Proceedings of the Fourth Biennial National Conference on Health Issues in the Arab American Community

May 11–12, 2006

Including Summaries of Pre- and Post-Conference Workshops (May 8–9 and May 13, 2006)

Editors: Wael A. Sakr, MD Adnan Hammad, PhD David J. P. Bassett, PhD May Darwish-Yassine, PhD

Associate Editors Virginia Hill Rice, PhD, RN Linda Jaber, PharmD Basim Dubaybo, MD Julie Hakim Larson, PhD

Ethnicity & Disease Volume 17, Number 2, Supplement 3 An International Journal on Population Differences in Disease Patterns

______CONTENTS

PROCEEDINGS FROM THE FOURTH BIENNIAL NATIONAL CONFERENCE ON HEALTH ISSUES IN THE ARAB AMERICAN COMMUNITY SECTION I Introduction ...... S3-1 Wael A. Sakr, MD; Adnan Hammad, PhD; May Darwish-Yassine, PhD

SECTION II. HIGHLIGHTS OF KEYNOTE PRESENTATIONS ...... S3-3 Adnan Hammad, PhD; May Darwish-Yassine, PhD; Wael A. Sakr, MD

SECTION III. TOBACCO AND HEALTH A. Overview ...... S3-6 Editors: David J.P. Bassett, PhD; Virginia Hill Rice, PhD, RN B. Commentary on Tobacco: The World’s Leading Cause of Cancer ...... S3-8 John R. Seffrin, PhD C. Commentary on the Global Epidemic of Tobacco, A Manufactured Disease. What it Looks Like Today and What’s to Come ...... S3-10 Kenneth E. Warner, PhD D. Global Epidemiology and Health Hazards of Tobacco Use: Arab World Patterns ...... S3-13 Omar Shafey, PhD, MPH E. A Review: Depression and Smoking ...... S3-16 Cynthia L. Arfken, PhD F. Collaborative Research of Tobacco Use and Its Predictors in Arab and Non-Arab American 9th Graders ...... S3-19 Virginia Hill Rice, PhD, RN; Thomas Templin, PhD; Adnan Hammad, PhD; Linda Weglicki, PhD, RN; Hikmet Jamil, MD, PhD; Sharifa Abou-Mediene, MD, MPH G. Tobacco Use Patterns Among High School Students: Do Arab American Youth Differ? ...... S3-22 Linda S. Weglicki, PhD, RN; Thomas Templin, PhD; Adnan Hammad, PhD; Hikmet Jamil, MD, PhD; Sharifa Abou-Mediene, MD, MPH; Mona Farroukh; Virginia Hill Rice, PhD, RN H. Abstract: Patterns of Smoking Among Aleppo University Students ...... S3-25 Nizar Akil, MD I. Abstract: Active and Passive Smoking During Pregnancy in Aleppo, Syria: Does It Affect the Outcome? ...... S3-25 Moujahed Hammami, MD; Maed Ramamdan, MD; Ali Sereo, MD

SECTION IV. LIFE STYLE AND HEALTH OUTCOMES A. Overview ...... S3-26 Editors: May Darwish-Yassine, PhD; Linda Jaber, PharmD B. Managing Cardiovascular Risk Barriers to Optimal Health Outcomes in the Arab American Patient ...... S3-28 Walid A. Harb, MD C. Depression and Cardiovascular Disease ...... S3-31 Manuel E. Tancer, MD; Alireza Amirsadri, MD D. Male Infertility in Lebanon: A Case-Controlled Study ...... S3-33 Loulou Kobeissi, DrPH; Marcia C. Inhorn, PhD E. Project Salaam: Assessing Mental Health Needs Among San Diego’s Greater Middle Eastern and East African Communities ...... S3-39 Joachim O.F. Reimann, PhD; Dolores I. Rodriguez-Reimann, PhD; Mehboob Ghulan, MD; Mohammed F. Beylouni, PhD F. The Use of Glucose-Lowering Agents and Aspirin Among Arab Americans with Diabetes ...... S3-42 Helen D. Berlie, PharmD; Adnan Hammad, PhD; Linda A. Jaber, PharmD G. Abstract: Asthma, Environmental Risk Factors, and Hypertension Among Arab Americans in the Metro Detroit Area ...... S3-46 Mary Johnson, PhD; Jerome Nriagu, PhD; Adnan Hammad, PhD; Kathryn Savoie, PhD; Hikmet Jamil, MD, PhD

SECTION V. REPORT:INTERACTIVE PANEL DISCUSSION ON HEALTH-RELATED POLICY, ENVIRONMENTAL HEALTH, AND CHRONIC DISEASE ...... S3-47 Editors: David J.P. Bassett, PhD; May Darwish-Yassine, PhD

SECTION VI. GLOBAL HEALTH FROM ARAB AND DEVELOPING WORLD PERSPECTIVES A. Overview ...... S3-50 Editors: Wael A. Sakr, MD; Nizar Akil, MD B. Commentary: The Growing Risk Factors for Noncommunicable Diseases in the Arab World ...... S3-51 Sabri Belqacem, MPA, MD C. Global Health from the Arab and Developing World Perspectives ...... S3-53 Hassen Ghannem, MD, MSc D. Chronic Diseases and the Potential for Prevention in the Arab World: The Jordanian Experience ...... S3-55 Ali H. Mokdad, PhD

SECTION VII. INTEGRATED HEALTH CARE DELIVERY:PAST,PRESENT AND FUTURE.ASSESSMENT OF LOCAL MODELS OF INTEGRATING PHYSICAL AND MENTAL HEALTH CONCERNS A. Overview ...... S3-57 Editors: Wael Sakr, MD; Michael Massanari, MD, MS B. Integrated Care in the History of Arab Medicine – A Historical Perspective ...... S3-59 Samir Yahia, MD C. Integrated Health Care Delivery – A Mandate for Systems Transformation ...... S3-60 R. Michael Massanari, MD, MS D. Integrating Mental and General Medical Health Care – The Henry Ford Health System Experience ...... S3-62 C. Edward Coffey, MD E. The Oakwood Health Care System Experience ...... S3-64 Issam Khraizat, MD F. Models of Health and Mental Health Integration: ACCESS Community Health and Research Center Model ...... S3-66 Ibrahim Kira, PhD; Adnan Hammad, PhD; Sharifa Abou-Mediene, MD

SECTION VIII. MENTAL HEALTH A. Overview ...... S3-70 Editors: Julie Hakim Larson, PhD; Nancy Wrobel, PhD; Adnan Hammad, PhD B. Arab Americans in Publicly Financed Substance Abuse Treatment ...... S3-72 Cynthia L. Arfken, MD; Sheryl Pimlott Kubiak, PhD, MSW; Alison L. Koch, BS C. Medical Complaints of Iraqi American People Before and After the 1991 Gulf War ...... S3-77 Hikmet Jamil, MD, PhD; Sylvia Nassar-McMillan, PhD; Richard Lambert, PhD; Adnan Hammad, PhD D. The Physical and Mental Status of Iraqi Refugees and its Etiology ...... S3-79 Ibrahim Kira, PhD; Adnan Hammad, PhD; Linda Lewandowski, PhD; Thomas Templin, PhD; Vidya Ramaswamy, PhD; Bulent Ozkan; Jamal Nohanesh E. Hope and Fostering the Well-Being of Refugees from Iraq ...... S3-83 Julie Hakim Larson, PhD; Mohamed Farrag, PhD; Hikmet Jamil, MD, PhD; Talib Kafaji, EdD; Husam Abdulkhaleq, MA; Adnan Hammad, PhD F. The Psychosocial Rehabilitation Approach in Treating Torture Survivors ...... S3-85 Mohamed Farrag, PhD; Husam Abdulkhaleq, MA; Galaleldin Abdelkarim, MA, PhD; Rima Souidan, MSW; Haitham Safo, MA

SECTION IX. PRE-CONFERENCE WORKSHOP:REDUCING THE CANCER BURDEN IN ARABS AND ARAB AMERICANS ...... S3-88 Editor: Amr Soliman, MD

SECTION X. POST-CONFERENCE WORKSHOP: HIV/AIDS IN THE ARAB AMERICAN COMMUNITY: BREAKING THE SILENCE! A. Overview ...... S3-92 Editors: Adnan Hammad, PhD; Miguel Gomez, MA B. Summary Report: Arab Americans and HIV/AIDS in Michigan ...... S3-94 Loretta Davis-Satterla, MSA C. Summary Report: HIV/AIDS in the Arab World ...... S3-96 Sabri Belgacem, MPA, MD D. Summary Report: HIV/AIDS in the Middle East and North Africa ...... S3-97 Nithya Mani, MPH E. Summary Report: Treating HIV/AIDS ...... S3-100 Raida Rabah, MD

SECTION XI. APPENDICES Conference Committees ...... S3-102 Conference Supporters ...... S3-104 Proceedings of the Fourth Biennial National Conference on Health Issues in the Arab American Community Copyright E 2007 by ISHIB. Material printed in the journal is covered by copyright. All rights reserved. No part of this publication may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying or by any information storage or retrieval system, without permission in writing from the publisher.

