Yale Psychiatry Grand Rounds: September 8, 2023

Transcript

• 00:00To be here today and let me just start
• 00:04by sharing my screen and then I'll,
• 00:06I guess I'll introduce people.
• 00:08So my name is Sonia.
• 00:10My full name is Sierra Ganya Girala Monkon.
• 00:12I'm a fourth year psychiatry resident here.
• 00:15I've been the resident leader of
• 00:17the global mental health program for
• 00:19three years and I'm stepping down.
• 00:22And the three resident leaders
• 00:24coming up are Marcos, Jay and Matt,
• 00:26who are all presenting today.
• 00:28And they're really, really spectacular
• 00:31and wonderful and compassionate.
• 00:33So very excited to have
• 00:34them on the leadership.
• 00:36And I will start with our presentation.
• 00:41All right. If there's any hiccups,
• 00:44please let me know because
• 00:46I won't be able to see us.
• 00:50All right.
• 00:52So the table of contents today I'll
• 00:55be introducing the Yale Global of the
• 00:58introduction to global mental Health,
• 01:00spending about 20 minutes on
• 01:01that briefly going over the Yale
• 01:02Global Mental Health Program.
• 01:04And then the three residents will be
• 01:06talking about their capstone projects.
• 01:08So our objectives today,
• 01:09we want to define global mental
• 01:11health and HealthEquity.
• 01:13We want to discuss some key principles
• 01:15in bidirectional learning and global
• 01:17mental health and then we'll be
• 01:19discussing the wonderful academic projects,
• 01:22no disclosures for any of us.
• 01:24And so we're getting started with
• 01:26the introduction global Mental
• 01:28Health and HealthEquity.
• 01:29I want to let you guys know that I'm taking
• 01:33you guys on a little bit of a journey,
• 01:35a little bit of a story this morning.
• 01:37So I want us to to hopefully
• 01:41have our minds open and sort of
• 01:43take us where the journey goes.
• 01:45And I'm going to pose a lot of questions
• 01:47and unfortunately due to time constraints,
• 01:49I won't be able to get audience answers.
• 01:52But these questions are not by all
• 01:55means limited to just this talk,
• 01:57but continued discussion,
• 01:59hopefully for the future as well.
• 02:03So global mental health,
• 02:04it's an area for study,
• 02:06research and practice that places
• 02:08a priority on improving mental
• 02:10health and achieving equity in
• 02:12health for all people worldwide.
• 02:14That's The Lancet definition.
• 02:18In our history,
• 02:19there's been significant changes that's
• 02:21been made in the world's mental health care.
• 02:23So I do want to acknowledge
• 02:25that that we've come a long way.
• 02:26Even in my lifetime alone,
• 02:28we've certainly come a long way.
• 02:30And a big part of that is how much
• 02:32we care about our mental health now
• 02:35and how much is talked about now.
• 02:37So this is a quote from a current
• 02:40psychiatric mental health practitioner
• 02:43I knew.
• 02:44My father was hospitalized for
• 02:45mental health issues in the 1970s.
• 02:48He's passed now.
• 02:49We didn't talk about it back then.
• 02:51It's still weird for me to talk about it now.
• 02:53There was so much shame and guilt.
• 02:56I knew that he was hospitalized
• 02:58for mental health reasons,
• 02:59but I didn't know anything else.
• 03:02So I think this is beautiful quote
• 03:05that really depicts how mental
• 03:08illness was really not talked about
• 03:11and how even family members who love
• 03:14individuals suffering so much are
• 03:17were unable to help them in the
• 03:20way that they really wanted to.
• 03:23So our present, you know,
• 03:24there's certainly still a way to go
• 03:27in our world's mental health care.
• 03:29This is by The Who.
• 03:31One in eight individuals live
• 03:33with a mental health condition.
• 03:3571% of people with psychosis do
• 03:37not receive mental health services
• 03:39and only 2% of health budgets.
• 03:41So 2% of the health budgets,
• 03:44not the whole budget,
• 03:45but the health budgets on
• 03:47average go to mental health.
• 03:49So it's certainly widespread,
• 03:51undertreated and under resourced.
• 03:54And this is a term that's been
• 03:57coined a failure of humanity
• 04:00not only on a systemic level,
• 04:01but certainly on a 1 to 1 interaction
• 04:04and every day especially on a
• 04:07everyday life interaction as well.
• 04:10So when we think of global mental health,
• 04:13I think we normally think about going
• 04:16internationally and practicing in
• 04:17a low middle income country to help
• 04:21and to save and to create systemic
• 04:23changes in those countries that we
• 04:25think of as having less resources.
• 04:28So more than 85% of the world's
• 04:31population do live in a low and
• 04:33middle income country and more than
• 04:3580% of people who do have mental
• 04:37disorders are residing in low and
• 04:40middle income country just by virtue
• 04:42of having higher population alone.
• 04:44And by Doctor Patel,
• 04:46the most striking in equity is
• 04:48that concerning the disparities in
• 04:51provision of care and respect for
• 04:53human rights of people living in
• 04:56with mental disorders between high
• 04:58and low and middle income countries.
• 05:00So certainly there is a huge in
• 05:03equity and disparity in the care
• 05:06and the services that are able
• 05:08to be provided between high and
• 05:10low and middle income countries.
• 05:12So when I show these kind of statistics
• 05:14or when these kind of statistics are shown,
• 05:16I think it easily leads us to
• 05:19believe that oh,
• 05:20maybe we're doing better off
• 05:21in the United States or maybe,
• 05:24oh,
• 05:24at least we're doing better than
• 05:26in low and middle income country.
• 05:28So that could be a very common
• 05:30perception and that certainly
• 05:32was my own perception as well.
• 05:34So I just wanted to dive a
• 05:36little bit more into that.
• 05:37More than 70% of Americans say that
• 05:40the US stand above all other countries
• 05:42in the world or is one of the greatest
• 05:45countries along with some other countries,
• 05:47a U.S.
• 05:48Department of Defense News article noted.
• 05:51A number of African countries are
• 05:52among the most fragile in the world.
• 05:55These countries have ungoverned or
• 05:57little governed areas and that attracts
• 06:00violent extremist organizations which
• 06:02capitalize on economic and political
• 06:05dysfunction to extend their reach.
• 06:07These governments are in are in need of help,
• 06:11so I want to highlight these
• 06:14very common statements.
• 06:15the US stand above all other countries.
• 06:18Africa countries are most
• 06:19fragile and they need help.
• 06:21So this view is certainly pervasive
• 06:24in almost every area of practice
• 06:27we have and certainly extensively
• 06:29pervasive in global mental health
• 06:32whether consciously or unconsciously.
• 06:35And I am posing and many others that
• 06:38this may be rooted in white supremacy
• 06:41and white savior complex and this is
• 06:44certainly a mindset that I had coming
• 06:47into the residency program that oh I need
• 06:49to go to someone somewhere in Africa
• 06:52to help them because they need help.
• 06:55So I'm certainly this is this was certainly
• 06:59pervasive in my thought process as well
• 07:02some more statistics for you guys.
• 07:04So they did an analysis of over
• 07:0675,000 research grants 90 more than
• 07:1098% of mental research.
• 07:11Mental health research is funded by
• 07:14high income countries and less than
• 07:165% of research funding is conducted
• 07:18in low and middle income country.
• 07:20So you know this high discrepancy of
• 07:23where research is actually being funded.
• 07:26And even when the research is funded
• 07:28in a low middle income country,
• 07:30it's usually led by researchers from
• 07:32or based in high income countries.
• 07:34And certainly this father reinforces the
• 07:39power asymmetry that currently exists today.
• 07:43So I did a dive of a basic Google search
• 07:45and I just wrote in Google Mental Health
• 07:48and and I put in a name of a country.
• 07:50So this list is a high income country.
• 07:53So like Australia, the UK,
• 07:54the US, New Zealand,
• 07:56and these were the pictures that
• 07:59came up in my Google searches.
• 08:01They're all numbers,
• 08:02they're all words and they're all statistics.
• 08:05And when I did the same thing and I
• 08:08did a Google search of mental health
• 08:10in and I put in a low income country,
• 08:12So South Africa,
• 08:13which is not exactly a low income country,
• 08:17Bangladesh and Nigeria.
• 08:20So this is the images that are
• 08:25pervasive when we're thinking about
• 08:27mental health in low income countries.
• 08:29And it may invoke us to think, wow,
• 08:31they're really suffering over there,
• 08:34they really need our help.
• 08:37How can this happen to someone else?
• 08:39How can we do something like this, right?
• 08:41Whereas when we're looking at these
• 08:43kind of images, it can show, oh, maybe,
• 08:48you know, they do have struggles,
• 08:50but maybe, like,
• 08:51they're really addressing these struggles.
• 08:54There's models of care,
• 08:55there's logic models,
• 08:57there's all these beautiful bar graphs.
• 09:00So they're really actively trying
• 09:02to address this concern.
• 09:04So it could seem you can really
• 09:06seem that way.
