23:18and, you know, I've had
• 23:19a decade long relationship with
• 23:20them. And in the middle
• 23:22are, you know, Kazindu and
• 23:23Peter, who I've known for
• 23:25ten plus years that remain
• 23:26like good friends. We've seen
• 23:27each other through, you know,
• 23:29through through through life, through,
• 23:30like, marriage, through having kids.
• 23:32And, these relationships, as well
• 23:34as the work, was so
• 23:35compelling that it kept me
• 23:37coming back, year after year.
• 23:40And,
• 23:41in medical school,
• 23:43you know, at that point,
• 23:44I was doing several projects,
• 23:46you know, sending some
• 23:48American students from my, alma
• 23:49mater to go to Uganda
• 23:50to work on some projects.
• 23:52And in twenty eighteen, first
• 23:54year of medical school, medical
• 23:55school friend of mine donated
• 23:57forty thousand dollars, and we
• 23:58started, Empowered through Health, which
• 24:00is a five one c
• 24:01three organization.
• 24:03So our focus is in
• 24:04health care, research and education.
• 24:07So I'll talk briefly about
• 24:08that to kind of give
• 24:09you a background.
• 24:11So the purple district is
• 24:12where we work. It's called
• 24:13Brianda district. So Uganda is
• 24:15a low income country, but,
• 24:17you know, within Uganda, there's
• 24:18a lot of regional disparities
• 24:19as well. So, the area
• 24:21that we work is called
• 24:22the Busoga region. It's one
• 24:23of nine major regions in
• 24:24Uganda. It has approximately about
• 24:26four million
• 24:27people. It consistently has about
• 24:29the second worst health outcomes
• 24:30in Uganda out of all
• 24:31the regions.
• 24:33And when we were picking
• 24:34a site to really make
• 24:37a base for us, we
• 24:38wanted to go where the
• 24:39need was sacred where where
• 24:41there were the most gaps.
• 24:42So we need assessments. We
• 24:44did we did,
• 24:45consult we consulted with government
• 24:47officials, and, you know, we
• 24:48found a community that, you
• 24:49know, didn't really have
• 24:51very consistent access to modern,
• 24:53medical care.
• 24:56So, that's behind the district
• 24:57and then Tunde.
• 24:59So we started a health
• 25:00center,
• 25:01and since we started operating,
• 25:03we've provided care to over
• 25:04fifty thousand people, general medical
• 25:06care, like, maternal maternal care,
• 25:08mental health care.
• 25:10We have, like, collaborations with
• 25:11district for the,
• 25:13referral center for mental health
• 25:14for this whole district, and
• 25:16anecdotally, people from surrounding districts
• 25:18also come. So,
• 25:20I think our catchment area
• 25:21is even, like, you know,
• 25:23more than the district population.
• 25:26And we also run various
• 25:27public health interventions out of
• 25:29the health center.
• 25:31And we began providing psychiatric
• 25:32care in twenty twenty one,
• 25:34in partnership with the district
• 25:36where, you know, it's kinda
• 25:37like, okay. We don't have,
• 25:38like, psychiatric care. We we
• 25:40don't have any, any services
• 25:42available. So, you know, so
• 25:43we can, like, work together
• 25:44to, start this out of
• 25:46our health center.
• 25:48And in terms of education,
• 25:50you know, we do two
• 25:51things with education. One thing
• 25:53one one one,
• 25:54one, avenue is working with
• 25:56predoctoral students. So, like, MD
• 25:58students, master students, and undergraduate
• 26:00students,
• 26:01in both Uganda and America,
• 26:03and we do a simultaneous
• 26:05training model. So that's a
• 26:06global health experiential fellowship.
• 26:09We just recently,
• 26:10submitted an article to Global
• 26:11Health Science and Practice,
• 26:13about a review of this
• 26:14program that, some people in
• 26:16the department were a part
• 26:16of such as, doctor Rorba,
• 26:20over there.
• 26:21And,
• 26:22and, so so, basically, you
• 26:24know, through this simultaneous training
• 26:25model, which is like a
• 26:26five week in person experience,
• 26:28in Uganda,
• 26:30that has both Ugandan and
• 26:31American students, like, working together
• 26:33on research. We found significant
• 26:36increases in research in observable,
• 26:38measurable research skills, in the
• 26:40Ugandan students, and the quality
• 26:42of data was also very
• 26:43rich in terms of, like,
• 26:44what people got out of
• 26:44this experience. So it can
• 26:44be a
• 26:48so it's a new model
• 26:49of working together,
• 26:50of, like, global health, capacity
• 26:52building.
• 26:53And we also do, education
• 26:55in the community, which means,
• 26:57like, public health education, but
• 26:58we're also building a primary
• 26:59school, as well.
• 27:01And, you know, we do
• 27:02sensitization
• 27:03regarding,
• 27:04like, menstrual,
• 27:05menstrual dignity.