Citation: Sakr WA, Hammad A, Bassett DJP, Darwish-Yassine M, eds. Proceedings of the Fourth Biennial National Conference on Health Issues in the Arab American Community. Ethn Dis. 2007; 17(2), suppl 3. INTRODUCTION

SECTION I: INTRODUCTION

Wael A. Sakr, MD; Adnan Hammad, PhD; May Darwish-Yassine, PhD

Ethn Dis. 2007;17[Suppl 3]:S3-1–S3-2 INTRODUCTION ifiable risk factors within the Arab American community and the popula- Key Words: Arab American Health, Tobacco Control, Lifestyle Modifications, Public Health We are glad to offer the Proceedings tion-at-large. A significant component of Risk Factors, Global Health, Mental Health, of the Fourth National Conference on our fourth forum was devoted to the Cancer, HIV/AIDS Health Issues in the Arab American devastating effects of tobacco use in every Community in this supplement to corner of the globe and every age bracket Ethnicity and Disease.Thisbiennial of all populations, particularly in the conference began in 1999 to achieve developing world and alarmingly in ambitious objectives, including: teenagers and young adults. Contribu- N tions on the subject encompassed areas of to gather and generate data on Arab epidemiology, relationship to mental American health issues; N health and depression in particular, and to compare the standards of care for the local, national and international specific diseases within the commu- efforts to combat the problem. nity to other ethnicities within the During the fourth conference, the United States; and N scientific committee enhanced the em- to use the data to help direct phasis on aspects of integrated health- resources, obtain funding, and design care delivery. Our objective was to research projects to address areas of initiate a dialogue on developing a com- deficiencies. prehensive approach to health care that The long-term goal of the confer- addresses patients’ physical and mental ence continues to be aligning the health health concerns in a coherent and planning of ACCESS (Arab Communi- systematic way, despite the highly ty Center for Economic and Social technical and specialized system within Services) and its academic and commu- the United States. nity affiliates with Healthy People 2010. We continue to build on the in- Through the four conferences spanning ternational component of this effort with the last eight years, barriers and ob- the growing participation of researchers, stacles to improving the health of Arab specialists, and public health leaders from Americans have been identified and the Arab world. Presentations, from researched and have resulted in policies multiple Arab countries, offered data From Wayne State University and the and programs to address the barriers. related to the main topics of the confer- Detroit Medical Center (WAS), ACCESS The conferences have offered a unique ence. These exchanges offer unique Community Health & Research Center exposure to Arab American health issues opportunities to enrich collaborations in (AH); Detroit, Michigan; and Michigan to numerous constituencies including areas of mutual interest, such as: programs Public Health Institute (MDY), Okemos, academic institutions, healthcare pro- designed to protect teenagers from start- Michigan. viders, public health agencies and coming tobacco use, educational efforts aimed Address correspondence and reprint munity-based organizations, as well as at modifying lifestyle risk factors and the requests of the complete issue to Wael Sakr, individual physicians and other health- effort to emphasize the need for the MD; Professor & Vice Chair of Pathology; care professionals working with mem- detection and early treatment of mental Wayne State University and the Detroit bers of the Arab American community. health issues in the primary care setting. Medical Center; President of the Medical Staff, Karmanos Cancer Hospital; 3990 John In keeping with the goals of Healthy Two significant additional activities R; Detroit, MI 48201. 313-745-2525; 313- People 2010, the major themes of this took place in coordination with this 745-9299 (fax); [email protected] year’s conference continued to be mod- year’s conference.

Ethnicity & Disease, Volume 17, Summer 2007 S3-1 INTRODUCTION - Sakr et al

Pre-Conference Workshop on Re- design and analysis of translational it. The workshop also highlighted ducing the Cancer Burden in Arabs and clinical studies in such a setting. current ACCESS efforts to address and Arab Americans. Sponsored by the Overcoming these deficiencies repre- HIV/AIDS. Collaborative Group of Research on sents an immense challenge to those Finally, on an editorial note, the Cancer and the University of Michigan dedicated to cancer control throughout sequence of the material in this supple- School of Public Health. the world. ment is reflective of the structure of the Because of the variations in genetics Post-Conference Workshop on conference and presents original articles of different ethnic groups and the HIV/AIDS in the Arab American based on the topics grouped by sections. differences in the exposure of diverse Community: Breaking the Silence! In addition, other articles include: populations to environmental carcino- Sponsored by The Leadership Cam- a summary of the keynote presentation gens, the annual incidence, the relative paign on AIDS (TLCA) from the US by Admiral John O. Agwunobi, MD, frequency and the subtypes of various Department of Health and Human assistance secretary of health, US De- cancers, differ markedly from one Services. partment of Health and Human Ser- country, or population subgroup, to Because HIV/AIDS is rarely ad- vices; excerpts from a keynote address another. Moreover, the availability of dressed in private conversations among by John Seffrin, PhD, CEO of the particular treatments, as well as patients’ Arabs or Arab Americans, and until now American Cancer Society; and excerpts tolerance to treatment, varies from one has never been publicly addressed, from a keynote address by Sabri Belga- country or population group to another. infection rates are unclear within this cem, MD, MPA, FFPHM, director of Thus, an improved ability to control population living in the United States. Systems and Services Development of cancer among population groups, such The goal of this workshop was to offer the WHO-Eastern Mediterranean Re- as Arabs and Arab Americans, and to insight on HIV/AIDS in the Arab gional Office. These summaries appear more efficiently use available resources American community. It fostered dis- in Section II-Highlights from Keynote will only be achieved by performing cussion among domestic and interna- Presentations, with a more-detailed research in these populations. Yet, the tional Arab healthcare experts and account of presentations by Seffrin and lack of resources—both human and residents about HIV/AIDS and ways Belgacem incorporated in Section II and financial—has hindered the optimal that Arab Americans can respond to VI, respectively.

S3-2 Ethnicity & Disease, Volume 17, Summer 2007 HIGHLIGHTS OF CONFERENCE KEYNOTE PRESENTATIONS

SECTION II: HIGHLIGHTS OF CONFERENCE KEYNOTE PRESENTATIONS

Adnan Hammad, PhD; May Darwish-Yassine, PhD; Wael A. Sakr, MD

Ethn Dis. 2007;17[Suppl 3]:S3-3–S3-5 OVERVIEW to the Middle East where the incidence of lung cancer, especially among Key Words: Tobacco, Noncommunicable Diseases, Arab American The fourth biennial conference had youngmen,isincreasingatanalarm- the privilege of securing distinguished ing rate. According to Seffrin, deaths national and international authorities from cancer in developing countries, to deliver keynote presentations de- including the Middle East, are clearly signed to address the main themes of linked to tobacco use and the increased the conference. During the first day of risks associated with lifestyle beha- the conference, John Seffrin, PhD, viors, including obesity and lack of CEO of the American Cancer Society physical exercise. Public health offi- and president of the Union of In- cials face major challenges in helping ternational Cancer Control and Sabri individuals to quit smoking and in Belgacem,MD,MPA,FFPHM,di- preventing young men and women rector of Systems and Services De- from starting. velopment of the WHO-Eastern Med- Seffrin emphasized several points: iterranean Regional Office in Cairo, N Tobacco is the only consumer prod- Egypt delivered presentations on to- uct proven to kill more than half of bacco and health and noncommunic- its regular users. able diseases, respectively. During the N Tobacco will be responsible for 4.9 secondday,AdmiralJohnO.Agwu- million deaths worldwide this year nobi, MD, the assistant secretary for alone. health at the United States Depart- N If today’s trends continue, the cancer ment of Health and Human Services burden in the developing world will and a pediatrician by specialty, de- more than triple in the next 25 years, livered the keynote address. resulting in a global total of 10 The following paragraphs provide million deaths worldwide each and summaries of these addresses with the every year. details of the presentations of Seffrin N Tobacco will kill an estimated 650 and Belgacem incorporated within the million people alive today, half of Section III, Tobacco and Health and whom are now children. Section VI, Global Health, respectively. N Half of these people killed by Agwunobi’s remarks are accounted for From the ACCESS Community Health & tobacco will die in middle age, when Research Center (AH) Detroit, Michigan; in this section. Michigan Public Health Institute (MDY), they are most productive for their Okemos, Michigan; and Wayne State Uni- economies, their societies and their versity and the Detroit Medical Center families. (WAS); Detroit, Michigan. SEFFRIN:TOBACCO AS A GLOBAL HEALTH THREAT Without intervention, the tobacco Address correspondence and reprint pandemic will be the worst case of requests to Adnan Hammad, PhD, Director; In his address, Seffrin discussed avoidable loss of life in recorded ACCESS Community Health & Research tobacco as a global health threat and history. Lung cancer has surpassed Center; 6450 Maple Street; Dearborn, Michigan 48126. 313-216-2239; 313-584- the leading cause of cancer worldwide. prostate cancer incidence among men 3622 (fax); ahammad@accesscommunity. He highlighted trends in tobacco use in Tunisia, Algeria and Jordan. In one org across the globe, with special reference US study of Arab Americans in Dear-

Ethnicity & Disease, Volume 17, Summer 2007 S3-3 HIGHLIGHTS OF CONFERENCE KEYNOTE PRESENTATIONS - Hammad et al born, Michigan, 62% of respondents BELGACEM: realize the paramount importance of reported smoking at least half a pack of NONCOMMUNICABLE investing in empowering individuals cigarettes each day. Another study of DISEASES and communities to take active re- young Arab Americans smokers responsibility in health promotion. vealed more were exposed to environ- Sabri Belgacem, MD, MPA, WHO is providing technical sup- mental smoke at an earlier age than the FFPHM, focused on the growing mor- port in developing national NCD US national average. bidity and mortality related to non- programs, in developing guidelines for The political and economic strength communicable diseases (NCD) in the managing risk factors and noncommu- of the tobacco industry is a major Arab world. Countries in this region are nicable diseases, and in promoting obstacle, especially with the enhanced at different stages with respect to their national and regional NCD registries. recruitment of new smokers in Asia, epidemiologic and demographic transi- WHO also encourages networking be- Africa, and Latin America, Seffrin told tion and many low- and some middle- tween professionals from the region in conference participants. The nefarious income countries face the double bur- order to facilitate sharing of experiences marketing techniques used to lure more den of disease. However, the trend is and good working models. of the world’s children into deadly toward an increase of risk factors and addiction is particularly problematic. As non-communicable diseases. smoking rates decline in the United The rise of the main risk factors AGWUNOBI: USDHHS, States and many other industrialized affecting noncommunicable diseases, ACCESS AND EFFORTS TO nations, the tobacco industry has dra- such as tobacco, obesity, lack of physical KEEP ARAB matically stepped up its efforts in activity, and high blood pressure, is AMERICANS HEALTHY emerging markets in Asia, Africa, and statistically supported and indeed Latin America. Worldwide, one in seven alarming. Unhealthy lifestyles are also In his remarks, Admiral John O. teens, aged 13 to 15, smokes, 25% of growing among younger populations Agwunobi, MD, offered an overview of them having tried their first cigarette and are being exacerbated by globaliza- the mission of the United States De- before the age of 10. Nearly 100,000 tionandextendedcommunication, partment of Health and Human Ser- children and adolescents become ad- particularly through the very popular vices (USDHHS) and emphasized the dicted worldwide every day. satellite channels in the region. Ischemic department’s dedication to public In the last segment of his keynote heart and vascular diseases and cancers health and its long-standing history of address, Seffrin discussed the world’s represent the major causes of morbidity providing services with compassion. As first global public health treaty—the and mortality in the Arab world. he thanked the conference speakers and Framework Convention on Tobacco Most countries of the region are participants for their efforts to increase Control (FCTC). Developed by the developing noncommunicable disease the knowledge and understanding of World Health Organization (WHO), (NCD) control strategies and programs health issues related to Arab Americans, FCTC was formally adopted and rati- focusing on health promotion and Agwunobi emphasized that the fied by 40 nations at the World Health advocacy of healthy lifestyles in terms USDHHS relationship with ACCESS Assembly in 2003. The FCTC was of eating habits, smoking cessation and is a long-term partnership in the fight formed to protect the citizens of increased physical activity. Efforts are against disease. He made particular member countries from the tobacco being made to improve the knowledge note of the combined work of his industry’s marketing techniques by about morbidity and mortality by non- department and ACCESS in developing banning all tobacco advertising and communicable diseases by improving solutions for diseases, such as HIV/ promotion and by requiring that warn- national health information systems and AIDS, most difficult to address openly ing labels cover at least 30% of by introducing national and subnational in the Arab American community, and cigarette packaging. The treaty also has registries. he saluted ACCESS for breaking that developed efforts to shield citizens from Considering the financial pressures silence. secondhand smoke, increase tobacco within the countries of the region, their Agwunobi spoke of the diverse excise taxes, prevent cigarette smug- ability to address risk factors and ethnic and geographic spectrum of the gling, promote public awareness of noncommunicable diseases is costly for US population and that many living in the deadly consequences of tobacco the already strained health systems. the United States continue to have use, provide greater access to treatment Some countries are investing in more family members, friends and loved ones for nicotine dependence, and provide cost-effective strategies for health pro- in other countries. The environment of more stringent regulation of tobacco motion starting at school and in work globalization also introduces concerns products. settings. All countries are beginning to regarding the ease by which infectious