• 09:09So I did another Google search and this time
• 09:11I put life in rather than mental health,
• 09:14justice, overall life, life in Bangladesh.
• 09:18This is the first image that comes
• 09:20up children next to garbage.
• 09:22And one might evoke from this emotion that,
• 09:28wow, how can these kids be
• 09:29living in such a poor condition?
• 09:32It's so dirty, it's so impoverished.
• 09:35This is a picture in Laos.
• 09:37This little girl's cute and smiling.
• 09:40Laos is a neighboring country
• 09:42to Thailand where I'm from,
• 09:43and so this picture reminds me of myself.
• 09:47But this is the little girl is in
• 09:49mud and you know, she's so cute.
• 09:51Maybe she needs our help.
• 09:53And actually, when I looked on the website,
• 09:56it was of of an American going to
• 09:59Laos and listing all the things,
• 10:02all the statistics of Laos and how
• 10:05one man can truly change the world
• 10:08and really help alleviate poverty
• 10:10by changes in policy and changes
• 10:14in implementation worldwide.
• 10:16This is the first picture that
• 10:18pops up life in Chad.
• 10:19So this one is still of children.
• 10:23Something about children being
• 10:24depicted in images for some reason.
• 10:26And you may think, wow,
• 10:28they don't have a toilet,
• 10:29they don't have functioning
• 10:31bathroom and they're outside the
• 10:33Hut like washing their hands,
• 10:36you know, this is the hot sun.
• 10:38Oh my goodness, like these these poor kids.
• 10:43And then this one is life in America.
• 10:46So again,
• 10:48a child smiling child,
• 10:52which is different from the other photos
• 10:56and really industrialized well manicured
• 10:59houses and fences and properties.
• 11:02So this website was actually
• 11:05a website that said, oh,
• 11:08this is how you can immigrate to America,
• 11:11come live with us.
• 11:12Life in America is really wonderful.
• 11:14These are all the wonderful
• 11:16things about America.
• 11:17And this is how you can get a visa.
• 11:19So that was the first Google image search.
• 11:24So, you know, power and privilege
• 11:28is certainly the current state
• 11:29of things in today's world.
• 11:31And I want to emphasize that that doesn't
• 11:36only come from the high income countries.
• 11:39And so it's not only the US that's
• 11:41saying we need to go to these other
• 11:44countries and really help them and
• 11:46really build up their capacity,
• 11:48but it also comes from low income
• 11:50countries who have internalized,
• 11:52oh, maybe I am worse off and I do
• 11:55need help and I really do need,
• 11:58you know, the technological advances
• 12:00or the medical advances of the
• 12:02Western world to to bring that in,
• 12:05to really help us go to the next level.
• 12:08So that's certainly the current
• 12:11thought process that's pervasive
• 12:12in a lot of us today.
• 12:15And that may be rude in white
• 12:19supremacy and saviorism,
• 12:20lack of diversity, equity and inclusion,
• 12:23the history of colonialism,
• 12:26the forever foreign gays that you
• 12:28can never really be one of us.
• 12:29Patriarchy and racism.
• 12:33Because I think, you know,
• 12:37we all know as mental healthcare
• 12:39practitioners that there is another
• 12:41important reality in the United
• 12:43States that is certainly not widely
• 12:45advertised or not widely depicted.
• 12:49And this is something that makes
• 12:51us feel really uncomfortable.
• 12:53So this is a prison in the United States.
• 12:57This is an individual with homelessness.
• 13:00In Chicago,
• 13:01I had to do a really,
• 13:04really specific Google search
• 13:06to find these images.
• 13:08This is actually a woman in New
• 13:11Haven struggling with homelessness.
• 13:13And this is actually a picture
• 13:15from my personal archive.
• 13:17We don't see a lot of pictures
• 13:20of Asian Americans struggling,
• 13:22and I think it really further contributes
• 13:25to the invisibility that we have.
• 13:28So this picture is actually of my mom
• 13:31in the hospital with schizophrenia.
• 13:35This is in the New Haven Green.
• 13:38This is in the prison in Kentucky.
• 13:42This is also in the prison in Kentucky,
• 13:47and a statistic is that at any given time,
• 13:52there are many more people with
• 13:55untreated severe psychiatric illnesses
• 13:57living on America's streets than
• 13:59are receiving care in hospitals.
• 14:02And over 1/3 of individuals
• 14:05in prisons and experiencing
• 14:07homelessness have a mental illness.
• 14:10And sometimes we may want
• 14:13to comfort ourselves with,
• 14:15oh at least we're better off than
• 14:18individuals in those other countries.
• 14:20But I want to ask you guys, are we really?
• 14:24Is that the the whole story?
• 14:28So another important reality
• 14:31in low middle income countries.
• 14:35This is a really beautiful picture.
• 14:38It's a power of the community in Nigeria.
• 14:41This one is in Bangladesh again,
• 14:44the power of the community.
• 14:47And this one is my personal favorite.
• 14:49This one is in Laos.
• 14:51Certainly reminds me of how I grew
• 14:54up and the childhood that I had
• 14:58there in Thailand close to Laos.
• 15:00And then I just, I'm such a proud big sister,
• 15:03and this is my little sister.
• 15:05She's so unapologically herself
• 15:07and she I think really has taught
• 15:09me to be more that way and she's
• 15:12my role model in many ways.
• 15:13So this is certainly another
• 15:17reality that's not often depicted
• 15:19in low middle income countries.
• 15:23And then these are some last slides
• 15:26with statistics for all of us.
• 15:28So the global prevalence of mental disorders,
• 15:31this was published by The Who in 2019.
• 15:34So 13% of global population is
• 15:37living with mental disorders.
• 15:39And when we zoom in by economic growth,
• 15:43it's interesting because more than 15%
• 15:48this is the high income country and
• 15:51then a little bit over 10% that's the
• 15:54prevalence in the low income country.
• 15:56So actually, you know high income countries
• 15:59have a higher prevalence in mental
• 16:02disorders than low income countries do.
• 16:05And why might that be and what
• 16:08might explain this difference?
• 16:10Perhaps there's under diagnosis
• 16:13in low low income countries due
• 16:16to less accessible services.
• 16:19And then the WH O's also notes that
• 16:22maybe their demographic factors like
• 16:24low income country tends to have higher
• 16:27population proportion of children under
• 16:29the age of 10 and in that population
• 16:32mental disorders are less common.
• 16:34And then this is something I would
• 16:37like to ask all of us is what about
• 16:40factors in high income countries
• 16:42that could contribute to higher
• 16:44prevalence of mental disorders?
• 16:46Are there factors and if
• 16:48So what are the factors?
• 16:52This is prevalence again,
• 16:54but this time by regions.
• 16:57Notice again in the Americas we have
• 17:00the highest prevalence and then Africa
• 17:04has the lowest prevalence and for some
• 17:08reason this statistic is in the 100
• 17:11page WHO report and not easily found,
• 17:14not found in a Google image search actually.
• 17:18And this is this is also another
• 17:22statistic and reality that that is
• 17:24true that in America we have a higher
• 17:27prevalence whatever the reason may be
• 17:29and in Africa they have the lowest,
• 17:31lowest prevalence of all regions.
• 17:34So I'm asking us have we been
• 17:36telling ourselves the whole story.
• 17:41So I haven't been able to test this yet
• 17:43but some of the hypothesis that I have
• 17:46is that there may be factors in high
• 17:48income countries that contribute to
• 17:50higher prevalence of mental disorders.
• 17:52So things like need and drive for
• 17:54productivity and equating one's
• 17:56value and one's self worth with
• 17:58one's job and productivity.
• 18:00And then the other side to that
• 18:02is with the lower prevalence in
• 18:04Africa and low income countries,
• 18:06is there prevention?
• 18:07I don't believe that there is a cure,
• 18:11but I really do think there is
• 18:15prevention there and prevention
• 18:17to mental disorders makes this,
• 18:19but perhaps it is not yet quantified
• 18:21or perhaps it's not something
• 18:24that's even quantifiable.
• 18:25So maybe that's why it's not so
• 18:28advertised or so acknowledged.
• 18:31And some of these factors that are
• 18:33preventative to mental disorders,
• 18:35maybe community and family,
• 18:37sense of interconnectedness and
• 18:39responsibility to another's wellbeing,
• 18:42sense of belonging,
• 18:44lack of the need for urgency,
• 18:46living more in the moment,
• 18:49and maybe even dealing with
• 18:51life's inconveniences like hand
• 18:53washing your clothes.
• 18:54Like it's actually one of my
• 18:57favorite memories growing up in
• 18:58Thailand was hand washing my clothes.
• 19:00And I think when I tell
• 19:02that story to people here,
• 19:03it it just brings an image
• 19:05of them being like, oh,
• 19:06you must have been poor and struggling.
• 19:08But for me it was actually something
• 19:10like I love doing and it was a
• 19:13responsibility that I felt that
• 19:15I was really proud of because
• 19:16I was helping my household.
• 19:21So this is a quote that I heard a long time
• 19:24ago that still stays with me to today.