• 27:07We we make reusable pads
• 27:08to distribute them, work with
• 27:10schools to incorporate that into
• 27:11their tuitions too.
• 27:13So global health experiential fellowship
• 27:15has also been like a
• 27:17a very productive vehicle for
• 27:18research as well.
• 27:19So from, GHEF,
• 27:21from twenty twenty three, we
• 27:23have three peer reviewed publications
• 27:25published, three under reviews, I
• 27:26think two with minor revisions
• 27:28and one with major revision,
• 27:30and three more that we're
• 27:31about to submit. So it's
• 27:33become also very, productive as
• 27:35well.
• 27:36So our research,
• 27:37derives from our on the
• 27:39ground work. Right? So when
• 27:41we started psychiatric care,
• 27:43in twenty twenty one,
• 27:45at first, we were getting
• 27:46less than ten patients a
• 27:47month. And it's like,
• 27:49okay. You know, we are
• 27:50serving an area of, like,
• 27:51half a million people. Why
• 27:52why are we only getting,
• 27:53like, less than ten patients
• 27:54a month? Right? And this
• 27:55is an area that didn't
• 27:56really have access
• 27:57to the biomedical mental health
• 27:59care before. Right? And there's
• 28:00a lot of different,
• 28:02perceived etiologies of mental health
• 28:04and, you know, different people
• 28:05that people go to, like
• 28:06traditional healers and religious leaders.
• 28:08So we thought that the
• 28:09first step was to characterize
• 28:11and reduce, like, mental illness
• 28:12stigma and increase psychoeducation.
• 28:15So I'm gonna talk about
• 28:16that.
• 28:18So we've done some work
• 28:19characterizing mental illness stigma. So,
• 28:22you know, we use a
• 28:23vignette model to kind of,
• 28:24like, characterize
• 28:26what about mental illness is
• 28:27stigmatizing
• 28:28and,
• 28:29and, you know, what conditions
• 28:30might be most stigmatized.
• 28:32So we've done, some work
• 28:34on that. We've done some
• 28:35some,
• 28:36interpretive,
• 28:37phenomenological
• 28:38analysis on
• 28:40on, you know, theories of
• 28:41mental illness in Uganda as
• 28:43well.
• 28:44And we also have these,
• 28:45like, other works in progress
• 28:46that further characterizes mental illness
• 28:47stigma that, you know, we're
• 28:49hoping to publish within within
• 28:50a within a year that
• 28:51we already have data collected
• 28:53for.
• 28:53So I I'm just gonna
• 28:54give you give an example
• 28:55of a community based intervention
• 28:57that we conducted for mental
• 28:58illness stigma. So,
• 29:00so when we were starting
• 29:01psychiatric care, you know, as
• 29:03I said, you know, not
• 29:04many people are coming. Right?
• 29:05So we thought the first
• 29:06step was, you know, like
• 29:07a program.
• 29:08So what we did was
• 29:10we did some focus groups,
• 29:12to
• 29:13figure out, you know, what
• 29:15people think about, you know,
• 29:16current beliefs and attitudes for
• 29:17severe mental illnesses. So we
• 29:19have four focus group discussions.
• 29:21And from that, we need
• 29:22a list of criteria
• 29:24for a community play, and
• 29:26then we had an open
• 29:27come open competition with everybody
• 29:29in the community that could,
• 29:31you know, they could team
• 29:32up, and they could,
• 29:33and and they could, and
• 29:35and they could, you know,
• 29:36perform a play that met
• 29:37the criteria
• 29:38of destigmatizing mental illness.
• 29:41And,
• 29:42so
• 29:43we chose theater as a
• 29:44medium because it's a a
• 29:45common entertainment medium in rural
• 29:47Uganda.
• 29:48And so four teams competed,
• 29:49won one, and, you know,
• 29:50we had them tour some
• 29:52villages, and they won a
• 29:53monetary prize as well. So
• 29:55we evaluated the effectiveness of
• 29:56the intervention one weekend and
• 29:58one year one week
• 30:00after the intervention and one
• 30:01year in.
• 30:02So this is kinda like
• 30:03the flowchart for,
• 30:04for for for the study.
• 30:06So one hundred and one
• 30:07participants were administered in the
• 30:09initial questionnaire.
• 30:10Seventy seven that attended the
• 30:11initial theater intervention. Fifty seven
• 30:13of the seventy seven were
• 30:14administered a questionnaire one week
• 30:16later, and forty six of
• 30:17fifty seven were found one
• 30:19year later to, ask a
• 30:20questionnaire measuring mental illness stigma.
• 30:23So as you can see,
• 30:26acceptance for those with severe
• 30:28mental illness increased,
• 30:29pretty significantly. The effect size
• 30:31is about one point o,
• 30:32both in the one week
• 30:33follow-up and the one year
• 30:34follow-up as well.