S3-4 Ethnicity & Disease, Volume 17, Summer 2007 HIGHLIGHTS OF CONFERENCE KEYNOTE PRESENTATIONS - Hammad et al diseases can travel and affect popula- would affect every community and very and preparedness to deal with such tions in all parts of the world. His likely many regions and nations simul- disasters can not be over-emphasized. message concentrated on the need for taneously, it is imperative that commu- According to Agwunobi, these efforts preparedness for such threats. He cited nities, cultures and religions come to- must be initiated at the community some current and historical examples, gether to minimize the devastating level and not dependent on federal help; most notably: the Avian influenza. This effects. Such a cooperative effort is more it is estimated that at least 40% of the infectious disease has spread from successful when built on relationships government workforce would be sick in southeast Asia into eastern Europe to that have been established and nour- a pandemic. Agwunobi referred the the Middle East and now into middle ished. audience to the website, http:// Africa. Scientists at the Centers for A true test of humanity would be to www.pandemicflu.gov, for more infor- Disease Control and Prevention and witness how nations reach out and care mation. the National Institutes of Health are for all in need around the world if, for Also in his remarks, Agwunobi char- concerned about a pandemic resulting example, the Avian influenza became acterized the rise in tobacco use and poor from this disease that can overwhelm a pandemic with rapid transfer from one nutrition as pandemics affecting many the capacities of health systems. human to another. Real-life crises were populations, including Arab Americans. Agwunobi indicated that, based on introduced by hurricane Katrina in He praised the efforts of ACCESS and historical patterns of three major pan- 2005, with victims and devastation the conference in raising awareness of demics that took place in the last relating to many of us with afflicted these risks and designing and implement- 100 years (1918, 1957 and 1968), it is family members and friends in the ing strategies to combat them. Simply likely that the Unite States will experi- disaster area. stated, Agwunobi insisted that the mes- ence a pandemic in the future. These Such tragedies can, and have, oc- sage, ‘‘cigarettes kill,’’ must be repeated pandemics could result from natural or curred in remote places with similar through every channel possible. Other biological causes and not necessarily the devastation and with lack of resources important messages should emphasize Avian influenza. Since such a pandemic and timely help. The need for education physical activity and healthy diets.

Ethnicity & Disease, Volume 17, Summer 2007 S3-5 TOBACCO AND HEALTH

SECTION III: TOBACCO AND HEALTH

Section III has been edited by David J. P. Bassett, PhD; Virginia Hill Rice, PhD, RN

Ethn Dis. 2007;17[Suppl 3]:S3-6–S3-25 A. OVERVIEW The narghile is typically a decorated glass water pipe with a long snake-like Key Words: Tobacco, Arab American Health, Cancer, Depression Background.AtthefirstArabAmer- tube. The pipe is filled with a mixture of ican health conference in 1998, we tobacco, which may be combined with reported a relative lack of information on molasses, honey or fruit-flavored prod- the prevalence of environmental and ucts. Smokers inhale the tobacco that is tobacco-related problems in the Arab heated by charcoal and travels through American community and little was the water. The water is used to clean known about tobacco use among the soot belched out of the burning tobacco young. Facilitated by these conferences, and to reduce such harmful constituents community-based studies have been con- as acrolein and other aldehydes before it ducted that have brought together the is inhaled through long flexible tube(s) ACCESS research group with investigators with detachable mouthpieces. The use from Michigan universities. At subsequent of charcoal generates rather high levels conferences, findings of the potential of carbon monoxide, thus increasing adverse health effects associated with secondhand exposure for others.2 Re- pollutant exposures of the ambient, work- searchers in the Middle East are just place and home environments have been beginning to examine narghile smoking presented, together with some preliminary among the young. assessments of environmental health Associated with these collaborations knowledge, attitudes and beliefs. This are two major studies funded by the information is now being used as a basis National Institutes of Health. One for developing intervention strategies. In study, Environmental Impacts on Arab particular, a major focus of ongoing work Americans in Metropolitan Detroit,was is the development of effective, culturally conducted by Hammad, Nriagu, and sensitive programs for reducing both adult colleagues at ACCESS and the Univer- and adolescent tobacco uses. sity of Michigan. The ongoing results of In addition to cigarette smoking, this study were reported at the 3rd more recent investigations are being biennial meeting and included a pre- directed toward a greater understanding sentation of findings from a series of of the reasons and dynamics for the community-based workshops on envi- growing use of narghile smoking. The ronmental health, a pilot project to narghile also known as the water pipe, assess contaminant exposures, and narghileh, argileh, hubble-bubble (HB), a household assessment of environmen- hookah, shisha, and goza (with variations tal risk factors for respiratory health in spelling and pronunciation depending with an emphasis on the triggers of on global location) is found in the asthmatic reactions. New findings from Middle East, Southeast Asia and North this project are described in Sections III Africa dating back some 500 years. and IV. A second study entitled Arab Traditionally associated with older male American Youth: Tobacco Use and In- From the Eugene Applebaum College use, its history has undergone a renais- tervention is being conducted by Ham- of Pharmacy and Health Sciences (DJPB), the School of Medicine (DJPB) and the sance in recent years and is growing in mad(ACCESS)andRiceandher College of Nursing (VHR), Wayne State popularity, particularly among the colleagues at the Wayne State Univer- University, Detroit, Michigan. young, around the world.1 sity College of Nursing.

S3-6 Ethnicity & Disease, Volume 17, Summer 2007 TOBACCO AND HEALTH - Bassett and Rice

In previous conferences, data were kowski, executive vice president of Dr. Maziak’s comprehensive pre- presented that examined trends and Medical Activities at the American sentation demonstrated that water pipe predictors of tobacco use among differ- Cancer Society’s Great Lakes Division smoking is a growing public health ent Arab-American adolescent sub- and John Ruckdeschel, PhD, president threat in Syria and probably in other groups, as well as school-based findings and CEO of the Karmanos Cancer Middle Eastern nations. Its use is of the psychosocial factors among Institute. different than that of cigarette smok- adolescents and the influence of peer In this section, readers will find ing, although some similarities with and parental smoking. In addition, the presentations from additional speakers dependency were observed in cigarette redesigning of the Project Toward No in the first session: smokers. The use of the water pipe as a substitute for cigarette smoking Tobacco (Project TNT) to make it Kenneth E. Warner, PhD on the global culturally and ethnically sensitive for epidemic of tobacco; among cigarette quitters is particularly 3 Arab-American youth was presented. Omar Shafey, PhD, MPH on the global disturbing. The acute and chronic Findings demonstrated that: Arab epidemiology and health hazards of health effects may also differ between American adolescents are more likely tobacco use; these two methods of tobacco smok- Cynthia L. Artfken, PhD on depression to smoke cigarettes if they were born in ing. and smoking; this country; their peers and parents are Virginia Hill Rice, PhD, RN and colleagues Moujahed Hammami, MD, direc- smokers; and, they have high levels of on collaborative research on tobacco use tor, University Hospital, Aleppo, Syria, stress and/or depression and low levels and its predictors in Arab and nonArab and May Darwish-Yassine, PhD of the of self-esteem. It is interesting to note American 9th graders; Michigan Public Health Institute mod- that, although the prevalence of ciga- Although the paper is not provided erated the second session on tobacco rette smoking among Arab Americans is herein, Dr. Maziak, of the Syrian and health. The session featured oral actually lower than non-Arab adoles- Center for Tobacco Studies, served as presentations of scientific information cents in Michigan, the use of narghile is an additional speaker in this session from abstracts submitted to the scien- very high and was the subject of more andprovidedaverycomprehensive tific committee of the conference. recent investigations presented at this presentation on the dramatic increase Briefs are provided within this section conference. in the use of the water pipe among for: The invited presentations to this college-age students in Syria since the Linda S. Weglicki, PhD, RN and collea- conference were designed to put these 1980s. This growing epidemic is in gues on tobacco use patterns among high previous endeavors into a more global part attributed to the introduction of school students; health perspective. Research from the Maasal, a sweetened and flavored Nizar Akil, MD on patterns of smoking Middle East and from the above among Aleppo University students; tobacco, increased accessibility, and Moujahed Hammami, MD et al on active Michigan-based investigators provided enhanced promotion by the media and passive smoking during pregnancy in an important broad-based view to and marketing on the Internet. Ac- Aleppo, Syria. move health professionals forward in cording to Maziak, 25% of the males addressing tobacco-related health and nearly 5% of female students at problems. REFERENCES Aleppo University apparently use the 1. Maziak W, Ward K, Soweid RA, Eisenberg T. The first of two sessions on tobacco water pipe. A study of smoking among Tobacco smoking using a waterpipe: A re- and health followed speeches by the 90,000 13- to 15- year olds across the emerging strain in a global epidemic. Tob conference keynoters. One of the Middle East suggested a far greater use Control. 2004;13(4):327–333. keynote addresses was delivered by of tobacco products other than cigar- 2. The Sacred Narghile (Hookah, Shisha, Water Pipe). Available at http://www.sacrednarghile. John Seffrin, PhD, CEO of the Amer- ettes, assumed in part to include the 4 com/narghile/en/health.html. Accessed on 10/ ican Cancer Society and president of water pipe. The greater percentage of 13/05. Union of International Cancer Con- 13- to 15-year-old girls smoking 3. Sussman S, Dent C, Burton D, Stacy A, Flay B. trol. Section II provides highlights products other than cigarettes com- Developing School-Based Tobacco Use Prevention from this presentation while a more pared to the rate observed in Aleppo and Cessation Programs. Thousand Oaks, CA: in-depth paper is presented within this University female students further in- Sage Publications; 1995. section. 4. World Health Organization. Global Youth dicated a potential for an even greater Tobacco Survey. Available at: http://www. The first session on Tobacco and increase in non-cigarette tobacco use who.int/tobacco/surveillance/gyts/en/index.html Health was moderated by Vicki Ra- in the future. Accessed on: 5/15/06.