• 19:26Make what is important measurable and
• 19:29not what is measurable, important.
• 19:33And some last food for thought going back
• 19:36to these pictures of the statistics is,
• 19:38you know, I discussed with you guys
• 19:40about the potential harm that's done
• 19:42when we're only focusing on the
• 19:44bad in low middle income countries.
• 19:46So potential harm like further
• 19:49oppression and further devaluation.
• 19:51But with us having mainly these pictures,
• 19:55is there also harm done to
• 19:58us by thinking this way?
• 20:01And if so, what is the harm?
• 20:03And why might we have depicted mental
• 20:07health as statistics rather than personhood?
• 20:12So also another hypothesis is just that
• 20:15it makes our humanity less acknowledged.
• 20:19Certainly in the US,
• 20:20and it makes our suffering and our
• 20:23clients and our family members
• 20:25and our patients or ourselves.
• 20:27It makes our sufferings less acknowledged.
• 20:30And these statistics may be
• 20:32because they help ease our
• 20:34uncomfortability with human suffering.
• 20:39So our future, you know,
• 20:40if we can conceptualize that there are
• 20:42things in the US that we're good at
• 20:44and there are things in low and middle
• 20:46income countries that they excel at,
• 20:48then we might be able to benefit
• 20:50and really truly learn from one
• 20:52another a bidirectional partnership
• 20:54rooted in mutual respect and value.
• 21:00I know I'm running out of time,
• 21:01but these are some really amazing programs.
• 21:04This one is the friendship bench in
• 21:06Zimbabwe and it's a task sharing approach.
• 21:08Basically, these grandmothers sit in
• 21:10front of a bench right in front of
• 21:12a community Health Center where they
• 21:13can provide mental health services and
• 21:15the grandmothers are trained in basic
• 21:17CBT and anyone in the community can
• 21:20sit on the bench to provide this care.
• 21:23And the numbers are 14% of patients in
• 21:26friendship bench experience symptoms
• 21:28of depression after six months
• 21:29compared to 50% standard of care.
• 21:31And with standard of care means they
• 21:33went into the community Health Center
• 21:36themselves and either had medication or
• 21:39treatment by a trained psychologist or both.
• 21:42So 12% with anxiety compared to 48% in
• 21:46standard of care and 2% with suicidal
• 21:48thoughts compared to 12% in standard of care.
• 21:51So what is going on that these
• 21:54grandmothers are doing such an amazing
• 21:57job and perhaps even more improvement
• 22:00than community health infrastructure?
• 22:02And the other interesting thing is
• 22:05that they actually did this study with
• 22:09grandfathers sitting on the bench and
• 22:11the numbers were not as good when the
• 22:15grandfathers were sitting on the bench.
• 22:17So something about grandmothers
• 22:19and community this one is a dream
• 22:22of world Jamaica.
• 22:23They went to the school,
• 22:24did a multimodal therapy intervention,
• 22:28training both teachers and children,
• 22:31and actually the primary school they
• 22:33piloted out went from being the worst
• 22:35to being one of the best programs,
• 22:37the best schools in the country.
• 22:39Then this is the last statistics,
• 22:42mental health research.
• 22:44The majority of our funding goes into
• 22:47basic research at theology and underpinning,
• 22:50and only 7% goes into prevention.
• 22:54So why might be that we want to invest
• 22:56so much of it into basic research?
• 23:02So a brief overview of our
• 23:06global mental health program.
• 23:07We have two arms, the Resident Distinction
• 23:09Pathway and the Seminar Series.
• 23:11With our seminar series,
• 23:13I think we've been extremely successful.
• 23:15They've been zoom and hybrid.
• 23:17We've been trying to really emphasize
• 23:19community health leaders from their home
• 23:22country rather than the traditional
• 23:23model of someone in the US going abroad.
• 23:25So we had, you know, doctors,
• 23:27Banda from the friendship bench along
• 23:31with many other wonderful speakers.
• 23:33We also had cosponsored the Muslim
• 23:36Mental Health Conference in 2022.
• 23:37That was also very successful
• 23:39as well and highly educational.
• 23:41Our inaugural resident distinction
• 23:43pathway has four residents in it,
• 23:46Yvonne, Paul, myself and Enoch.
• 23:49And then this year of course is our
• 23:52three residents that we presenting
• 23:54today and this is our leadership
• 23:55team for the last three years.
• 23:57I just want to say they've been amazing
• 23:59and wonderful and such a pleasure to work
• 24:02with and I'm so grateful for the experience.
• 24:05And our acknowledgement,
• 24:06of course is to our former faculty leaders,
• 24:10resident leaders,
• 24:11school of public health leaders
• 24:13and community volunteers.
• 24:14We certainly could not have done any of this
• 24:16without you guys and growing the program,
• 24:19you know,
• 24:19since Doctor Robot started in 2008.
• 24:22So without further ado,
• 24:24I will stop my share and hand it over to Max.
• 24:31Thank you so much, Sonia.
• 24:33Just going to pull up my slides quickly.
• 24:44So really honored to to speak with all
• 24:47of you today and follows the incredible
• 24:50work that Sonya and and others have done
• 24:54at Yale and and to build presence of of
• 24:56gold mental health here which we think
• 24:58of the definition of global health.
• 25:00It probably extends to essentially every
• 25:03activity that that our department does.
• 25:06But I'm going to offer just a flavor
• 25:09of some things that I've been working,
• 25:12working on, thinking about and we were
• 25:14asked to give just a little bit of history
• 25:16into what brought us into this field,
• 25:18how we kind of came to identify with
• 25:20with with global health and my story.
• 25:24I would I would take back to when I was
• 25:2718 and I actually had decided not to
• 25:30go straight to college and to pursue
• 25:32a career as a professional athletes.
• 25:34But I was, I was also in a jazz band
• 25:36in that that Jasmine we were on tour
• 25:39in South Africa and it was actually
• 25:41at this particular place which is
• 25:43a casino called Sun City.
• 25:45And we've been mostly improvising with
• 25:48local groups and Township schools etcetera.
• 25:52And despite language barriers you
• 25:55know jazz music offers a chance for
• 25:58your human connection that that can
• 26:01kind of transcend a you know many
• 26:03many other types of social barriers.
• 26:06And so kind of recognizing that all
• 26:08at once you know the just incredible
• 26:10similarities that we share while these
• 26:13just unbelievable economic and health
• 26:15inequalities that that related on top.
• 26:18So it was actually right here at
• 26:20this casino that the just.
• 26:22The overwhelming level of inequality
• 26:26in health and economic outcomes
• 26:29really struck me.
• 26:30And I decided to,
• 26:32on that day become a doctor and if I could.
• 26:35And so it kind of ended up shifting
• 26:37my career towards medicine and ended
• 26:38up pursuing a PhD in economics to
• 26:40try to understand inequality better.
• 26:45So I I ended up spending a
• 26:48couple of years living in Malawi,
• 26:49spent my my summers working with partners
• 26:52in Health and which is a group like
• 26:55Doctors at Borders in in Haiti and Rwanda.
• 26:58I work for the president of the
• 27:00World Bank for a couple years and
• 27:02like I said it kind of develops
• 27:06expertise in history of science,
• 27:08medicine and and economics.
• 27:10Doing a piece in Economics at Harvard.
• 27:15Currently I serve on 2 faculties
• 27:18at Harvard in a parttime role,
• 27:20one at the Department of Global
• 27:21Health and Social Medicine,
• 27:22the other in Department Economics.
• 27:24I had the privilege of writing a
• 27:27textbook when I was just out of college
• 27:30with Paul Farmer who's passed away.
• 27:31Jim Kim who is the former president
• 27:33of the World Bank and Arthur Kleinman
• 27:35who's a well known psychiatrist
• 27:38trying to kind of reintroduce the
• 27:41field along several the the the
• 27:43lines of post colonial thinking
• 27:45that Sonia mentioned and that's you
• 27:48know continue to be a either number
• 27:51one or two most used textbook in
• 27:54in the field of global health.
• 27:56I also teach a lecture course between
• 27:59100 and 200 students on the economics
• 28:01of development and global health,
• 28:02kind of taking a deep historical
• 28:04look at why we have the types
• 28:06of inequalities that we have.
• 28:07And also as as Sonia mentioned
• 28:09that the levels of happiness,
• 28:11the types of,
• 28:12you know,
• 28:13social outcomes,
• 28:14I think economists expected haven't really
• 28:17kept pace with with with economic models.
• 28:21I mentioned all this is by way of saying
• 28:23that I I come as well from a kind of
• 28:25general global health orientation.
• 28:26And I I think it's more and more
• 28:29true that the types of problems
• 28:30and questions that we ask in
• 28:32global mental health are really
• 28:34the questions of global health and
• 28:36and global policy in the future.
• 28:38We just unfortunately lost Paul Farmer,
• 28:41who is the chair of the Department
• 28:43Health and global part of global
• 28:44health and social Medicine,
• 28:45a real pioneer in the field.