• 30:36And, also, you know, more
• 30:38practically, the number of patients
• 30:40that we're seeing for severe
• 30:41mental illness in Uganda is
• 30:43now over one hundred a
• 30:44month as well. So, you
• 30:45know, although that's not you
• 30:47know, you can't really assume
• 30:49causality there, but, you know,
• 30:51it's
• 30:52you know, they're
• 30:54the it it it has
• 30:55helped in terms of, like,
• 30:56you know, providing more care
• 30:57to more people as well.
• 30:59And we also converted this
• 31:00to, like, a radio intervention
• 31:02too that, we,
• 31:03that we, published about too.
• 31:06So I submitted a k
• 31:07twenty three a few months
• 31:08ago on, you know, furthering
• 31:10the same. So, you know,
• 31:13so so so some of,
• 31:13like, research and, you know,
• 31:15we certainly have a lot
• 31:16of preliminary data on this.
• 31:17So research aim one is
• 31:19to just characterize the media,
• 31:21you know, preferences, like health
• 31:22information delivery networks, like what
• 31:24that's like in this patient.
• 31:26And aim two is to
• 31:27refine the intervention that we
• 31:29already have.
• 31:31Aim three is to assess
• 31:32the feasibility,
• 31:33acceptability, and preliminary efficacy of
• 31:35the intervention.
• 31:37So
• 31:37I have five different mentors
• 31:39from five different institutions,
• 31:40k, and two from Uganda
• 31:42and three from US, including,
• 31:44Robert Rosenheck at Yale. So
• 31:46these are some of the,
• 31:48expertise that I hope to
• 31:49gain.
• 31:50So
• 31:51I wanna be somebody that
• 31:52can develop interventions, community based
• 31:55interventions, and test the effectiveness
• 31:57of those interventions
• 31:58and scale it up. So
• 32:00I feel like the training
• 32:01that I'm getting in the
• 32:02k is setting the is
• 32:04setting a good stage,
• 32:05for my future,
• 32:07goals.
• 32:09And some of the other,
• 32:10things that, you know, I'm
• 32:11interested into is working with
• 32:13existing communities to improve care
• 32:15delivery as well. So we've
• 32:16we've done, you know, some
• 32:18preliminary work on the existing
• 32:21care delivery networks in Uganda
• 32:23and how we can work
• 32:24with them
• 32:25to, to provide better care.
• 32:27Right? So a lot of
• 32:28people so majority of people
• 32:29in rural Uganda, first go
• 32:31to religious leaders and traditional
• 32:33healers. Right?
• 32:34So we've done some work
• 32:35characterizing that as well as
• 32:37some, you know, some some,
• 32:39some
• 32:40some data on,
• 32:42willingness to collaborate among, like,
• 32:44religious leaders, traditional healers, and
• 32:46biomedical providers as well.
• 32:48So
• 32:50so we're,
• 32:51planning,
• 32:52a r thirty four submission
• 32:53in June.
• 32:55Initially, I was planning in
• 32:56October, but, you know, doctor
• 32:57Crystal pointed out that I
• 32:58can apply for it in
• 32:59June as a as a
• 33:01resident. So
• 33:03so, so so, basically, one
• 33:05intervention is, you know, this
• 33:07collaborative care model for severe
• 33:09mental illness,
• 33:10utilizing
• 33:11traditional healers, religious leaders, and
• 33:13biomedical providers.
• 33:14So researching one is develop
• 33:16a culturally tailored collaborative care
• 33:18model and two, evaluate the
• 33:20feasibility of that intervention.
• 33:23So,
• 33:24there has been, collaborative models
• 33:26for severe mental illness and
• 33:28LMICs. Like, Vikram Patel did
• 33:30one with late, community health
• 33:32providers, but not with, you
• 33:34know, traditional healers and religious
• 33:35leaders. We had graduated did
• 33:36one in Nigeria, but it
• 33:38was in the context of
• 33:39prayer camps. So prayer camps
• 33:40in West Africa are where
• 33:42hundreds of people with severe
• 33:43mental illness are all together,
• 33:44and that's a model that's
• 33:45pretty exclusive to West Africa
• 33:47only. So this is this
• 33:49this could be a template
• 33:50in how we work with
• 33:51with existing care systems
• 33:53in delivering care to severe
• 33:54mental illness, including in the
• 33:56United States.
• 33:58So
• 33:59and another r thirty four,
• 34:00that I have planned, I
• 34:01submitted a pilot grant to,
• 34:03Sierra,
• 34:05regarding this,
• 34:06is a client with care
• 34:07models for for depression. So,
• 34:09you know, group psychotherapy has
• 34:11been shown to be very
• 34:12effective in treating depression in
• 34:13LMI C settings.
• 34:15So, you know, why don't
• 34:16we train people that people
• 34:17already go for depression, like
• 34:18religious leaders, you know, traditional
• 34:20healers,
• 34:21and better the effectiveness?