Ethnicity & Disease, Volume 17, Summer 2007 S3-7 B. COMMENTARY ON TOBACCO:THE WORLD’S LEADING CAUSE OF CANCER

Abstract: Cancer incidence is on the rise in John R. Seffrin, PhD many regions of the world, including the Middle East, where incidence rates for both men and women are increasing. Like many regions of the TOBACCO AND LUNG total of 10 million deaths world- world, increased tobacco use, combined with 5 other factors, is driving cancer incidence in the CANCER wide each year. Seven million of these Middle East. Tobacco, the only consumer deaths will occur in the developing product proven to kill more than half of its Despite new treatments, better pre- world, in nations least prepared to deal regular users, will be responsible for 4.9 million vention, and early detection techniques with the financial, social and political deaths worldwide this year alone. That burden and other advances, cancer continues to consequences of this global public is fairly evenly shared by industrialized and 5 developing nations today but, if current trends be a growing global public health threat. health tragedy. In the Arab world, lung continue, the cancer burden in the developing Today, cancer kills more people than cancer is already occurring with in- world will more than triple in the next 25 years, AIDS, tuberculosis and malaria com- creasing frequency, particularly among 3 resulting in a global total of 10 million deaths bined. To understand why the cancer men. worldwide each year. Seven million of these Lung cancer is already the most deaths will occur in the developing world, in burden is increasing despite years of nations least prepared to deal with the financial, progress in the United States and other common cancer among men in Tunisia, social, and political consequences of this global developed nations, we must look to the Algeria and Jordan – surpassing prostate 3 public health tragedy. In the Arab world, lung developing world. By 2020, an estimat- cancer. Without intervention, this cancer is already occurring with increasing ed 70 percent of the forecasted 10 mil- trend is likely to continue in other frequency, particularly among men. (Ethn Dis. countries. Even in Arab immigrant 2007;17[Suppl 3]:S3-8–S3-9) lion annual deaths will occur in developing countries, which are least populations in the United States, tobac- Key Words: Cancer, Tobacco prepared to address their growing cancer co use is high. In one study of Arab burdens.1,2 Americans in Dearborn, Michigan, 62 Cancer incidence is on the rise in percent of respondents reported smok- many regions of the world, including ing at least half a pack of cigarettes each 6 the Middle East, where incidence rates day. The study also revealed that young for both men and women are increas- Arab Americans who smoke were ex- ing.3 Like many regions of the world, posed to environmental smoke at an increased tobacco use combined with earlier age than the US national aver- 6 other factors is driving cancer incidence age. in the Middle East. Although commu- Worldwide, similar tobacco use nicable diseases still account for a large trends are taking their toll. Tobacco percentage of deaths in emerging na- will kill 650 million people, half of 5 tions, improvements in vaccination and whom are now children. Half of these prevention efforts are reducing the people killed by tobacco will die in deadly toll of these diseases. But deaths middle age, when they are most pro- from non-communicable diseases like ductive for their economies, their soci- 5 cancer are rising steadily, driven by eties and their families. In the last an increase in tobacco use and the century alone, tobacco use killed 7 spread of Western lifestyle behaviors, 100 million smokers. If left un- such as lack of physical activity, that checked, tobacco use will kill more than lead to obesity. a billion people in this century. Tobacco, the only consumer prod- This extraordinary suffering and uct proven to kill more than half of its death is not inevitable. Without in- regular users, will be responsible for tervention, the tobacco pandemic 4.9 million deaths worldwide this year will be the worst case of avoidable alone.4 That burden is fairly evenly loss of life in recorded history. Yet, shared by industrialized and developing with comprehensive, concerted action, nations today but, if current trends we can eliminate the global scourge continue, the cancer burden in the of tobacco and save hundreds of From the American Cancer Society, developing world will more than triple millions of lives within the next few Atlanta, Georgia. in the next 25 years, resulting in a global decades.

S3-8 Ethnicity & Disease, Volume 17, Summer 2007 TOBACCO AND HEALTH - Seffrin

INTERVENTION formally adopted by the World Health vorship. If the growing cancer burden is Assembly in 2003, the treaty required to be reversed in the Middle East and To save lives, we must help current ratification by 40 nations before it could other areas of the developing world, smokers quit and we must stop the become legally binding on the countries cancer and tobacco control agencies tobacco industry from using its market- that have adopted it. Ratification of the must work together and surpass political ing techniques to lure the world’s FCTC was a tremendous milestone for and cultural barriers. The benefits of children into deadly addiction. If we global public health, putting us on the international collaborations to achieve choose to act, we could save thousands track to saving the millions of lives we cancer and tobacco control initiatives of lives. For example, if we were able to know we can save each year just by are reaped globally. International efforts cut adult cigarette consumption by just reducing tobacco consumption. to build the capacity of emerging cancer 50% worldwide, we could avert more The FCTC hits the tobacco compa- societies and to enhance worldwide than 200 million needless deaths within nies where they live by restricting their tobacco control efforts lay the necessary the next 50 years. unscrupulous marketing tactics. It gives foundation for healthy, peaceful, pros- As smoking rates decline in the nations—particularly the low-income perous and productive societies. United States and many other industrial- nations the tobacco companies have ized nations, the tobacco industry has targeted as their most promising mar- REFERENCES dramatically stepped up its efforts in kets—powerful new tools to protect 1. Vastag J. Developing Countries Face Growing emerging markets in Asia, Africa and their citizens from the tobacco indus- Cancer Burden. Natl. Cancer Inst. 2006;98: Latin America. Because tobacco kills the try’s deception. The treaty commits 1106–1107. 2. Parkin DM, Bray FI, Devesa DD. Cancer majority of its customer base, the industry nations to ban all tobacco advertising, Burden in the Year 2000: The Global Picture. must recruit millions of new smokers each promotion and sponsorship (with an Eur J of Cancer. 2001;37(Suppl. 8):S4–S66. year just to break even. In the unrestricted exception for countries with constitu- 3. Elattar IA. Cancer in the Arab World: markets of the developing world, that tional constraints). It also requires that Magnitude of the Problem, as presented at nd means that no one is immune from the warning labels cover at least 30% of the 132 Annual Meeting of the American Public Health Association (APHA), Novem- industry’s tactics, especially the most cigarette packaging. ber 6–10, 2004. Available at: http://apha. vulnerable people of all – children. In addition to aggressively combat- confex.com/apha/132am/techprogram/paper_ Worldwide, one in seven teens, aged ing tobacco marketing, the FCTC 80999.html. Accessed on: 5/17/06. 13 to 15, smokes.8 One-quarter of them requires many other measures to protect 4. World Health Organization. An International Treaty for Tobacco Control. August 12, 2003. tried their first cigarette before the age the citizens of the world, including Available at: http://www.who.int/features/ of 10 years. Nearly 100,000 children shielding citizens from secondhand 2003/08/en/print.html. Accessed on: 5/17/06. and adolescents become addicted world- smoke, increasing tobacco excise taxes, 5. The World Bank. Development in practice: wide every day. In the United States preventing cigarette smuggling, promot- Curbing the epidemic: Governments and the alone, the tobacco industry spends more ing public awareness of the deadly Economics of Tobacco Control. Tob Control. 1999 Summer;8(2):196–201. than one million dollars an hour, consequences of tobacco use, providing 6. Rice VH, Kulwicki A. Cigarette use among 24 hours a day, seven days a week, greater access to treatment for nicotine Arab Americans in the Detroit metropolitan 9 marketing its products. dependence and providing more strin- area. Public Health Rep. 1992 Sep–Oct;107(5): Fortunately, thanks to the rigorous gent regulation of tobacco products – an 589–594. educational, scientific and advocacy especially important action since these 7. ASH- Action on smoking and health UK. Avail- able at: http://www.ash.org.uk/?international. efforts of dedicated tobacco-control products will continue to be freely and Accessed on 5/17/06. activists worldwide, many nations of legitimately available to youth and 8. Global Youth Tobacco Survey (GYTS). In- the world are taking a stand against adults worldwide. troduction available at: http://www.cdc.gov/ tobacco by supporting the world’s first tobacco/global/GYTS/intro.htm. Accessed on: global public health treaty—the Frame- 5/15/06. 9. United States Federal Trade Commission. work Convention on Tobacco Control CONCLUSIONS Federal Trade Commission Cigarette Report 10 (FCTC). In fact, the campaign to for 2002. Issued 2004. Available at http://www. reduce the global burden of tobacco- In combating tobacco trends, it is ftc.gov/reports/cigarette/041022cigaretterpt.pdf. related disease celebrated a significant crucial to understand that increased Accessed on: 5/17/06. 10. World Health Organization. An International victory in November 2004, when Peru knowledge about cancer prevention, th Treaty for Tobacco Control. August 12 2003. became the 40 nation to ratify the cancer treatment or tobacco control Available at: http://www.who.int/features/ FCTC. Developed by the WHO and does not equal successful cancer survi- 2003/08/en/print.html.