• 28:47And there was a kind of long extensive
• 28:51search and real soul search to see
• 28:53kind of who would be the future
• 28:56leader of this department and in a
• 28:58lot of kind of the the top names
• 29:00and global health considered and
• 29:01and the community really landed on
• 29:04a psychiatrist Vikram Patel who has
• 29:06been a real pioneer in in the global
• 29:09mental health space asking you know
• 29:11exactly the type of questions that
• 29:12that Sonia covered in in terms of
• 29:14you know community based supports
• 29:16you know treatment of common mental
• 29:18health disorders and and and how
• 29:19do we really understand you know
• 29:21the the relationships between power
• 29:23equity access and and mental health.
• 29:25And so I I think that you know certainly the,
• 29:28the,
• 29:28the words I get from my my colleagues
• 29:30are that this,
• 29:31this which often considered a small
• 29:33field in psychiatry department is
• 29:35really kind of the future of a lot
• 29:37of these these big questions
• 29:39and and and health and as you'll see
• 29:41hopefully in this brief talk of the economy.
• 29:44So I'll just check briefly about a couple
• 29:47presentations I did at the American
• 29:49Psychiatric Association last year,
• 29:51which are taking on a question that's
• 29:55very well known in macroeconomics
• 29:57called the Eastern paradox.
• 29:59And it's simply the finding that mean
• 30:02country income does not increase as,
• 30:06sorry, mean country wellbeing does not
• 30:08increase as mean country income increases.
• 30:10And that might sound like a simple statement,
• 30:13but it's it's pretty shocking in
• 30:15regards to most macroeconomic models.
• 30:17We assume that increasing income
• 30:19should make people feel better,
• 30:21should pay people better off
• 30:22on a country level.
• 30:23We do see that income
• 30:25correlates with wellbeing,
• 30:26but unfortunately we see that as
• 30:28countries grow they tend to not,
• 30:30you know, be on average better off.
• 30:32And so this has been implications for
• 30:34global health, for mental health.
• 30:35It's often pointed this is maybe one of the
• 30:38the key questions environmental economics,
• 30:40because we are essentially
• 30:42destroying the environment as an
• 30:44externality of economic growth,
• 30:45but that growth is not
• 30:48really producing well-being.
• 30:49It leaves a lot of questions in tow.
• 30:52It's related to a similar puzzle
• 30:54on the attack that I'm gonna take
• 30:57which is economists that have gone
• 30:59in search for explanations for the
• 31:01modern opioid epidemic and increase
• 31:03in all cause mortality have really
• 31:04landed back in the mule.
• 31:06Durkheim's theory of anime essentially
• 31:09saying there seems to be something
• 31:11that goes wrong when when society
• 31:14has some type of fracture to its
• 31:16core notions of identity.
• 31:18And this is seen not just in the
• 31:20prevalence of particular disorder,
• 31:21but several things happening
• 31:22at the same time.
• 31:24Whether that's deaths of despair,
• 31:26this, you know, alcohol, liver disease,
• 31:28suicide overdose, death,
• 31:29but also changes in political psychology,
• 31:31increases in authoritarianism,
• 31:32which is what the Frankfort
• 31:34school was very focused on,
• 31:35was not Sierra.
• 31:36But essentially the hypothesis is that this
• 31:38has been seeing you in the Weimar Republic.
• 31:40This Soviet Russian's been seen in the
• 31:43United States for the past two decades.
• 31:45So my approach to this puzzle,
• 31:48Eastern paradox,
• 31:49is to say potentially this is
• 31:51what's called a Simpsons paradox.
• 31:54You know as well,
• 31:55correlation doesn't equal causation,
• 31:56and in fact,
• 31:57sometimes you can have a trend that's
• 32:00the average of two opposing trends.
• 32:02So perhaps in fact,
• 32:03income increasing security does
• 32:05lead to a better wellbeing.
• 32:07But there's something that's
• 32:08been happening at the same time,
• 32:09along with economic change on
• 32:11the past 300 years.
• 32:12It's making
• 32:16wellbeing and mental health worse.
• 32:18So establishing causation on a
• 32:19question like this is challenging.
• 32:21We certainly can't run an RCT on, you know,
• 32:24these are the change in the last 300 years.
• 32:26So instead what we do in economics
• 32:28typically look for natural experiments.
• 32:30And so the framework for these should be,
• 32:34you know, very natural.
• 32:35Just as in a treatment assignment,
• 32:37say like a variable D,
• 32:39which could be your your
• 32:42ketamine to an outcome,
• 32:43say depression, right.
• 32:44Z would be your random assignment
• 32:46of you know patients to to ketamine
• 32:48and the the keys are you know
• 32:51Z is as if randomly assigned.
• 32:53Z has a sizable effect on the
• 32:55distribution of medication and
• 32:56there's an exclusion restriction,
• 32:58which is random assignments only affecting
• 33:01the outcome of interest through your
• 33:06predictor variable thing.
• 33:07So that's the same framework that it
• 33:10that's used for natural experiments.
• 33:12In this case, we're going to use,
• 33:15you know, geoclimactic instability
• 33:17as an instrument for tradition
• 33:20over the past 2000 years.
• 33:23So this came from a now very
• 33:25influential article Giuliano and None.
• 33:26This was also presented at 2023
• 33:29American Economic Association plenary
• 33:32session which is essentially seen as
• 33:34the biggest lecture in our field both
• 33:36presenting a model of of mismatch
• 33:38really one of the first evolutionary
• 33:39models to take off in the field as
• 33:42well as the result that exposure to
• 33:46historical geoclimactic instability
• 33:49predicts society level tradition.
• 33:53And the the essentially link
• 33:56there is that where there's been
• 33:59more climactic instability,
• 34:02groups will go in search of new
• 34:04explanations for what's happening
• 34:06and essentially lose are more likely
• 34:07to to lose such of their tradition.
• 34:09And we see that in in the
• 34:10results of of Giuliano and None.
• 34:12And so these are 50 year increments
• 34:15just on the the variance of of six
• 34:18different geoclimactic measures.
• 34:20Here's essentially a distribution
• 34:21of that predictor variable.
• 34:23And so essentially the hypothesis is
• 34:25that that these 50 year increments of
• 34:27variance in Geo collecting stability
• 34:29are only influencing our outcomes of
• 34:31interest through this loss of tradition.
• 34:33And so I'm curious if this is affecting
• 34:35essentially mental health outcomes and
• 34:37my initial results I won't kind of bore
• 34:40you with the data matching process.
• 34:42But essentially in brief overview what
• 34:44happens is we have the ethnographic
• 34:46Atlas from Murdoch where we can
• 34:49characterize the location and and
• 34:51several features of of ancestral groups.
• 34:53We can then match them linguistically
• 34:57to essentially give a waiting score
• 35:00to to any variable of interest in
• 35:04in modern geographic populations.
• 35:05So I'll just start with my my Table 2,
• 35:08which is the,
• 35:09the essentially reduced form of
• 35:11the sorry the the ordinary least
• 35:13squares just as you say,
• 35:15we do see the tradition has a has an
• 35:19impact on suicide rates and when we
• 35:22instrument for that in table one by
• 35:25asking it does geoclimactic instability
• 35:28in fact predict global suicide rates today,
• 35:31we do see a very positive
• 35:33and significant effect.
• 35:35So the essentially the the,
• 35:38the mechanism here,
• 35:39the hypothesis again is that
• 35:41geoclimactic instability is leading
• 35:43to a loss of tradition and then
• 35:47that's increasing suicide rates at
• 35:49a country level around the globe.
• 35:52So this would be kind of one
• 35:54example of the type of,
• 35:55you know,
• 35:55historical evidence or you know plausibly
• 35:57causal evidence that we could bring to
• 35:59bear with that kind of common set of
• 36:02covariates included for
• 36:04various robustness checks.
• 36:07And that's kind of adjunct to this
• 36:09is what this is actually saying
• 36:10is that the loss of tradition in,
• 36:12you know, the several 1000 years
• 36:15from zero 80 to 1900 is is you know,
• 36:19predicts modern variations in the
• 36:22suicide rate across countries.
• 36:24I also look at other notions
• 36:26of cultural persistence on.
• 36:27This comes from another famous paper
• 36:30in economics literature essentially
• 36:32showing that historical plow use
• 36:35predicts modern gender norms.
• 36:37So I instrument Using historical
• 36:40plow use for gender norms to find
• 36:43that depressive disorders for both
• 36:45males and females are higher in
• 36:48countries that have historically,
• 36:50you know,
• 36:51had more on equal gender norms through
• 36:53this different mode of production.
• 36:55All these findings suggest that
• 36:57there's kind of deep transmission
• 37:01from these core cultural notions
• 37:05of power and order and identity
• 37:09to modern mental health outcomes.