• 34:23So those are, you know,
• 34:23some of the other, research
• 34:25aims too.
• 34:26And some potential directions that
• 34:28we haven't really, collected preliminary
• 34:30data for, but we're planning
• 34:31to this summer,
• 34:33is, the overlap between education
• 34:35and mental health.
• 34:37So school discontinuation is, like,
• 34:39a major issue,
• 34:40you know,
• 34:42in LMICs and in Uganda,
• 34:44in America too. But, you
• 34:45know,
• 34:47if you go to the
• 34:47school in Uganda,
• 34:49in the area that we
• 34:50work, so there's a lot
• 34:51of regional disparities as well.
• 34:53But, in first grade, there
• 34:54might be two hundred people
• 34:55enrolled. So there's, like, a
• 34:56roster at the school showing
• 34:57you how many people are
• 34:58enrolled in in each grade.
• 35:00So grade one, two hundred
• 35:01people. By the time you
• 35:02get to grade six, like,
• 35:03sixth grade, there's ten people.
• 35:05So school discontinuation is, like,
• 35:07a major issue.
• 35:09So and, you know, it's
• 35:10also I don't associated, like,
• 35:12as, like, a very traumatic
• 35:13experience for a lot of
• 35:14people,
• 35:16not being able to afford
• 35:17to continue going to school.
• 35:19So, like, what if you
• 35:20can combine a psychological and
• 35:22an economic intervention,
• 35:23creating a community mentorship system,
• 35:25a vocational training system in
• 35:27the community
• 35:28that, that
• 35:30that can, you know, empower
• 35:32people at, like, a very
• 35:33critical phase of their lives.
• 35:35So we're collecting some preliminary
• 35:37data for this this summer.
• 35:38So hopefully, this this can
• 35:39become another potential aim.
• 35:42So this is just generally
• 35:44my five year plan. For
• 35:45the sake of simplicity, I
• 35:46made a
• 35:48for the sake of simplicity
• 35:49simplicity, I made the assumption
• 35:50that it'll take each grant
• 35:51one resubmission to receive it.
• 35:54So, you know, several paths
• 35:55to, like, r ones and
• 35:56becoming an independent researcher. I'm
• 35:58also very interested in, taking
• 35:59some of the lessons, centered
• 36:01around community based interventions to
• 36:03the United States.
• 36:04For example, in in the
• 36:05elderly, in the United States,
• 36:07loneliness is a huge epidemic.
• 36:09So is, like, elderly, you
• 36:10know, a common mental illnesses
• 36:12as well. So and and
• 36:13treatment in America, I feel
• 36:15like a lot of times
• 36:16is very devoid of community
• 36:17aspects. So what if we
• 36:18can train activity managers at
• 36:20nursing homes too in providing
• 36:21group psychotherapy,
• 36:23right, and measure outcomes that
• 36:25way. So so some more
• 36:26directions that I'm interested in
• 36:28as well, domestically too.
• 36:32So we're gonna actually save
• 36:33questions until the end of
• 36:35the end of,
• 36:37our overall talk.
• 36:38But, you know, it's a
• 36:40pleasure to introduce,
• 36:41another
• 36:42one of my, colleagues, Marcus.
• 36:45He's been a he he's
• 36:46a chief resident of,
• 36:49of the residency,
• 36:50currently.
• 36:51He's a member of the
• 36:54Yaqui tribe in Arizona,
• 36:56and he's a leader in
• 36:57his community as well. And,
• 36:59you know, I I had
• 36:59the privilege of visiting him
• 37:01in Tucson,
• 37:02like, last month, and I
• 37:04saw how much
• 37:05how much he means and
• 37:06how much it means that,
• 37:07you know, he's achieved what
• 37:08he has achieved to this
• 37:09degree, to his community, to
• 37:10thousands of people in this
• 37:11community.
• 37:13And I think it's like
• 37:14and, you know, his plan
• 37:15is to go back to
• 37:15Arizona,
• 37:16work with his community, and,
• 37:18you know, empower his community,
• 37:20and better better mental health
• 37:21care. So,
• 37:23so it's an honor to
• 37:23be a co resident with
• 37:25you. And,
• 37:27yeah. And I'll Thanks for
• 37:28that, Dave.
• 37:33Well, good morning, everyone.
• 37:36For
• 37:37time purposes, I'll there will
• 37:39be some slides
• 37:40I skip and also because
• 37:41I just realized I gave
• 37:42Matt the wrong version,
• 37:44but it's mostly there. So
• 37:46we'll jump right into it.