Ethnicity & Disease, Volume 17, Summer 2007 S3-9 C. COMMENTARY ON THE GLOBAL EPIDEMIC OF TOBACCO,AMANUFACTURED DISEASE.WHAT IT LOOKS LIKE TODAY AND WHAT’S TO COME

Abstract: An estimated 1.2 billion citizens of Kenneth E. Warner, PhD the world are smokers. In developing countries, half the males smoke. WHO projects a global smoking population of 1.6 billion by During the 20th century, smoking the end of the next two decades. Collectively, PATTERNS OF CIGARETTE today the world’s smokers annually consume SMOKING AND ASSOCIATED claimed the lives of a phenomenal nearly 1,000 cigarettes for every man, woman MORTALITY 100 million people. However, without and child on the planet. Almost 5 million significant public health progress, that people die as a result of smoking, half during Cigarette smoking is a remarkably figure will increase to one billion human their productive working years, with half st prevalent behavior around the world. beings during the 21 century. Among occurring in developing countries. Two decades hence, tobacco products will kill an Currently, nearly a billion men smoke, them will be millions of nonsmokers, estimated 10 million people every year, 70% as do a quarter of a billion women or the victims of passive or involuntary of them in the world’s poor nations. During the 1.2 billion people altogether.1 Thirty- smoking, the inhalation of smoke from th 20 century, smoking killed 100 million peo- five percent of males in developed the cigarettes of others. Passive smoking ple. Without significant public health progress, countries are smokers, as are 22% of increases the risk of death from lung cigarettes will claim the lives of an estimated 4 one billion during the 21st century. Progress women. In developing countries, half cancer and heart disease by 20–30%. can be achieved, however, through the the males smoke (including some Smoking patterns vary significantly adoption and enforcement of effective tobacco 300 million in China alone), while the by region, with male-female differences control policies. Such policies are embedded smoking rate among women is much in prevalence rates being far smaller in in the Framework Convention on Tobacco lower (9%).1 Of great concern, howev- Europe and the Americas, for example, Control, the world’s first international health treaty. They include protecting nonsmokers er, is the fact that the smoking rate for than they are in Asia and the Middle from the hazards of secondhand smoke in all females in the world’s poorer nations is East. Still, patterns diverge among indoor workplaces and public places, banning growing. Considering projected popu- countries within regions, as is seen in tobacco advertising and sponsorship, raising lation growth, WHO estimates a global Table 1, which presents male and tobacco taxes and eliminating the smuggling of smoking population of 1.6 billion by female smoking rates in 18 Arab untaxed cigarettes. The future health of the 1 world’s population rests on the success that the end of the next two decades. countries. The predominant pattern is will be achieved in global tobacco control. Collectively, the world’s smokers one of substantial male smoking and (Ethn Dis. 2007;17[Suppl 3]:S3-10–S3-12) consume approximately 5.5 trillion very little smoking by women. Howev- cigarettes per year or nearly 1,000 for er, in two of the countries, Lebanon and Key Words: Tobacco, Cancer every man, woman and child on the Yemen, nearly a third of women are planet.1 The toll is enormous. Current- smokers. The high rates of smoking ly, according to the World Health among children in countries throughout Organization, close to 5 million people the world, with male-female differences annually succumb to diseases caused by in prevalence far smaller than in the smoking, half of them during the adult population are of greatest con- 5 productive working years of ages 35– cern. 69, with half of the deaths occurring in developing countries. This huge figure pales in comparison, however, with THE FUTURE OF GLOBAL WHO’s estimate for the toll two TOBACCO CONTROL decades hence, when the smoking epidemic will have ‘‘matured’’ within In many of the developed nations of the developing world – smokers will the world, education about the dangers have been smoking long enough and of smoking emerged 40 years ago. Over intensively enough for smoking to subsequent decades, tobacco control wreak its maximal damage. At that policies emerged to the point that, time, barring major changes in smoking today, roughly a dozen countries ban trends, tobacco products will kill smoking in all workplaces, including all From the University of Michigan 10 million citizens in the world every bars and restaurants. Many more are School of Public Health, Ann Arbor, Michi- year, 70% of them in the world’s poor certain to follow over the next decade. gan. nations.2,3 The impact has been substantial and

S3-10 Ethnicity & Disease, Volume 17, Summer 2007 TOBACCO AND HEALTH - Warner

product regulation throughout the Table 1. Smoking prevalence in Arab countries world) and measures to reduce cigarette Country Male (%) Female (%) smuggling (cigarettes constituting the Algeria 44 7 most widely smuggled legal product of Bahrain 24 6 any); in recent years, it has been Dijibouti 58 5 estimated that fully 30% of all legally Egypt 35 2 Iran 27 3 exported cigarettes were never imported 10 Iraq 40 5 legally anywhere. Legal procedures to Jordan 48 10 diminishing the toll of tobacco, in- Kuwait 30 2 cluding product liability lawsuits, are Lebanon 46 35 Morocco 35 2 also encouraged in the treaty. Oman 16 2 Qatar 37 1 Saudi Arabia 22 1 Sudan 24 1 CONCLUSIONS Syria 51 10 Tunisia 62 8 The degree to which participating UAE 18 ,1 nations will effectively implement the Yemen 60 29 provisions of the FCTC remains to be 1 Source: Mackay and Ericksen, 2002. seen, as does the ultimate impact of implementation on smoking and its disease sequelae. Nevertheless, it seems profound, with smoking converted from lence of tobacco use…’’ Negotiated over safe to conclude that the existence of a common, highly public, sociable a three-year period, the treaty has been this internationally binding treaty and behavior to one that is increasingly rare ratified by 125 countries (as of April 12, the genuine enthusiasm for it in many and increasingly viewed as anti-social 2006) that are now parties to its countries will moderate the future behavior. Control of the tobacco epi- multiple tobacco control provisions.8 growth in the world’s tobacco disease demic in the developed world is one of Among others, these include the fol- pandemic. Particularly, in many coun- the great public health success stories of lowing policy mandates:9 tries in Africa, in which poverty has the past half century.6 N Adoption of ‘‘effective measures’’ to limited the spread of intensive smoking The same is not the case in the protect nonsmokers from the hazards thus far, and in countries in Asia and in developing world. With smoking on the of secondhand smoke in all indoor the Arab world, where social convention rise in many countries, where knowl- workplaces and public places. has produced low, but growing smoking edge of its hazards is limited and N Banning all tobacco advertising and rates among women, the potential to policies discouraging smoking are a rar- sponsorship, direct and indirect, short-circuit much of that pandemic is ity, the purveyors of cigarettes have within 5 years, save for those coun- significant. For the foreseeable future, found fertile ground for expanding their tries in which national law prohibits markets and their profits. A handful of tobacco use is likely to grow, the world’s banning commercial speech. poor nations are implementing serious best efforts notwithstanding, and the N Consideration of health objectives in tobacco control measures (eg, India and mortality burden of tobacco will grow setting tobacco taxes (with the South Africa), but the norm is to ignore too. But making even a sizable dent in treaty’s noting that higher prices smoking as one of the ‘‘small, affordable this enormous burden would represent discourage tobacco consumption). pleasures’’ for the globe’s impoverished a public health achievement of pro- N Implementation of rotating health peoples. digious proportions. Public health pro- warning labels covering at least 30% This is likely to change in the fessionals around the world will invest of the fronts and backs of all cigarette coming years. On February 27, 2005 heavily in global tobacco control and packs. an unprecedented international health eagerly await the outcome of their N Prohibition of sales to minors, treaty, the Framework Convention on efforts. distribution of free samples and sale Tobacco Control (FCTC), took effect.7 of ‘‘loosies’’ (single cigarettes). According to Article 3 of the treaty, its REFERENCES purpose is ‘‘[T]o protect…future gen- As well, the treaty calls for product 1. Mackay J, Eriksen M. The Tobacco Atlas. Geneva: World Health Organization; 2002. erations…by providing a framework for regulation (tobacco products being 2. Peto R, Lopez AD. Future worldwide health tobacco control measures…to reduce among the few consumer products effects of current smoking patterns. In: Koop continually and substantially the preva- currently subjected to virtually no CE, Pearson CE, Schwarz MR, eds. Critical

Ethnicity & Disease, Volume 17, Summer 2007 S3-11 TOBACCO AND HEALTH - Warner

Issues in Global Health. San Francisco: Jossey- Promotion, Office on Smoking and Health; Tobacco Control. AJPH. 2005;95(6): Bass; 2001:154–161. 2006. 936–938. 3. Ezzati M, Lopez AD. Smoking and oral 5. Global Youth Tobacco Survey. World Health 8. World Health Organization. Updated status of tobacco use. In: Ezzati M, Lopez AD, Rodgers Organization and Centers for Disease Control the WHO Framework Convention on Tobac- A, Murray CJL, eds. Comparative Quantifica- and Prevention. 2005. Available at: http:// co Control, 2006. Available at: http:// tion of Health Risks: Global and Regional Burden www.cdc.gov/tobacco/Global/GYTS.htm. www.who.int/tobacco/framework/countrylist/ of Disease Attributable to Major Risk Factors. Last accessed June 23, 2006. en/. Lat accessed June 23, 2006. Geneva: World Health Organization; 2004. 6. Centers for Disease Control and Prevention. 9. Framework Convention Alliance for Tobacco 4. US Dept. of Health and Human Services. The Ten Great Public Health Achievements – Control. 2006. Available at: http://www. Health Consequences of Involuntary Exposure to United States, 1900–1999. Morb Mortal fctc.org. Last accessed June 23, 2006. Tobacco Smoke: A Report of the Surgeon Wkly Rep. 1999;48(12):241–243. Available 10. Joossens L, Chaloupka FJ, Merriman D, General. Washington, DC: U.S. Department at: http://www.cdc.gov/mmwr/preview/ Yurekli A. Issues in the smuggling of tobacco of Health and Human Services, Centers for mmwrhtml/00056796.htm. Last accessed June products. In: Jha P, Chaloupka FJ, eds. Disease Control and Prevention, Coordinating 23, 2006. Tobacco Control in Developing Countries. Center for Health Promotion, National Cen- 7. Roemer R, Taylor A, Lariviere J. Origins London: Oxford University Press; 2000: ter for Chronic Disease Prevention and Health of the WHO Framework Convention on 393–406.