• 37:11And you know potentially if we
• 37:13think that the loss of some of these
• 37:16identities is is meaningful for for
• 37:18wellbeing and mental health outcomes
• 37:21that this can begin to give us some
• 37:23purchase on why it is that as income
• 37:26increases these other changes in
• 37:28society in particular the labor
• 37:30market sending people you know very
• 37:33far from their close contacts and you
• 37:36know other types of cultural changes
• 37:38have been disruptive in a way that's
• 37:40counteracted some of the gains materially.
• 37:44Just my final piece is almost
• 37:46a plea I'd say you know their
• 37:49clinical mental health and then the
• 37:51institutions very influenced by
• 37:52economists are are are quite different.
• 37:55There are is a vascerative discussion
• 37:57some which I was privileged to
• 38:01observe it at the the World Bank
• 38:02that I think have a very big impact
• 38:04on on essentially the the future
• 38:06trajectory of of global mental health.
• 38:08And this used to be an argument for
• 38:11kind of my career and now it's almost
• 38:13a plea which is to say I'm as far as
• 38:15I understand the only person is there
• 38:1810 MDP issues in economics and the
• 38:19seven have done residency so far of all done.
• 38:21I am so there there,
• 38:23there are really very few people
• 38:24that are in the space of translating
• 38:26between these these two spheres.
• 38:28So I would,
• 38:29you know,
• 38:29welcome you know anyone's input
• 38:31thoughts as I do this.
• 38:33I'm currently teaching a seminar
• 38:34on the economics of mental health
• 38:36at Harvard on this this fall,
• 38:39which was apparently the most subscribed to.
• 38:42And if anything,
• 38:43I feel like there there's just so many
• 38:46connections here to make some really
• 38:48important ideas between economic change,
• 38:50mental health and homelessness
• 38:51that I would really appreciate any
• 38:54and all thoughts that folks have.
• 38:56But thank you so much for the
• 38:58time and really appreciate just
• 39:00the incredible community here.
• 39:05I'll pass off to Jay.
• 39:08Hi,
• 39:14everybody. Can you see my slides now? Just
• 39:19need to put it into the slide
• 39:22show mode. Okay. Sounds good.
• 39:26Perfect. Perfect. All
• 39:28right, awesome. So my name is Jay.
• 39:31I'm a 30 year resident with Marcos and Matt,
• 39:34and today I'm going to be talking about
• 39:37mental stigma and Uganda and the work that
• 39:39we've been doing there for almost a decade.
• 39:43So this is a map of the world and
• 39:45these are the places that I've lived.
• 39:47So I was born in South Korea.
• 39:49I lived there until I was 9.
• 39:51My father passed away when I was 5,
• 39:53and then my mom married an American
• 39:55soldier and he ended up coming to
• 39:57America and being a part of a military
• 39:59family in the USI moved around a lot,
• 40:02meaning the Deep South,
• 40:03where I was the only Asian person
• 40:06in the vast majority of places.
• 40:09And you know, this needs me.
• 40:12Like a bit of loss of community
• 40:15and there was some kind of pretty
• 40:18explicit other racism that happens
• 40:21and that happens deeps out.
• 40:24So it made me feel not very American.
• 40:27And when I go back to Korea,
• 40:28it also make me not feel Korean because,
• 40:31you know, now I'm like an American kid
• 40:33but like trying to go back to Korea.
• 40:35And you know, so.
• 40:36So I kind of felt at a loss of community.
• 40:38And, you know, I felt like I I quite
• 40:40know where I belong in the world.
• 40:42And I felt kind of lost,
• 40:44frankly, after high school.
• 40:46So I took,
• 40:48but I worked some jobs in high school
• 40:51and then I used that money to go
• 40:53live in Ghana and go live in China.
• 40:55And the idea is that, you know,
• 40:57I'm trying to broaden my horizons.
• 40:59I'm trying to learn more about the
• 41:01world and try to find my place or try
• 41:03to makes sense of to try to make sense
• 41:06of the world that makes sense and
• 41:08throughout this experience really need
• 41:11me question a definition of community.
• 41:14So what do you mean when you
• 41:16say my community?
• 41:16Does that mean that we value our
• 41:19community to be more to be more
• 41:22valuable than outside of our community?
• 41:24How do we even define community
• 41:26and the relationships that I mean,
• 41:29you know,
• 41:30in Ghana and the warmth of community,
• 41:32you know,
• 41:33that really welcomes me And like a lot
• 41:35of places that travels to meet me,
• 41:38meet me made me embrace the
• 41:42idea that community is global.
• 41:44You know, community is humanity.
• 41:46And you know,
• 41:47I care about people regardless
• 41:48of like where they're from.
• 41:49You know, like my mission is to care
• 41:52for people and that's my community.
• 41:54So with this mindset, you know,
• 41:56I started college and I've always
• 41:58been pretty curious about the world.
• 42:00So I look for opportunities to be
• 42:02involved in global development.
• 42:05So in 2015,
• 42:06I first went to Uganda for like the
• 42:09journalism project as well as some
• 42:12mentored the research project as well.
• 42:14And during that summer I
• 42:18made like really close,
• 42:19you know,
• 42:20friendships with people like
• 42:21around my age or Uganda and that,
• 42:23you know, I still like very close friends
• 42:26to friends with to the to this day.
• 42:28And this made me keep coming back.
• 42:30So the relationships and gone to the adult
• 42:32kept making me come back And you know,
• 42:34as I've been able to you know,
• 42:36see these guys, you know,
• 42:37like have have kids, you know both families
• 42:39and you know for the past decade or so.
• 42:42And, you know, they've gotten to
• 42:43meet my fiance and my parents.
• 42:45So it's, you know, the sense of community
• 42:48in Uganda kept kept me coming back.
• 42:50So you can see some pictures here.
• 42:53So on the far right is Doctor Weissman,
• 42:55one of my earliest mentors.
• 42:58He's a professor at Monterrey
• 43:00University in Carlin Institute.
• 43:01You know,
• 43:02he's been like a really great mentor to me.
• 43:05And in the middle picture,
• 43:06you see my friends Peter and Kazungu,
• 43:08you know, we both each other and about
• 43:11our families and you know, we just,
• 43:13you know, have like a very close
• 43:15kind of connection with each other.
• 43:17So these relationships that make me
• 43:18wanting to come back to Uganda and do more,
• 43:20do more there.
• 43:23So in about 5 years ago,
• 43:27you know,
• 43:27I had an opportunity to,
• 43:29I got some funding to start an organization
• 43:31by helping power through health.
• 43:33So it's a final C3 organization
• 43:36that's based in the US and Uganda.
• 43:37So there's the ETH Uganda also.
• 43:40And so you know,
• 43:41I asked some of my colleagues in Uganda
• 43:43if they're interested in doing this and
• 43:45they enthusiastically have jumped on board.
• 43:47So we've been operating since
• 43:50we're all over five years now,
• 43:53not over 99 like 99% of the money that
• 43:56we raised goes straight to Uganda
• 43:59to pay staff to provide healthcare.
• 44:01So we're very proud of this progress so far.
• 44:03It's grown every year since since started
• 44:07and one of the main focuses that,
• 44:10you know I've been working on in
• 44:11the context of this organization
• 44:13is reducing mental illness stigma
• 44:15and providing mental healthcare and
• 44:16and studying in a way that that
• 44:18makes sense in Uganda.
• 44:21So a little bit of context of where we work.
• 44:25So it's one of the most impoverished
• 44:27rural regions of Uganda.
• 44:29So there's just as in America,
• 44:30there's a lot of intraregional
• 44:32variety or diversity in terms
• 44:34of ECONSOCI economic status.
• 44:36You can take them.
• 44:37This happens to be like one of the most,
• 44:40one of the worst outcomes region and
• 44:42healthcare in terms of our infrastructure.
• 44:45So 414,600 people with one tax in position.
• 44:49I think this is going to change soon,
• 44:51but that's where it was when
• 44:53we started working.
• 44:55The majority of the population
• 44:57of subsistence farmers,
• 44:5945% illiteracy rate and there is no
• 45:03previous mental healthcare available.
• 45:04So you know people would see your
• 45:06schizophrenia or the manic and they
• 45:09didn't likely have somewhere to go.
• 45:11You know that there are some community
• 45:14structures but no medications and also
• 45:17no paid rates or for the electricity either.
• 45:21So what do you do?
• 45:22We generally do,
• 45:23we do three things with healthcare,
• 45:25education and research.
• 45:26So we provide essential healthcare
• 45:28services to the most vulnerable
• 45:31populations through Antunde health centers.
• 45:33We provide, we give healthcare to
• 45:35approximately over 10,000 people a
• 45:37year and that's including primary care,
• 45:39maternal care, mental healthcare
• 45:42innovations we can check up and urgent
• 45:46visits and we also are the mental
• 45:48healthcare providers for this district.
• 45:50So we work with the DHO District
• 45:52Health officer and the district
• 45:54leadership to to provide mental
• 45:56health care about the district,
• 45:58mainly severe mental illnesses,
• 46:00you know with medications so far.
• 46:04And another large part of
• 46:05what we do is education.
• 46:07So you know we have a fellowship.
• 46:09We have a summer fellowship called
• 46:11Global Health Experiential Fellowship
• 46:13that's open to both Ugandan and American.