• 37:47It it's kinda fitting. I
• 37:48I didn't I don't think
• 37:49we planned this, but the
• 37:50way we really started with,
• 37:52you know, Matt's, like, systems
• 37:53level
• 37:54kind of view, Jay at
• 37:56the country level, and then
• 37:57going further and further down,
• 37:58looking at the community level
• 38:00and at a much smaller
• 38:01scale of of what I've
• 38:02been doing. So
• 38:04I have been involved,
• 38:05with
• 38:07basically two projects longitudinally
• 38:09since I've been in residency
• 38:10related to, community health needs
• 38:13assessments and stigma reduction. So
• 38:15I'll be talking about two
• 38:16projects mostly because they they
• 38:18tie together.
• 38:19So the first thing I
• 38:20wanna jump in with, just
• 38:21to give you guys a
• 38:22backdrop of, like, who we're
• 38:22talking about. So as Jay
• 38:24mentioned,
• 38:24this is the Pascua Yaqui
• 38:26tribe. This is the tribe
• 38:27that I'm from.
• 38:28There is a unique setup
• 38:30here where the tribe is
• 38:31concentrated in the southwestern United
• 38:33States, both in the US
• 38:35and on the Mexican side
• 38:36of the border. Roughly ten
• 38:37thousand,
• 38:39enrolled members in the United
• 38:40States, another thirty thousand in
• 38:41Mexico.
• 38:42The largest clustering is our
• 38:44reservation in Southern Arizona where
• 38:46I'm from. It's just outside
• 38:47of Tucson.
• 38:48But we do have smaller
• 38:49metro community areas in Tucson
• 38:51and Phoenix,
• 38:52Central Arizona. There's also a
• 38:54small community in Texas and,
• 38:56Southern California,
• 38:58just to give you a
• 38:58backdrop of who this is.
• 39:01And the relevance. Relevance to
• 39:02global health. Native Americans occupy
• 39:04a really odd space in
• 39:05America because, you know, they're
• 39:07American citizens, but they often
• 39:09live in communities that are
• 39:10designated, you know, not entities
• 39:12of the United States. And
• 39:13because of that, there's a
• 39:14lot of different ideas around
• 39:15mental health, around, you know,
• 39:17how treatment is received in
• 39:18these communities.
• 39:20The other just pure relevance
• 39:21point from a psychiatric
• 39:23standpoint is, you know, Native
• 39:25Americans, if you look at
• 39:25health disparities
• 39:27for substance use,
• 39:28for trauma disorders,
• 39:29highest rate of any ethnic
• 39:31group, and it's really not
• 39:32close.
• 39:33There's also a really,
• 39:35you know,
• 39:36lot of research out there
• 39:37that talks about the completion
• 39:39of suicide in these communities
• 39:40being really just off the
• 39:41charts. And despite these
• 39:43depths of despair,
• 39:44very often, you know, there's
• 39:46not a lot of access
• 39:47to behavioral health centers and
• 39:48services, and really a lot
• 39:50of resistance for native communities
• 39:52to engage with Western medicine.
• 39:54And we'll talk a little
• 39:54bit about why.
• 39:57Don't just take my word
• 39:58for it. So this is
• 39:59from the CDC.
• 40:00This was released in twenty
• 40:01twenty one. This trend goes
• 40:03back much further than twenty
• 40:05fifteen.
• 40:06That top blue bar you
• 40:07see there is the, suicide
• 40:09completion rate by,
• 40:11Native Americans. And then that
• 40:13black bar there is the
• 40:15white population in the US.
• 40:16That dotted gray line is
• 40:18the US average. And then
• 40:19everyone else kinda clusters together.
• 40:21As you can see, one
• 40:22of the odd things, twenty
• 40:23nineteen, I guess not odd,
• 40:24not surprising. This disparity started
• 40:26to worsen a little bit.
• 40:27We think in response to
• 40:29the COVID nineteen pandemic,
• 40:31all minority populations saw a
• 40:33little bit of an increase
• 40:34around then.
• 40:36I like to include this
• 40:37just to give people a
• 40:38backdrop of what we're dealing
• 40:39with and also just show,
• 40:40you know, the disparity is
• 40:41pretty significant in these communities,
• 40:43particularly
• 40:44for native populations living in
• 40:46reservation communities.
• 40:49So what have we been
• 40:50doing about it? So back,
• 40:52in twenty twenty two, during
• 40:54my PGY2 year,
• 40:56I used my case rotation
• 40:59here at Yale, the, clinical
• 41:00and academic selective experience to
• 41:03basically work with my tribal
• 41:05health department
• 41:06on
• 41:07what was our first really
• 41:09broad
• 41:10community health needs assessments focused
• 41:11on behavioral health. And to
• 41:13do this with,
• 41:15basically to do this with
• 41:16validated scales and screening metrics,
• 41:18because we didn't have a
• 41:20lot of people utilizing behavioral
• 41:21healthcare services, unfortunately.
• 41:23Although we had a suspicion
• 41:24based on national trends that
• 41:25there should be a lot
• 41:26of this in the community.
• 41:28So we ended up getting
• 41:29a pretty good sample size.
• 41:30This was more than I'd
• 41:31ever been surveyed for behavioral
• 41:32health purposes in my community.