S3-12 Ethnicity & Disease, Volume 17, Summer 2007 D. GLOBAL EPIDEMIOLOGY AND HEALTH HAZARDS OF TOBACCO USE: ARAB WORLD PATTERNS

Omar Shafey, PhD, MPH

Ethn Dis. 2007;17[Suppl 3]:S3-13–S3-15 INTRODUCTION:SMOKING tobacco in the world but in the Arab countries, the hookah is also used Key Words: Tobacco, Arab World PATTERNS widely. Jordan, Tunisia and Iraqi Kur- Between 1990 and 1997, cigarette distan are the only places where ciga- consumption increased 24% in the rette smoking prevalence is higher than 3 Middle East. The Middle East and Asia hookah use. are the only two regions of the world The hookah is often perceived as the where cigarette sales increased during ‘‘traditional’’ Arab way of consuming that period. This trend reflects the high tobacco, often while socializing. Arab male smoking prevalence in the Arab American youth use the hookah as world and the uptake of smoking by a form of ethnic identification and a growing number of women.1 because hookah smoking meets with Male smoking prevalence in the less parental disapproval than cigarettes. Arab world remains significantly higher Among non-Arabs in the United States than female smoking prevalence. Al- and elsewhere, hookah smoking is seen most all the large Arab countries (Ye- largely as an exotic novelty but the men, Lebanon, Jordan, Egypt, Tunisia, practice may serve as a gateway to Syria, and Iraq) have very high adult cigarette addiction. There is a common male smoking prevalence rates. Yemen misconception that water filtration re- and Djibouti have some of the highest duces carcinogen content of tobacco male smoking prevalence rates in the smoke, making hookah smoking ‘‘safer’’ world, above 75%. Rates of male than cigarettes.4 smoking are also exceptionally high, In Egypt, also, perceptions about the above 40%, in Jordan, Tunisia, Egypt, hookah are couched in gender roles and Syria, Lebanon and Palestine. Smoking expectations. Many people think it is prevalence among women in Arab indecent for women to smoke and that countries is generally low, under 10%, smoking reflects badly on the character with only three exceptions: Egypt, and morality of women. The Arab Lebanon and Yemen. A larger percent- world’s economy is becoming more age of women in Lebanon and Yemen globally integrated and the social pres- smoke tobacco than women in the sures of encroaching western cultural United States. Ominously, there are values are being felt through the media, more than 12 Arab countries where at consumerism and promotion of neo- least 10% of girls age 13–15 smoke. liberal values including Western femi- This seems to indicate a dangerous nism. The reaction to that is to trend toward more widespread female sometimes turn inward and resolve smoking in the Arab World.2 self-identity by reasserting traditional values and practices and advancing the tenets of Islamic feminism. Women THE HOOKAH PROBLEM who smoke shisha may believe they are making strides for gender equality.5 The hookah (also known as the The immediate health effects of water pipe, shisha, nargileh, arghileh hookah smoking include: increased or hubble-bubble) poses a special tobac- expired carbon monoxide, plasma nico- From the International Cancer Control co problem in the Middle East. Cigar- tine and higher heart rate. Short-term Research, Atlanta, GA. ettes are the most widely used form of health risks associated with spreading

Ethnicity & Disease, Volume 17, Summer 2007 S3-13 TOBACCO AND HEALTH - Shafey infection (if the hookah is shared) throughout the region. The industry Emirates, and Yemen (ratification pend- include tuberculosis, hepatitis and re- also sought to ‘‘identify Islamic religious ing). Bahrain, Palestine, and Somalia spiratory tract infections. Long-term leaders who oppose interpretations of have yet to sign the treaty. Other Arab health risks of hookah smoking include: the Quran which would ban the use of countries party to the treaty include the nicotine dependence/addiction, cancer tobacco and encourage support for these Comoros and Mauritania.8 of the lung, trachea, bronchus and oral leaders.’’7 The American Cancer Society cavity, cardiovascular disease, respirato- (ACS) and other public health groups ry disease/emphysema/chronic obstruc- are campaigning worldwide for all tive pulmonary disease (COPD) and TOBACCO CONTROL governments to sign and ratify the heavy metal poisoning from arsenic, EFFORTS FCTC. United States ratification would cadmium, cobalt, chromium and lead.6 be an enormous success and would have The WHO Eastern Mediterranean a great impact on the global tobacco Regional Office (EMRO) has a strategy epidemic. Citizens of every country TOBACCO INDUSTRY of linking religion with health pro- need to hold their own tobacco compa- ACTIVITIES motion. The Right Path to Health; nies responsible for the millions of Health Education through Religion; Is- death worldwide that their products Women in the Middle East repre- lamic Ruling on Smoking was published cause and make sure that they are sent one of the last great untapped in 1996 to confront tobacco addiction regulated appropriately. The main goal markets for the tobacco industry. The with religious edicts. Because smoking is is to see widespread ratification and tobacco industry sponsors female-ori- injurious to the smoker and others, it is implementation of the FCTC. ented events, such as fashion shows, and considered haram (forbidden) under increasingly employs advertising tech- Sharia (Islamic law). Some religious niques that exploit the tropes of free- scholars believe that tobacco is only CONCLUSIONS dom, equality and modernity to seduce makhrouh (undesirable) rather than women into adopting the traditionally forbidden. Statements against smok- Male cigarette smoking prevalence male behavior of smoking. ing from Eastern Orthodox priests in the Arab World is relatively high but Cigarette smuggling remains a signif- and the Vatican are also used to female prevalence remains generally icant problem in the Middle East. promote health behavior in Arab Chris- low. Hookah use is widespread and Much of the region’s cigarette-smug- tian communities. For more informa- appears to be increasing rapidly among gling operations are conducted through tion, visit http://www.emro.who.int/tfi/ youth and women. Tobacco-related Cyprus, Jordan and the Gulf emirates. emroleads.htm disease will become more prevalent as Large-scale cigarette smuggling would As mentioned previously in this the course of the epidemic continues. not be possible without collusion by the section, the WHO’s Framework Con- Legislative measures and religious ex- tobacco industry. In 2002, the Europe- vention on Tobacco Control (WHO hortations are being used to control an Union filed a lawsuit against RJ FCTC) requires countries that ratify the tobacco use but smuggling operations Reynolds, Japan Tobacco and Philip treaty to take specific measures to and advertising campaigns threaten to Morris, claiming that they were violat- control tobacco consumption, produc- undermine tobacco control measures. ing UN sanctions by smuggling billions tion and advertising. The treaty was Commitment to tobacco control is of cigarettes into Iraq. The lawsuit activated on February 27, 2005 and as lacking in some influential countries. claimed that smuggling was often of July 2006, 168 countries had signed Despite a lack of commitment, carried out with the aid of terrorist the treaty and 134 had become parties actions can be taken. ACS has been organizations. After the United States to the treaty. Nineteen out of 22 instrumental in changing the social invasion of Iraq in 2003, the charges countries in the WHO EMRO have acceptability of tobacco in the United were dropped. signed and 14 countries have become States. Americans smoked even more Tobacco industry collusion in the parties to the treaty: Afghanistan (rati- heavily than Arabs did a few decades Middle East began in the late 1970s fication pending), Djibouti, Egypt, ago. Ratification and implementation of with the formation of the Middle East Iran, Iraq (ratification pending), Jordan, FCTC offers the best strategy for Tobacco Association (META). The Kuwait, Lebanon, Libyan Arab Jama- stemming the tobacco pandemic. Association engaged in sophisticated hiriya, Morocco (ratification pending), Change is not only possible; it is vital campaigns to plant pro-tobacco articles Oman, Pakistan, Qatar, Saudi Arabia, if we are to circumvent a toll of in regional newspapers and defeat or Sudan, Syrian Arab Republic, Tunisia unnecessary death and illness in the water down advertising ban proposals (ratification pending), United Arab Arab world.

S3-14 Ethnicity & Disease, Volume 17, Summer 2007 TOBACCO AND HEALTH - Shafey

REFERENCES on tobacco dependence in narghile users. Drug 6. Knishkowy B, Amitai Y. Water-Pipe (Narghile) 1. World Health Organization. Tobacco or Health: Alcohol Depend. 2004. Smoking: An Emerging Health Risk Behavior. A Global Status Report. Geneva, Switzerland: 4. Shihadeh A. Investigation of mainstream smoke Peds. 2005;116(1):e113–119. World Health Organization; 1997. aerosol of the argileh water pipe. Food Chem 7. Middle East Tobacco Association (META). 2. Jha P, Ranson MK, Nguyen SN, et al. Estimates Toxicol. 2003;41:143–152. Available at: http://aolsearch.aol.com/aol/ of global and regional smoking prevalence in 5. Maziak W, Fouad MF, Hammal F, Asfar T, search?invocationType5topsearchbox.search& 1995 by age and sex. Am J Public Health.2002 Bachir EM, Rastam S, Eissenberg TE, Ward query5META. Accessed on: 5/06/06. June;92(6):1002–1006. KD. Prevalence and characteristics of narghile 8. World Health Organization Eastern Mediterra- 3. Maziak W, Eissenberg TE, Ward KD. Factors smoking among university students in Aleppo, nean Regional Office (EMRO). Available at: related to level of narghile use: the first insights Syria. Int J Tuberc Lung Dis. 2004;8:882–889. http://www.emro.who.int/. Accessed on: 4/30/06.

Ethnicity & Disease, Volume 17, Summer 2007 S3-15 E. A REVIEW:DEPRESSION AND SMOKING