• 46:15So it's a five to six week
• 46:18experience where you know people
• 46:20were students pre doctoral students
• 46:22including medical students,
• 46:23masters students and undergrads from
• 46:25both Uganda and America can work
• 46:28together and an intercultural team to
• 46:30work on a project in global medical health.
• 46:33So the American students pay a
• 46:35tuition and this helps you know fund
• 46:36it and you know it also helps fund
• 46:38you know like a lot of our research
• 46:40and a lot of our healthcare also and
• 46:42Ugandan students are 10 for free
• 46:45to the summer. We hosted 2 sessions
• 46:47of 29 three doctoral students each
• 46:49that are about 58 and total And
• 46:52we also have a university chapter
• 46:54system where you know where you
• 46:57know American students can engage in
• 46:59learning about global mental health.
• 47:00We have speakers from Uganda and from
• 47:03other global health experts and also in
• 47:06helps us fund for this and for research.
• 47:09You know we I've been focusing on
• 47:122 main areas of research here.
• 47:15One is reducing mental illness stigma
• 47:16and the other one's working with
• 47:19existing community structures to
• 47:20deliver effective mental healthcare.
• 47:22So mental health stigma is very you know,
• 47:25multilayered, you know,
• 47:27offers the structural level,
• 47:29you know, could explain that,
• 47:30you know,
• 47:31like partially explained that less
• 47:33than 1% of Ugandan's Ugandan healthcare
• 47:36expenditure goes towards healthcare
• 47:38or goes towards mental healthcare.
• 47:42And you know it results in lowers
• 47:44treatment seeking behaviors for people also.
• 47:47So it seemed like a pretty fundamental
• 47:49problem to you know,
• 47:51try to try to address right there
• 47:54to improve mental healthcare.
• 47:56So I'm going to be talking about
• 47:58an example project that we've done
• 47:59in the past just just briefly.
• 48:03So we attempted a pilot community to
• 48:06add mental illness E stigma station,
• 48:08the other intervention in the role
• 48:10of Uganda and this is inspired
• 48:13by HIV AIDS interventions.
• 48:15And you know I I see a lot of parallels
• 48:17between HIV AIDS and senior chronic
• 48:18mental illness and that both are very
• 48:21stigmatized and that they're both chronic.
• 48:22So I saw a lot of parallels and you know,
• 48:25we we came up with this project where
• 48:28we are using like a lot of lessons
• 48:31learned from HIV AIDS epidemic or
• 48:32addressing HIV AIDS to mental health.
• 48:35So the steps that we took was we
• 48:37did 4 focus groups to examine the
• 48:39current beliefs and attitudes for
• 48:41severe mental illness.
• 48:43And then we utilize those findings
• 48:45to provide guidelines for community
• 48:47members to participate in a
• 48:50competition for the other skill.
• 48:53So we have about four teams compete
• 48:56to we have four teams compete to
• 48:58see who has the best play and he
• 49:00knows and and the voters were you
• 49:02know people in the community who
• 49:03they thought was what was like the
• 49:05best way but they had a criteria
• 49:07that they had to meet basically that
• 49:09mental illness can be treatable.
• 49:11That people with mental illness should
• 49:13be treated with respect and that
• 49:15that they should be treated nicely.
• 49:17And so we had like a winner and and
• 49:19then we evaluated the effectiveness
• 49:21of intervention by serving people
• 49:23before they watched intervention
• 49:24and after they watched intervention
• 49:26with one week apart between watching
• 49:29the intervention and asking them,
• 49:32you know, asking about the results.
• 49:37So this is a flow chart.
• 49:38101 participants were initially
• 49:41administered initial questionnaire.
• 49:426 weeks later 77 of 101 attended
• 49:45the other intervention.
• 49:46One week later,
• 49:4757 of the 77 were administered
• 49:49questionnaire to value short term
• 49:50effects and one year later 46
• 49:52of the 57 were administered questionnaire
• 49:54to value long term effects.
• 49:56So you can see the results and you
• 49:58know as you can see it's very,
• 50:00very physically significant and you
• 50:02know large effect size for both
• 50:05broad and personal acceptance scale.
• 50:07So broad acceptance scale is roughly
• 50:10structural stigma and personal acceptance
• 50:12scale is roughly interpersonal
• 50:14stigma and these are some projects
• 50:16that we are working on right now.
• 50:19So data collection is fully
• 50:21complete for these.
• 50:22So most of this happened during the summer.
• 50:26So thank you Dr.
• 50:28Orba and in the department for
• 50:31generous funding and time to
• 50:33you know help work on this.
• 50:35We conduct so we conducted cluster
• 50:37randomized control trial on
• 50:38the effectiveness of the radio,
• 50:40the other program to be stigmatized
• 50:42mental illness.
• 50:43So we converted the other program
• 50:45into radio show into audio show and
• 50:48then we showed it to people and yeah,
• 50:50that's quite before and after and
• 50:52the control group that that have
• 50:55an audio intervention that's not
• 50:56related to mental illness.
• 50:57And then we also examine stigma for
• 50:59suicide defense survivors in the
• 51:01community through mixed methods.
• 51:02We surveyed with survivors,
• 51:04family members,
• 51:05healthcare workers and community
• 51:06health workers.
• 51:07So we're excited for data there
• 51:09also evaluated the different levels
• 51:13of stigma that people might have
• 51:14towards different mental health
• 51:16conditions and whether the gender
• 51:17of the person with mental illness
• 51:20affects affects the level of stigma
• 51:23expressed or is that person And
• 51:26so those are some of the projects
• 51:28that might have worked on and for
• 51:30community structures you know it's
• 51:32important to work with existing
• 51:34structures that are in place other
• 51:36people use that people trust and
• 51:38that that you know have been around
• 51:40for such a long time.
• 51:41So,
• 51:42so we we've done two projects
• 51:45regarding that regarding that in that
• 51:47just and one is like pathways here.
• 51:49So what do people do like if they
• 51:51have a city or mental illness
• 51:53like whether to people that they
• 51:54go seek and why do we seek those
• 51:56people and like what happens
• 51:57after they go seek those people.
• 51:58So another mixed method study
• 52:00and another study evaluating the
• 52:02feasibility of collaborations among
• 52:03individuals in the back case of
• 52:05care includes traditional healers,
• 52:07religious leaders,
• 52:08biomedical providers who need health workers,
• 52:10local leaders.
• 52:11So you know seeing if this is you
• 52:14know what people think about the
• 52:15other party to see like what types of
• 52:18collaboration are happening already
• 52:19and to see what types that they think
• 52:21would be helpful in the future perhaps.
• 52:27So in terms of like future career goals,
• 52:30in terms of like where I hope to
• 52:32take my career and I want to continue
• 52:34addressing the health needs of the local
• 52:36community in Uganda collaboratively
• 52:38with the team there and like the
• 52:41local community leaders and and so on.
• 52:43And I would also,
• 52:44you know and we recently started a
• 52:46scholarship program for our team in
• 52:48Uganda to go on to get their masters.
• 52:50So the organization provides
• 52:52a tuition for their masters.
• 52:55So to build capacity build and
• 52:57to and to develop help develop
• 53:00leaders locally in Ubanka.
• 53:02I'm applying for a K23 October of next year.
• 53:05So my teacher by 4 year through the
• 53:08Center for Global Mental Health
• 53:09Research And you know so with the
• 53:12goal of eventually developing an
• 53:14independent physician scientists career
• 53:15in addressing global mental health needs.
• 53:21So here are my acknowledgements.
• 53:24So you know first the entire empower
• 53:27to help team who you know who you know
• 53:29we've been working on this project
• 53:31together for you know like almost
• 53:33for five years in the organization
• 53:35but like a lot a lot of them working
• 53:37on different projects and you've
• 53:38end up almost affecting the end of
• 53:41community health workers were you
• 53:42know very instrumental in gaining the
• 53:44trust of the community and also also
• 53:46showing the you know also teaching
• 53:48us you know what's being done and
• 53:50what they think would be helpful.
• 53:52And doctor Weissman my career.
• 53:54Ibrahims my long time colleague
• 53:58a long time partner in Uganda he was
• 54:00the executive director of ETH Uganda as
• 54:02executive director of ETH and now he's
• 54:05getting a PhD at the University of firm
• 54:07Bob Rosenak Bob Orba Alex Sign Donaldson.
• 54:11So I really appreciate and you know I
• 54:15have like so many people to thank for
• 54:17this work and it can't cover everything,
• 54:19but but I really appreciate
• 54:23all their help and thank you,
• 54:25thank you all for your time.
• 54:45I will our last piece of
• 54:49the today's presentation,
• 54:56so happy to be with you guys here
• 54:59today and discuss this project.
• 55:01I will try to be brief and leave some
• 55:04time for questions for all of us.
• 55:06Hopefully at the end
• 55:08today for my presentation,
• 55:10we'll be talking about a project that
• 55:12I completed with a community in Arizona
• 55:15known as the New Possible Reservation,
• 55:17affectionately referred to by me
• 55:19as a country within a country.