• 41:34Keep in mind, like I
• 41:35said, the reservation's roughly about
• 41:36five thousand ish people,
• 41:38but we were surveying people
• 41:39also in the surrounding,
• 41:41metro areas.
• 41:42So we ended up,
• 41:44having
• 41:45PHQ score on there, a
• 41:47PC five, an audit for
• 41:48alcohol use disorder screening.
• 41:50Not surprising.
• 41:51Some of the results per
• 41:53se as far as, like,
• 41:53what we were expecting was
• 41:54in line with you know,
• 41:55we know there's a high
• 41:56prevalence of trauma. We know
• 41:57there's a high prevalence
• 41:59of potentially PTSD,
• 42:01anxiety,
• 42:02substance use disorders.
• 42:04The thing that we were
• 42:05trying to kinda demonstrate was
• 42:06even people who were screening
• 42:07positive on these metrics were
• 42:10not reaching out for health
• 42:11care services, and even less
• 42:12were being seen. So, really,
• 42:14we're seeing almost nobody who's
• 42:16screening positive.
• 42:17And our question is why?
• 42:19What's going on? Why is
• 42:20nobody utilizing what's out there?
• 42:22Because the tribe does have
• 42:23a behavioral health department that
• 42:25has really expanded and has
• 42:26really, you know, tried to
• 42:27to bring in people to
• 42:29to receive treatment. But we
• 42:30got a lot of responses
• 42:31like this. So things talking
• 42:33about stigma, talking about
• 42:35concerns related to being judged.
• 42:37And, I mean, the other
• 42:38flavor we got from a
• 42:39lot of people in some
• 42:40of these qualitative feedbacks
• 42:42were related to people saying
• 42:43that's not a medical problem.
• 42:44I wouldn't go to someone
• 42:45for that. That's the family
• 42:46problem. That's a unit problem.
• 42:47That's a community problem. Why
• 42:49would I talk to my
• 42:50doctor about that?
• 42:51The other piece of it
• 42:52was there was, you know,
• 42:54we gleaned a lot of
• 42:56evidence
• 42:56suggesting
• 42:57there wasn't a lot of
• 42:59health literacy related to behavioral
• 43:01health and and frankly, just
• 43:02a lot of internalized stigma
• 43:03around it.
• 43:04So
• 43:05how I, you know, attempted
• 43:07to continue this project and
• 43:09continue,
• 43:11you know, addressing some of
• 43:12these disparities
• 43:13was through,
• 43:15I was fortunate to get
• 43:16some funding through the APA
• 43:18SAMHSA fellowship to,
• 43:20pilot a project that I
• 43:21call Project STAR, strengthening tribal
• 43:23awareness and resilience.
• 43:26Fun fact, for those of
• 43:27you who are interested in,
• 43:28like, Native American cosmology and
• 43:31origin stories, for a lot
• 43:32of Mesoamerican
• 43:33tribes in particular, they will
• 43:35refer to themselves as the
• 43:36people of the stars. You
• 43:37can look at it a
• 43:38bunch of different ways, but
• 43:39the cheeky name is kind
• 43:40of a nod to to
• 43:42that origin.
• 43:44So what were our objectives?
• 43:45What were we trying to
• 43:46do here?
• 43:47Number one, just community engagement.
• 43:48So we really wanted to
• 43:50bring the community in, educate
• 43:52community members about
• 43:53the
• 43:55about
• 43:56how, behavioral health is important
• 43:58and also do it in
• 43:59a culturally appropriate way. We
• 44:01wanted to open the dialogue
• 44:03and really just get community
• 44:04members, you know, out in
• 44:05the open talking about this
• 44:06and bringing in people with
• 44:08lived experience, which goes with
• 44:10our collaborative partnership. So with
• 44:11the grant, I was able
• 44:12to bring in speakers who,
• 44:14you know, we paid them
• 44:15whether they were,
• 44:17some were tribal members, some
• 44:18were involved just with the
• 44:20tribal health department and and
• 44:22the behavioral health department and,
• 44:23you know, doing work with
• 44:24the MAT clinic that we
• 44:25have there or, you know,
• 44:27as counselors.
• 44:28And
• 44:29the other piece of it
• 44:30was really compiling a list
• 44:32of resources and, and just
• 44:33kind of educating the masses,
• 44:35like, these are the services
• 44:36out there, this is something
• 44:37that medicine can help with,
• 44:38this is something that our
• 44:39services can help with, we
• 44:40need to start utilizing these
• 44:41and, and also there's an
• 44:43incorporation of alternative med practices
• 44:45for the tribe too. So
• 44:46we wanted to just let
• 44:47people know that you don't
• 44:48have to choose one or
• 44:48the other, there is a
• 44:49bridge that's available. And we're
• 44:50trying to increase that.
• 44:52So how we went about
• 44:53it.