Abstract: The association between depression Cynthia L. Arfken, PhD and smoking has been well-documented in multiple countries and age groups. This review examines recent publications that address the INTRODUCTION people with mental illness consume magnitude of the association and its causal patterns (ie, due to lowered success of quitting 44.3% of the cigarettes in the United 1 in people with depression, depression causing As smoking becomes a less-accepted States. smoking, smoking causing depression or third behavior in different societies, the Mental illness comprises multiple factor related to both smoking and depres- people who continue to smoke are more specific disorders, whether DSM-IV or sion). We conclude that the association may likely to be identified by certain char- the International Classification of Dis- be multi-factorial with each of the causal acteristics. One characteristic is mental directions possibly contributing to the ob- eases (ICD) criteria are used. From the served association. Also, the association ex- illness. The purpose of this review is to most recent United States national tends beyond depression to other mental examine the association between mental estimates (from the years 2000–2003 disorders, including consumption of illegal illness and smoking and factors contrib- with DSM-IV criteria),4 anxiety disor- drugs and non-medical use of prescription uting to it. The association or observed ders have the highest 12-month preva- medications. Although the studies emphasize co-occurrence between smoking and cigarette smoking, it is plausible to generalize lence of mental disorders (18.1%) the findings to other tobacco delivery systems mental illness is robust across countries followed by mood disorders (9.5%). involving deep inhalation, such as a hookah, and within them, across age, race and Within mood disorders, there are vari- due to the pharmacodynamics of nicotine. sex. As a testimony to its robustness, the ous disorders, including Major Depres- Although this review did not examine any association is found even across different sive Disorder (MDD). It is estimated studies specific to Arab Americans, the findings measures of mental illness and different should generalize if smoking is stigmatized or, that 6.6% currently meet criteria for measures of smoking. The data pre- alternatively, as stigmatization increases. The having MDD, with 16.2% either having good news is that even with the robust sented in this review will draw upon current MDD or a history of it. association between depression and smoking, these studies, with an emphasis on more Highlighting its importance, a high people with depression can quit smoking and recent studies, and their various mea- proportion of individuals with MDD continue to be smoke-free. Because 44.3% of sures of mental illness and smoking. cigarettes in the United States are consumed has severe or very severe impairment by individuals with mental illnesses1, mental (50.9%) and few are adequately treated illness deserves a prominent focus to allow our (21.7%). ACKGROUND public health goal of reducing the prevalence B In the 1997 National Household of smoking to be reached. (Ethn Dis. Survey on Drug Use, which sampled 2007;17[Suppl 3]:S3-16–S3-18) One of the first national reports in individuals aged $12 years of age living the United States used results from Key Words: Depression, Smoking in households, Richter et al found the 1990–1992 National Comorbidity MDD, as well as the use of illegal drugs Study, an in-person survey estimating or non-medical use of prescribed med- the prevalence of mental illnesses in ications, to be associated with smoking a national representative sample be- 5 tween 15 and 54 years of age.2 In that in the past 30 days. This association survey, data were collected on mental held even after controlling for age, sex, illness by highly trained lay interviewers race, education, regular source of care, using a structured interview with coded ever in drug treatment, perceived risk of responses that followed Diagnostic and smoking and alcohol binges. Statistical Manual of Mental Disorders (DSM) IIIR criteria.3 A diagnose of smoking and nicotine dependence were STUDY REVIEWS assessed for those who reported they smoked daily. Lasser et al reported that Lasser et al found the quit rate for of those with either a history of or people with current mental illnesses to current mental illness, 34.8% smoked be lower (30.5%) than those with daily.1 For those with a current mental history of mental illnesses (37.1%) or illness, 41.0% smoked daily. This those without a history of mental disorder (42.5%).3 Specific to depres- From the Wayne State University, prevalence of daily smoking was higher School of Medicine, Department of Psychi- than that of individuals without a history sion, Breslau et al followed a cohort of atry and Behavioral Neurosciences. of mental illness (22.5%). In addition, young people in southeastern Michigan

S3-16 Ethnicity & Disease, Volume 17, Summer 2007 TOBACCO AND HEALTH - Arfken and found the five-year quit rate did not ameliorating self-reported withdrawal In addition to cohort studies where vary by depression status at baseline symptoms. However, it had no impact data are collected from different time (19.0 vs. 21.6%).6 In contrast, Glass- on smoking cessation, either for the points, cross-sectional surveys can ad- man et al found a statistically significant entire sample or sub-samples defined as dress temporal sequence. Using data difference of successfully quitting smok- people with history of MDD or current from the National Comorbidity Study, ing by depression status when investi- depressive symptoms. The use of cog- Breslau et al examined the sequence of gating clonidine as an aid for smoking nitive behavioral therapy (and nicotine mental illnesses and smoking using self- cessation.7 patch) may have played a major role in reported timing of these events.17 They Hitsman et al conducted a meta- addressing coping strategies and dealing found consistent and strong associations analysis and found no difference in the with negative affect. between current or active mental illness quit rate for those with or without If the quit rate is not responsible for and progression to daily smoking or to depression in the short term (three the association between depression and nicotine dependence. This latter di- months) or longer term (six months).8 smoking, does smoking cause depres- agnosis is defined by criteria such as It is possible that the meta-analysis did sion or depression cause smoking? To difficulty quitting, presence of with- not examine a long enough timeframe. answer this question, observational drawal symptoms when abstaining, It has been reported that people, who studies must be used. The cohort excess time spent smoking/acquiring relapsed after successfully quitting assembled by Breslau et al, as described cigarettes and tolerance of smoking smoking, were more likely to report above, would be ideal to examine these symptoms.18 The associations held that they smoked when having a negative questions. They reported that MDD across a variety of mental illness, in- mood.9 To help predict who will predicted progression to daily smoking cluding MDD. relapse, Abrams et al used laboratory (23.0 vs. 9.3%, OR53.0).13 In addi- From these studies, it appears that procedures with former smokers and tion, smoking status at baseline pre- smoking predicts depression and de- current smokers. They found the former dicted MDD five years later (12.1 vs. pression predicts smoking. However, smokers displayed better coping and less 6.5%, OR51.9). Although controlling the association may not be causal if physiologic responses to stressful situa- for conduct disorder weakened the a third factor could explain these tions than current smokers.10 associations; they still showed consistent findings. Kendler et al used a sample Because research has demonstrated dose-responses for both directions of the of United States White female twins to that lower quit rates are found for those association. examine genetic factors predisposing to with depression, relapse was related to In Norway, Klungsøyr et al recently smoking and depression.19 They con- negative mood and that one of the reported on a cohort of adults followed cluded that smoking and depression co- withdrawal symptoms from smoking for 11 years.14 Consistent with Breslau occurred but that the association was is depressed mood, it was logical that et al, they found a dose-response due to an inherited predisposition to antidepressants be examined as a smok- between smoking quantity and years both. The results, while provocative, ing cessation aid. In 1997, the US and later development of ICD-10-de- have not been examined to our knowl- Food and Drug Administration ap- fined depression. The risk of developing edge in other more diverse samples. proved Bupropion for the treatment of a first episode depression was four times In a separate genetic study, Audrain- smoking. This approval was based upon higher in the heavy smokers compared McGovern et al, found that an in- three clinical trials that found 18% of to those who never smoked. teraction of specific genetic variants and those assigned to bupropion quit smok- The temporal sequence of depres- depression predicted progressing to ing vs 5% of those assigned to a place- sion predicting later smoking has also a higher level of smoking in adoles- bo.11 been found in children. In Australia, cents.20 The genetic variants did not, Other antidepressants were subse- Patton et al surveyed 2032 children and however, predict smoking initiation. quently examined. One, fluoxetine, was found depression and anxiety predicted Others have supported the argument investigated in Detroit.12 In 150 daily smoking in both boys and girls when that a third factor contributes to the smokers, who received cognitive-behav- their peers smoked.15 In California, association of depression and smoking. ioral therapy and nicotine patches, there Weiss et al followed an ethically diverse Covey et al argued in their study of was no difference in smoking cessation sample of children between 6th and 7th adolescents that high level of stress and between those who received placebo and grade.16 Among other factors, they specific (maladaptive) coping strategies either of two doses of fluoxetine. The found depressive factors at baseline may encourage both smoking and de- antidepressant was associated with ame- predicted smoking the next year and velopment of depression.21 A recent liorating weight gain among those who more frequent smoking among those report from China found smoking quit smoking. It was also associated with already smoking. (‘‘ever had a puff’’) and past 30-day

Ethnicity & Disease, Volume 17, Summer 2007 S3-17 TOBACCO AND HEALTH - Arfken smoking in early and late adolescents to nent focus if our public health goal of 11. U.S. Food and Drug Administration (FDA). be associated with a way to regulate reducing the prevalence of smoking is to Consumer Report, November-December 1997. Available at: http://www.fda.gov/fdac/ mood, either for relaxing or energiz- be reached. features/1997/797_smoke.html. Accessed on: 22 ing. Although smoking is not stigma- 5/2/06. tized in Chinese adults, it is stigmatized REFERENCES 12. Saules KK, Schuh LM, Arfken CL, Reed K, for adolescents, especially girls. The 1. Lasser K, Boyd JW, Woolhandler S, Himmel- Kilbey MM, Schuster CR. Double-blind observed associations may not have stein DU, McCormick D, Bor DH. Smoking placebo-controlled trial of fluoxetine in smok- and mental illness: A population-based prev- ing cessation treatment including nicotine found such a high endorsement if alence study. JAMA. 2000;284(20):2606–10. patch and cognitive behavioral group therapy. smoking were normative. 2. Kessler RC, McGonagle KA, Zhao S, Nelson Am J Addictions. 2004;13(5):438–46. CB, Hughes M, Eshleman S, et al. Lifetime 13. Breslau N, Peterson EL, Schultz LR, Chilcoat and 12-month prevalence of DSM-III-R HC, Andreski P. Major depression and stages of smoking. Arch Gen Psychiatry. 1998;55: CONCLUSIONS psychiatric disorders in the United States. Results from the National Comorbidity Sur- 161–166. vey. Arch Gen Psychiatry. 1994;51(1):8–19. 14. Klungsøyr O, Nyga˚rd JF, Sørensen T, San- From the data presented here and 3. American Psychiatric Association. Diagnostic danger I. Cigarette smoking and incidence of the extensive literature not reviewed, it and Statistical Manual of Mental Disorders.3rd first depressive episode: an 11-year population- is apparent that depression and smoking ed. Washington, DC: American Psychiatric based follow-up study. Am J Epidemiol. Publishing; 1994. 2006;163:421–432. are associated, at least in countries or 15. Patton GC, Carlin JB, Coffey C, Wolfe R, 4. Kessler RC, Chiu WT, Demler O, Merikangas subgroups where smoking is stigma- Hibbert M, Bowes G. The course of early KR, Walters EE. Prevalence, severity, and smoking: a population-based cohort study over tized, and the association may be comorbidity of 12-month DSM-IV disorders three years. Addiction. 1998;93(8):1251–60. multifactorial in nature. Moreover, it in the National Comorbidity Survey Replica- 16. Weiss JW, Mouttapa M, Chou C, Nezami E, appears that the association between tion. Arch Gen Psychiatry. 2005;62(6):617–27. Johnson CA, Palmer PH, et al. Hostility, 5. Richter KP, Ahluwalia HK, Mosier MC, Nazir smoking and mental illness extends depressive symptoms and smoking in early N, Ahluwalia JS. A population-based study of beyond depression to other disorders, adolescence. J Adol. 2005;28:49–62. cigarette smoking among illicit drug users in including consumption of illegal drugs 17. Breslau N, Novak SP, Kessler RC. Psychiatric the United States. Addiction. 2002;97:861– disorders and stages of smoking. Biol Psychi- and non-medical use of prescription 869. atry. 2004;55:69–76. medications. Although the studies em- 6. Breslau N, Johnson EO. Predicting smoking 18. American Psychiatric Association. Diagnostic phasize cigarette smoking, it is plausible cessation and major depression in nicotine- and Statistical Manual of Mental Disorders. to generalize the findings to other dependent smokers. Am J Public Health. DSM-IV-TR. Washington, DC: American tobacco delivery systems involving deep 2000;90(7):1122–7. Psychiatric Publishing; 2000. 7. Glassman AH, Stetner F, Walsh BT, Raizman inhalation, such as a hookah, due to the 19. Kendler KS, Neale MC, MacLean CJ, Heath PS, Fleiss JL, Cooper TB, et al. Heavy AC, Eaves LJ, Kessler RC. Smoking and major pharmacodynamics of nicotine. Al- smokers, smoking cessation, and clonidine. depression. A causal analysis. Arch Gen though the review did not examine Results of a double-blind, randomized trial. Psychiatry. 1993;50:36–43. any studies specific to Arab Americans, JAMA. 1988;259(19):2863–6. 20. Audrain-McGovern J, Lerman C, Wileyto EP, the findings should generalize if smok- 8. Hitsman B, Borrelli B, McChargue DE, Rodriguez D, Shields PG. Interacting effects of Spring B, Niaura R. History of depression ing is stigmatized or, alternatively, as genetic predisposition and depression on and smoking cessation outcome: a meta- adolescent smoking progression. Am J Psychi- stigmatization increases. The good news analysis. J Consult Clin Psychol. 2003;71(4): atry. 2004;161:1224–1230. from this review is that even with the 657–63. 21. Covey LS, Tam D. Depressive mood, the single- robust association between depression 9. Pomerleau O, Adkins D, Pertschuk M. parent home, and adolescent cigarette smoking. and smoking, people with depression Predictors of outcome and recidivism in Am J Pub Health. 1990;80:1330–1333. can quit smoking and continue to be smoking cessation treatment. Addict Behav. 22. Weiss JW, Spruijt-Metz D, Palmer PH, Chou 1978;3:65–70. C, Johnson CA. China Seven Cities Research smoke-free. In addition, with 44.3% of 10. Abrams DB, Monti PM, Rodger PP, Elder JP, Team. Smoking among adolescents in China: cigarettes being consumed in the United Brown RA, Jacobus SI. Psychosocial stress and An analysis based upon the meanings of States by individuals with mental ill- coping in smokers who relapse or quit. Health smoking theory. Am J Health Promotion. nesses, mental illness deserves a promi- Psychol. 1987;6(4):289–303. 2006;20:171–178.