• 55:21The reason being for that
• 55:23just fun little factoid.
• 55:24For those of you who don't know,
• 55:26Native American tribes in the
• 55:29United States are in this kind of
• 55:31on a political space where they
• 55:33are viewed by the United States
• 55:35as distinct sovereign entities
• 55:36in the United States negotiates
• 55:38with them as foreign entities.
• 55:41So the the group that I worked with
• 55:43is known as the Fosquiaqui Tribe.
• 55:44There,
• 55:45indigenous peoples in southern Arizona,
• 55:49but also have members on the
• 55:50Mexican side of the border,
• 55:52and that's primarily where most of
• 55:54the tribe membership is busted.
• 55:56Along the eight villages in one
• 55:58of the historical homelands there,
• 56:00There's roughly 10,000 members
• 56:02in the United States,
• 56:035000 of which are located on the
• 56:05Bosqueyaki Reservation just out of Tucson,
• 56:07AZ.
• 56:08It's roughly half hour away
• 56:10from the US Mexico border,
• 56:12but there are other communities
• 56:14in the southern Arizona region.
• 56:16So in the Tucson metro area as
• 56:18well as in the Phoenix metro area,
• 56:20there's a number of smaller Yaki
• 56:23communities where over hundreds of
• 56:25years groups have kind of migrated
• 56:27towards for jobs and maintained
• 56:30a significant cultural presence.
• 56:33So my motivation for collaborating
• 56:35with this group is this is my group,
• 56:37I was born and raised on the
• 56:39Foski Yaki reservation.
• 56:40I still have majority of my family there.
• 56:44All my friends who I grew up with this
• 56:46woman down here in the lower left hand.
• 56:48Here's my grandmother that's a
• 56:50woman who raised me very prominent
• 56:52figure in the community still
• 56:53and actually part of the first
• 56:55tribal council way back when
• 56:58friends and things that go back
• 57:00regularly and see but I've I've
• 57:02also maintained a a really close
• 57:05working relationship with the
• 57:06tribe for a number of years now.
• 57:08So one of the first projects that we
• 57:13were initially working on together
• 57:16was community health assessments.
• 57:18So this was something that we
• 57:22started in 2014 to achieve a national
• 57:25public public accreditation.
• 57:27But one of the areas that was always
• 57:29frustrating was we could never really
• 57:31gather good mental health data.
• 57:33And we weren't really sure why
• 57:35because we captured a lot of data for
• 57:37essentially every other facet of health.
• 57:39But you know kind of to to Max
• 57:42point about his discussion on on
• 57:44these like deaths of despair.
• 57:46Myself and other health oriented
• 57:48people in the community were always
• 57:50very suspicious that there was a high
• 57:53rate of mental illness that was just
• 57:55essentially not being captured or
• 57:57not being treated in the community
• 57:59because of the types of that causes of
• 58:00death and things that we were seeing.
• 58:02So like you know liver cirrhosis
• 58:04cracking the you know top one of the
• 58:07causes of death for the community.
• 58:09Obviously that will suggest substance
• 58:11abuse being significant.
• 58:13You know,
• 58:15component things like assault
• 58:17from firearm is like a surrogate
• 58:18for trauma within the community.
• 58:20But the the frustrating piece of it,
• 58:22even you know,
• 58:23to add another layer was when we asked
• 58:25the community about their thoughts
• 58:27on mental health and substance abuse.
• 58:29For the most part,
• 58:31everyone kind of gave the same feedback.
• 58:33They were very much, you know,
• 58:35of the belief that mental health
• 58:38and things like depression,
• 58:40anxiety, even,
• 58:40you know some people throwing out terms
• 58:43like generational trauma are are big deals.
• 58:45But nobody talks about the community
• 58:47and prior surveys even had mentioned,
• 58:50you know,
• 58:51we really think alcohol and drug
• 58:53use are big health problems.
• 58:54And and they rank them #2 and
• 58:56#3 for physical health problems,
• 58:58rank substance abuse,
• 58:59the number one community problem.
• 59:02But overwhelmingly a lot of people
• 59:03were saying, you know,
• 59:05it doesn't feel like we can talk
• 59:07about this or just feels too taboo.
• 59:09It doesn't feel like a health problem.
• 59:11So a lot of stigma regarding mental health.
• 59:13And you know,
• 59:14overwhelmingly people saying that
• 59:16the needs from a mental health and
• 59:18substance abuse standpoint aren't being met.
• 59:20So with that as the premise,
• 59:23one of the projects that I completed
• 59:25over the last year with with the
• 59:27tribe was essentially looking at
• 59:29how do we gather more quantitative
• 59:32data on conditions in the community.
• 59:35So, you know, looking at just general things,
• 59:36but also wanting to look at who's
• 59:38using mental health services and and
• 59:40looking at does it make a difference
• 59:42for people from the tribe who
• 59:44live on the reservation community
• 59:45versus those who live outside of
• 59:48the reservation community.
• 59:50The other thing we looked at,
• 59:51and this was with big help from the
• 59:54health IT department within the tribe,
• 59:57through our electronic health data,
• 59:59we were able to see that we
• 01:00:02essentially were under diagnosing
• 01:00:03or just not diagnosing people,
• 01:00:05not seeing people for for mental health
• 01:00:08conditions within the population at
• 01:00:10within our population it was like within
• 01:00:12the single digits that were, you know,
• 01:00:14having these diagnosis come back.
• 01:00:15But nationally,
• 01:00:16just looking at data objectively,
• 01:00:19that doesn't really make sense.
• 01:00:20Native Americans have the highest
• 01:00:22rates of substance disorders
• 01:00:24of any ethnic group in the US,
• 01:00:25highest rates of trauma disorders
• 01:00:27of any ethnic group in the US.
• 01:00:29Also one of the highest rates of
• 01:00:31suicide and completion of any.
• 01:00:32So it's something that we
• 01:00:33obviously want to stay on top of,
• 01:00:35but we're not seeing them,
• 01:00:37we're not seeing them in a number
• 01:00:39of like the alternative health
• 01:00:41options that we have available.
• 01:00:42So why and like what's what's the
• 01:00:44true kind of prevalence or how much
• 01:00:48is this really out in the community,
• 01:00:50the question.
• 01:00:50So what I wanted to just generally
• 01:00:53look at were this positive screening
• 01:00:55rate because it was something that
• 01:00:56seemed like an easy fix to be able to
• 01:00:58implement across our health system.
• 01:01:00Things like screening for depression,
• 01:01:02anxiety, PTSD,
• 01:01:03substance use,
• 01:01:04distorted among the tribal members
• 01:01:06among all the communities,
• 01:01:08not just within the reservation.
• 01:01:10Also wanted to again look at that
• 01:01:12relationship between those who live
• 01:01:14on the reservation and those who
• 01:01:15live outside of the reservation
• 01:01:17as far as you know,
• 01:01:19health utilization and also
• 01:01:20rates of screening.
• 01:01:21The other thing that we wanted to look at,
• 01:01:24and this was in large part at
• 01:01:27the request of the community,
• 01:01:29there's this inventory called
• 01:01:30the Wellness inventory,
• 01:01:31essentially an alternative to an
• 01:01:35alternative type of screening that
• 01:01:38looks more concretely at essentially
• 01:01:40like how people are functioning
• 01:01:42and they wanted me to compare
• 01:01:44that to more validated scales.
• 01:01:46So I went throughout the community.
• 01:01:49We had these QR codes up everywhere.
• 01:01:51We put them in tribal buildings,
• 01:01:52offices at the boys and Girls Club,
• 01:01:54at the middle school,
• 01:01:56at the high school facilities,
• 01:01:58the Wellness Center everywhere.
• 01:02:00I had like people from the
• 01:02:03health department put these in
• 01:02:04like the waiting room lobbies.
• 01:02:05We had our primary care physician kind of
• 01:02:08handing these out everywhere they could.
• 01:02:10And at the end we had just like
• 01:02:12a brief little snippet about the
• 01:02:13behavioral health crisis lines that
• 01:02:15we have in addition to just some
• 01:02:17of the services that we offer and
• 01:02:19kind of how to triage people to
• 01:02:20care if they were looking for it.
• 01:02:24The survey scales were pretty simple
• 01:02:26and I intentionally kind of kept
• 01:02:28them short just because I wanted
• 01:02:30something that can be completed.
• 01:02:32You know in theory while people are
• 01:02:33in the waiting room and just did a pH.
• 01:02:37Q4PC5 for trauma screening,
• 01:02:39audit C for alcohol use,
• 01:02:41DAS 10 for other substance of abuse,
• 01:02:44and then this Wellness inventory
• 01:02:46for the you know purposes of time.
• 01:02:49And also just simply,
• 01:02:51I'll primarily be talking
• 01:02:53about the adult survey results,
• 01:02:55but the youth one had some
• 01:02:58different scales only because
• 01:02:59of the validation reasons for
• 01:03:03the Wellness inventory is the item
• 01:03:07that they wanted me to include
• 01:03:09to kind of compare to like pH,
• 01:03:11Q4 and other screening that are available.