• 44:55There is a community
• 44:57attitudes of mental illness scale.
• 44:59There's not a lot of
• 45:01great scales out there for
• 45:02assessing stigma. This one I've
• 45:03seen replicated in a lot
• 45:05of different languages and studies.
• 45:07Essentially, a higher score on
• 45:09that correlates with a more
• 45:10positive attitude towards mental illness.
• 45:12So we did this before,
• 45:14the project started. We gathered
• 45:15some demographic data. We ran
• 45:17a whole awareness campaign that
• 45:18went over the course
• 45:20of, really, actively about six
• 45:22months, but in terms of
• 45:23the planning and everything else,
• 45:24it's over the course of
• 45:25a year. And then the
• 45:26crux of our opening the
• 45:28dialogue, opening the conversation to
• 45:30the community were these town
• 45:31hall style events where, you
• 45:33know, I flew back periodically.
• 45:34We would have these broadcast
• 45:36on
• 45:37the tribe social media pages.
• 45:39They're still up on their
• 45:40Facebook live pages, and they
• 45:42save the videos and catalog
• 45:43them there.
• 45:44And we would have people
• 45:45who were
• 45:46experts in, you know, community
• 45:48mental health, native health, native
• 45:50well-being,
• 45:51people who were doing work
• 45:52in the community. They each
• 45:53had, like, a different topic
• 45:54and focus, which we'll we'll
• 45:55talk about. And then at
• 45:56the end of it all,
• 45:57basically, we repeated the the
• 45:59scale, and we were looking
• 46:01at attendees versus non attendees
• 46:03in person. A crude metric,
• 46:04but really more so just
• 46:05to kind of get people
• 46:07involved in this and see
• 46:08if this is something we
• 46:09should sustainably do moving forward.
• 46:12So I just wanna show
• 46:13you guys, like, what the
• 46:14scale is. It's a cool,
• 46:15nifty little tool, basically, that,
• 46:17you know, it scores it
• 46:18on a Likert style scale.
• 46:20And, the long form is
• 46:22forty questions.
• 46:24The short form, which has
• 46:25been validated and replicated against
• 46:27itself,
• 46:28is only twenty questions. So
• 46:29it's not really cumbersome from
• 46:31a time standpoint. It's pretty,
• 46:33oops, pretty easy to,
• 46:35go about it in that
• 46:36way.
• 46:39Whoops, sorry.
• 46:41Just to talk about like
• 46:42our community messaging and our
• 46:44meetings, what they look like.
• 46:45So,
• 46:46we have a
• 46:48pretty nifty,
• 46:51youth council who does a
• 46:52lot of social media messaging.
• 46:53And we really just ramped
• 46:55that up during, you know,
• 46:56the time of my project
• 46:57to bring awareness to things
• 46:59related to addiction, things related
• 47:00to behavioral health services.
• 47:03We also had a lot
• 47:04of these signs posted out
• 47:05in the community with tribal
• 47:07symbols, tribal language, numbers to
• 47:09crisis lines, numbers to alternative
• 47:11medicine, to Centered Spirit, which
• 47:12is the main behavioral health
• 47:14center there.
• 47:15Everybody I knew in the
• 47:16community, I made sure to
• 47:17give them multiple signs as
• 47:18we're at every gate, every
• 47:20door,
• 47:21the community wellness center, all
• 47:23over the place.
• 47:25But the crux of it,
• 47:26as I mentioned, were these
• 47:27events. So these mind matters
• 47:28town hall events, as I
• 47:29mentioned, we we broadcast them
• 47:31on Zoom. We had them
• 47:32on Facebook Live. The tribal
• 47:34media team was involved. And
• 47:35all of these people were
• 47:37either community members or people
• 47:38directly involved with health care
• 47:40for the tribe and, behavioral
• 47:42health.
• 47:43We had sessions focused on
• 47:44addiction,
• 47:45on youth resilience, on, trauma
• 47:47and resilience healing, which ended
• 47:49up being our most well
• 47:51attended in person and also
• 47:52just offline, like, by views
• 47:54and videos shared, session.
• 47:57The in person sessions, obviously,
• 47:59you know, we had food.
• 47:59We had, like, these speakers
• 48:01come in. They were paid
• 48:02for their time.
• 48:04The lived experience side of
• 48:05things, I can't underscore
• 48:07just because
• 48:08there was
• 48:09this gentleman up here, you
• 48:11know, talked about his journey.
• 48:13Oops, sorry. Back.
• 48:17Whites.
• 48:18Whoops, sorry.
• 48:21One of these gentlemen's here
• 48:23was, part of the, the
• 48:24tribal methadone program and talked
• 48:25about, you know, his time
• 48:27and, and how recovery does
• 48:29happen. Really just giving people
• 48:30voice and hope. And it's
• 48:32something that means a lot
• 48:33more when it's coming from
• 48:34someone, you know, essentially.
• 48:36Really well attended
• 48:38our,
• 48:39viewership
• 48:40for
• 48:41the most popular video we
• 48:42had online was like fifteen
• 48:44thousand or something. So we
• 48:45had, I mean, we got
• 48:46to a pretty big audience
• 48:47considering this was shared beyond
• 48:49just, you know, our tribal
• 48:50community, but other tribal communities
• 48:52in Arizona who are interested
• 48:53in the model and interested
• 48:54in kind of how to
• 48:55get the word out about
• 48:56these services.
• 48:58I'll talk about outcomes. There's
• 49:00some typos on this next
• 49:02slide.
• 49:03You know, effectively, what we
• 49:04were able to show and
• 49:05see was there is at
• 49:07least in the short term,
• 49:08some change related to attitudes,
• 49:10stigmatizing attitudes towards mental illness.
• 49:12So unsurprisingly,
• 49:14people who,
• 49:16showed up in person pre
• 49:18any of this exposure, pre
• 49:19any of the
• 49:20teachings or psychoeducation, they already
• 49:22had a higher score. They
• 49:24were already less stigmatizing on
• 49:25mental health, but that makes
• 49:26sense because they're interested in
• 49:27this. But But even for
• 49:29that group, we were able
• 49:30to see a mild increase.
• 49:32The biggest increase we saw
• 49:33was actually for people who
• 49:34didn't attend anything in person.
• 49:35So whether that was them
• 49:37attending via just online, seeing
• 49:39the messaging in the community.
• 49:40We have a a nifty
• 49:42little app called Nixle where
• 49:43I can basically news blast
• 49:45and give people announcements about
• 49:46ongoings in the tribe at
• 49:48any time. So it gives
• 49:49me the ears of, like,
• 49:49five thousand people.
• 49:51Whether it's just that, whether
• 49:53it was just hearing from
• 49:54word-of-mouth,
• 49:55there's some changes
• 49:56effectively. We're trying to replicate
• 49:58this and see kind of
• 49:59similar to Jay's project if
• 50:00there's longitudinal results at six
• 50:02months at one year, which
• 50:03will happen this year.
• 50:05Qualitatively,
• 50:07we did have quite a
• 50:08bit
• 50:09of resource guides that came
• 50:11out of this. And just
• 50:12also, we, you know, had
• 50:13like QR codes and things
• 50:15that are sent out to
• 50:15people just as reminders. Like
• 50:17this is where you find
• 50:18all the services, even if
• 50:19you're not going within the
• 50:20tribe, but some people are
• 50:21reluctant to because they don't
• 50:22want to run into people
• 50:23they know.
• 50:24This is where you find
• 50:25services in Tucson or, you
• 50:27know, Southern Arizona type thing.
• 50:29For scalability,
• 50:31so I'm part of a
• 50:33center through the University of
• 50:34Arizona that recently formed focus
• 50:36on native American health.
• 50:38This center, right now has
• 50:40partnerships with multiple tribes in
• 50:42the Four Corners region, some
• 50:43in the Midwest now.
• 50:45They're interested in this project.
• 50:46We're trying to figure out
• 50:47a way to scale it
• 50:48so that we can have
• 50:49a similar model and a
• 50:50curriculum built where tribes who
• 50:52are kind of in the
• 50:53process of developing their behavioral
• 50:55health centers and really ramping
• 50:56up services and connection can
• 50:57start,
• 50:59with something at least. Some
• 51:00kind of way to to
• 51:01know that we're we're addressing
• 51:02stigma, we're addressing service underutilization.
• 51:07Just to give some acknowledgements
• 51:09to to these folks. So,
• 51:11our medical director, doctor Renteria,
• 51:13this dude,
• 51:14been with the tribe for
• 51:15a long time. He,
• 51:17was my primary care doc
• 51:19growing up.
• 51:20He's been super involved with
• 51:22a lot of efforts. He's
• 51:23approaching retirement, which I worry
• 51:25about.
• 51:27Our tribal health department has
• 51:28partnered with me for a
• 51:29number of endeavors, and we
• 51:30have a great working relationship
• 51:32as well as with our
• 51:33tribal council and obviously
• 51:35APA SAMHSA for putting the
• 51:36bill for this specifically.
• 51:39And then one last shameless
• 51:40plug. So upcoming next month,
• 51:42the Global Health Group will
• 51:44have one of our seminar
• 51:45series speakers, Doctor. Maval, coming
• 51:47in to talk about his
• 51:48work in, building bridges across
• 51:50the globe, developing joint collaboration,
• 51:53and interprofessional
• 51:54addiction education.
• 51:58I know we're ahead of
• 51:59time or maybe right on
• 52:00time, but I didn't wanna
• 52:01leave a chance for questions
• 52:03for everyone because I know
• 52:04we kind of deferred
• 52:06till the end. So if
• 52:07you guys wanna