• 01:03:14This one is it's interesting because
• 01:03:16it does address questions a little
• 01:03:19more on like the function of asking
• 01:03:20people like how they're sleeping,
• 01:03:22how they're eating.
• 01:03:23You feel connected to family,
• 01:03:25you enjoy creation or someone who
• 01:03:28laughs regularly, that kind of thing.
• 01:03:30And it scores it in a way that triages
• 01:03:33people to like the more they do those things,
• 01:03:36the higher their score.
• 01:03:37And you know it's supposed to be a
• 01:03:39clinical guide to say this person is fun,
• 01:03:41loving, healthy, balanced.
• 01:03:42We don't need to worry about them
• 01:03:44versus this person needs some
• 01:03:46appointment like today kind of thing.
• 01:03:47But the interesting thing to keep in mind,
• 01:03:51this survey does include a kind of loaded,
• 01:03:54ambiguous question about thoughts of like
• 01:03:58passive death wish versus self harm suicide.
• 01:04:01And I'll explain why I think it's
• 01:04:04a little ambiguous in a second.
• 01:04:06So obviously I'm not going to
• 01:04:07be able to go over everything,
• 01:04:08but just to give you guys a snippet
• 01:04:10of some of the highlights that
• 01:04:11were found in the survey.
• 01:04:12So you know,
• 01:04:13I think a couple of these statistics
• 01:04:16are a little inflated because
• 01:04:18unfortunately with like where
• 01:04:19some of these were located,
• 01:04:21it caters to people who are seeking care.
• 01:04:24But that being said what we found
• 01:04:26was majority of people are not
• 01:04:28reaching out for mental health
• 01:04:29care even less are receiving it.
• 01:04:31So that means some people reach
• 01:04:32out and are just not being seen for
• 01:04:34whatever reason over the past year
• 01:04:38trauma criteria on a exposure.
• 01:04:40So this is the requirement for PTSD
• 01:04:42diagnosis but also like to even
• 01:04:44continue on with the screening.
• 01:04:46You have to have a criteria on a 86%
• 01:04:49of the sample is or was endorsing that
• 01:04:52We we don't know about repeat traumas
• 01:04:54of potential that there's other people
• 01:04:56that had multiple and this is in line
• 01:04:58with what you'll see in literature.
• 01:04:59It's it's a very common kind of thing
• 01:05:02that happens to a lot of people.
• 01:05:03But what's uncommon or what was kind
• 01:05:06of surprising was like the rate at
• 01:05:08people screening positive for PTSD.
• 01:05:10Obviously this doesn't mean that
• 01:05:11all these people will have it,
• 01:05:12but it's still interesting that close
• 01:05:14to half of the sample population was
• 01:05:18essentially screening positive from
• 01:05:20the depression side of screening,
• 01:05:2228% of the sample was screening positive,
• 01:05:24anxiety side of screening 20%.
• 01:05:28The other thing we kind of uncovered
• 01:05:30when we parsed through the data was that
• 01:05:31there was a difference in community.
• 01:05:33So the community didn't matter.
• 01:05:35The reservation community family members
• 01:05:37who lived there were more likely to have
• 01:05:39at least one positive screen but less
• 01:05:41likely to reach out or receive care,
• 01:05:43which is kind of odd because that's where
• 01:05:45all of our health services offered from.
• 01:05:48It's headquartered from there.
• 01:05:49So you know, our behavioral Health Center,
• 01:05:51the alternative Med center, the sweat lodges,
• 01:05:54everything that people could get was there,
• 01:05:56but these are the people who are
• 01:05:57getting it less.
• 01:05:58The other thing was interesting.
• 01:06:00PTSD screening as well as audit
• 01:06:02screening had higher prevalences,
• 01:06:04significantly higher prevalences among
• 01:06:06people who live on the reservation
• 01:06:08versus people who live off the
• 01:06:10reservation but who are living in like
• 01:06:13the Tucson metro area or Phoenix metro,
• 01:06:15central Arizona, whatever.
• 01:06:18And it was so significant.
• 01:06:19So 53% screen positive for PTSD
• 01:06:22on the reservation versus 35% in
• 01:06:25all of the similar for the audit,
• 01:06:2755% in the reservation, 41%.
• 01:06:32The part that I want to touch on
• 01:06:35here about this suicidal ideation,
• 01:06:37passive death with self harm,
• 01:06:39I mentioned that it was a little bit of a
• 01:06:41loaded question and this is the one that
• 01:06:43was included in the Wellness inventory.
• 01:06:45And it's, it was interesting that what
• 01:06:49we found was a large percentage of
• 01:06:52the sample was endorsing, you know,
• 01:06:54at least having rare thoughts of this,
• 01:06:57but it's kind of hard to say what
• 01:06:58it is they're endorsing because
• 01:07:00it asks about all three.
• 01:07:01So do you think you're better off
• 01:07:03that you think you're purposely
• 01:07:04hurting yourself in some way?
• 01:07:06You can extrapolate that any other way.
• 01:07:08Reality is over a third of the sample
• 01:07:10is saying yes, I think about it.
• 01:07:12At least rarely,
• 01:07:13some people are saying they
• 01:07:14think about it daily,
• 01:07:15and this is over the last two weeks.
• 01:07:18The part when we looked at where
• 01:07:20these responses from that 34% came
• 01:07:23from shows a little bit of a cluster,
• 01:07:25again specific to the reservation community.
• 01:07:28So community members living here
• 01:07:29were five times more likely
• 01:07:31to endorse thoughts of this,
• 01:07:3380% who endorsed more than half of the
• 01:07:36time were residents of the reservation
• 01:07:38and 93% of those endorsing Daily
• 01:07:41Thoughts were residents of this community.
• 01:07:43And again these are the people
• 01:07:44not going to appointments,
• 01:07:46not receiving care,
• 01:07:47not going to alternative Med.
• 01:07:50It's it's it was a little shocking
• 01:07:53but I think it told us that we
• 01:07:56we have a lot of work to do and
• 01:07:58and I think we have some plans of
• 01:08:01action in place for next steps,
• 01:08:03one of which will be a pilot that
• 01:08:06I'll be running in collaboration
• 01:08:07with the trial moving forward.
• 01:08:09So I was fortunate enough to learn in
• 01:08:12the spring that I was awarded the APA
• 01:08:14SAMSA Fellowship and it's a smaller grant,
• 01:08:16but enough to kind of help us
• 01:08:19implement some efforts aimed at
• 01:08:20mental health STIMU reduction.
• 01:08:22And you know,
• 01:08:23we're planning on training community
• 01:08:25leaders and almost a a modest model
• 01:08:27similar to what Simon mentioned
• 01:08:29about the friendship pension,
• 01:08:31kind of incorporating the community
• 01:08:32into the healing process.
• 01:08:34But we're also going to focus on
• 01:08:36some town hall education series and
• 01:08:38just bringing this conversation to
• 01:08:40the forefront in the community.
• 01:08:42So it's we have work to do but we
• 01:08:44have some plans in place and and I
• 01:08:47think we'll we'll be able to make
• 01:08:49good on those brief acknowledgement.
• 01:08:52So this guy over on the left doctor,
• 01:08:55doctor R doctor and that he got this
• 01:08:57guy's been my mentor a long time.
• 01:08:58He was actually my primary care
• 01:09:00physician back in the day.
• 01:09:01He's the medical director for the tribe.
• 01:09:03Great guy, been with us forever.
• 01:09:05I'm really dreading the day and he
• 01:09:07has to leave and retire because
• 01:09:08I know it's coming soon.
• 01:09:09The health department really great in,
• 01:09:12you know,
• 01:09:13helping out with some of the manpower
• 01:09:14for these projects and you know,
• 01:09:16being all on board or helping
• 01:09:17get the word out.
• 01:09:18And really, really fortunate to
• 01:09:20have their support as well as
• 01:09:23support from private council
• 01:09:25who has been very supportive of,
• 01:09:27you know, all these ideas I've had
• 01:09:30and and are are working with us
• 01:09:32to continue making some progress.
• 01:09:35Lastly, our own Doctor Rohrbaugh
• 01:09:37very helpful in kind of helping
• 01:09:39me maneuver some of the logistical
• 01:09:42planning and funding for this project
• 01:09:44and also kind of started the pipeline.
• 01:09:47I'm not sure if people know this,
• 01:09:48but a number of years ago now,
• 01:09:50Doctor Rohrbaugh actually had another
• 01:09:53resident on their case project
• 01:09:54out in my community,
• 01:09:56and that was when I kind of first learned
• 01:09:58about Yale's novel approach to the
• 01:10:00residency program and put it on my radar.
• 01:10:04Big shout out to him starting that pipeline.
• 01:10:08I hope we have a little bit
• 01:10:10of time left for questions,
• 01:10:12but I'll stop screen sharing
• 01:10:15now and see if we have any.