S3-18 Ethnicity & Disease, Volume 17, Summer 2007 F. COLLABORATIVE RESEARCH OF TOBACCO USE AND ITS PREDICTORS IN ARAB AND TH NON-ARAB AMERICAN 9 GRADERS

Virginia Hill Rice, PhD, RN; Thomas Templin, PhD; Adnan Hammad, PhD; Linda Weglicki, PhD, RN; Hikmet Jamil, MD, PhD; Sharifa Abou-Mediene, MD, MPH

Ethn Dis. 2007;17[Suppl 3]:S3-19–S3-21 INTRODUCTION subgroup change was a reduction in current smoking among Black males Key Words: Depression, Tobacco, Narghile, 4 Smoking This presentation documents the from 19.3% to 14%. Few smoking development of a collaborative research behavior data are available for other effort between the university and an ethnic groups such as Arab Americans ethnic community center to determine who number almost four million and tobacco use and its predictors in Arab are one of the fastest growing immigrant 7 and non-Arab American 9th graders. groups in America. They live in all 50 Tobacco use, primarily cigarette smok- states; 66% reside in 10 of them. One- ing, is a major preventable public health third of the total live in Michigan, risk in most of the developing countries California and New York, and approx- of the world1 even as rates have declined imately 94% live in large metropolitan in developed countries like the United areas including Detroit, Los Angeles, States.2 The WHO reports smoking as New York City, Chicago, Washington, the second cause of death and disability D.C. and northeastern New Jersey. worldwide; it responsible for the death of Almost 490,000 Arab Americans live 8 one in ten adults. There are approxi- in Michigan. As they migrate around mately 1.1 billion smokers in the world; the world, Arabs bring with them their about one-third of the global population cultural traditions and behaviors, one of aged 15 years and over.3 Worldwide which is tobacco use. On average, 45% more than half of the adolescents of the men and 5% of the women in the 18 years and under have experimented Middle East smoke. Traditionally, to- with smoking.1 In America, 23% of all bacco use by women in the Middle East high school students reported smoking in has been very low; it is now on the rise.9 the past month with almost equal Estimated cigarette smoking among numbers of boys and girls4; this is slightly 13- to 15-year-old boys and girls in the higher than the 21% reported in 2003.5 Eastern Mediterranean region is 35% and More than half began smoking before 4%, respectively; 25% had smoked their the age of 14 and 90% before the age of first cigarette before the age of 10.3 While 19.Twenty-seven percent (27%) of 12th much is known about cigarette smoking graders are current users; one in four is and its dangers,2,10 less is known about a regular smoker by the time he or she another form of tobacco use commonly leaves high school.6 used by those in the Middle East (ME), Cigarette smoking rates among teens narghile smoking, as described earlier in declined during the 1970s and 1980s, this section. Today, more than 100 mil- From the Wayne State University Col- but increased in the early to mid-1990s lion people of all age groups worldwide lege of Nursing & Karmanos Cancer Institute among White, African American and smoke a water pipe on a daily basis.11–12 (VHR), Wayne State University, Center for Health Research (TT), Arab Community Hispanic high school students, especial- Researchers in the Middle East are 6 Center for Economic and Social Services ly girls. On the whole, Hispanic high just beginning to evaluate narghile (ACCESS), Community Health & Research school students were higher tobacco smoking by the young. Tamim and Center (AH), Wayne State University Col- users (18.4%) in the previous month others13 reported an overall smoking lege of Nursing (LSW), Wayne State Uni- than African American (15.1%) or rate of 40% in 2000 university students versity Department of Family Medicine (HJ), 5 Arab Community Center for Economic and Asian-American youth (12.8%). In in Lebanon; 21.1% indicated using only Social Services (ACCESS), Child & Adoles- 2006, the overall rate increased from the narghile; 12% smoked both cigar- cent Health Program (SAM). 22.9% to 23%; the only significant ettes and narghile. In a cross-sectional

Ethnicity & Disease, Volume 17, Summer 2007 S3-19 TOBACCO AND HEALTH - Rice et al study of university students in Syria, esteem, CESD-Depression, adolescent reason for this may be because narghile Maziak et al14 found 62.6% and 29.8% stress, and tobacco use history were use is a cultural form of hospitality among narghile use, respectively, for young completed in a single session. adults of the Middle East. As a youth men and women. Cigarette-smoking approaches adulthood, this behavior be- rates were 25.5% for men and 4.9% comes more and more acceptable.16 for women. Seven percent (7%) of the RESULTS Narghile use was also a strong predictor male students reported using the nar- of current cigarette smoking. This raises ghile daily. Although the World Health Regular, last 30 days, and experimen- serious concerns about the role of this Organization has documented cigarette tal use of cigarettes by Arab American commonly accepted cultural practice in smoking on a regular basis for a long youth were 1%, 2% and 9%, respectively the Arab American community. First, it period of time,1,3 it has just begun to compared to 5%, 9% and 27%, re- may be the narghile smoking is a gateway monitor narghile use. Few data were spectively, for non-Arab youth. In con- tobacco product leading to higher rates of found for narghile smoking among high trast, narghile use was 8%, 12% and 36% cigarette use in the long term. It is also school students and those younger in for regular, last 30 days, and experimen- possible that narghile smoking may be either the Middle East or the United tal use, respectively, by Arab American a substitute for cigarette smoking, but States. As cigarette and narghile smoking 9th graders compared to 3%, 4% and with as yet unrecognized and unstudied rates for Arab adults and college-aged 11%, respectively, for non- Arab youths. health risks. These risks may be equal to, students15 appear to be high, it is Logistic regressions revealed having three or more harmful than, those related to important to examine the patterns and or more close friends who smoked cigarette smoking. Clearly, further re- predictors in adolescents of all tobacco (OR55.72), brother(s) who smoked search is needed into this form of tobacco use so that effective prevention and/or (OR5 3.52), being US-born use that is spreading rapidly into the non- cessation programs can be initiated early. (OR55.08), receiving offers to smoke Arab community. Finally, tobacco use (OR53.82) and English not spoken at among friends and family members home (OR53.21) all contributed to appeared to have a sustaining effect for METHODS cigarette smoking in last 30 days. Vari- current cigarette smoking, while cultural ables predictive of experimenting with factors, offers and availability of tobacco Participants in this adolescent to- cigarettes included having one or more (in addition to friends’ use) contributed bacco use were 1455 9th grade students close friends who smoked (OR53.42), more to experimentation. These findings attending two community high schools brother(s) smoking (OR51.48), receiv- suggest further exploration and direction for the development of community pre- and able to read and write in English or ing offers to smoke (OR51.66), being vention and cessation programs in the Arabic and willing to participate. The depressed (OR51.77), exposed to smok- very young. average age was 14.54 (SD50.83); 55% ing at home (OR51.42) and easy access were male and 89% self-identified as to cigarettes (OR51.73). For experimen- REFERENCES Arab American. Information letters de- tal narghile use, being Middle Eastern 1. World Health Organization [WHO] Tobacco 5 5 scribing the study were mailed to (OR 8.55), male (OR 1.90), mother Free Initiative. (2005a). Why is tobacco a pub- parents by the school administration. smoking (OR51.82), sister(s) smoking lichealth priority. Available at http://www. Those who did not wish their child to (OR52.04), having one or more close who.int/tobacco/en/. Last accessed on January participate were instructed to contact friends who smoked (OR51.99), being 10, 2005. theschool;therewerenoparental stressed (OR51.73) and having easy 2. US Department of Health and Human Services. (USDHHS). The Health Consequences access (OR51.58) were all significant refusals. In addition, students were of Smoking: A Report of the Surgeon General. given a choice for participation in the predictors. Ethnicity, parents and peers Washington, DC.: U.S. Government Printing classroom and received a Human In- were all significant predictors of the two Office Number 0-16-051576-2. Atlanta: Cen- vestigative Committee (HIC) approved forms of tobacco use by 9th graders. ters for Disease Control and Prevention, Office Information Sheet; no students refused of Smoking and Health. 2004. 3. World Health Organization [WHO] Tobacco to participate. Fifty-seven percent Free Initiative. (2005b). Regional Databases (57%) of the youths reported being DISCUSSION (Eastern Mediterranean Region).Available born in the Middle East with a mean at: http://www.emro.who.int/TFI/Country time in the United States of 6.0 years Tobacco use in the form of exper- Profile-Part6.htm#table5. Last accessed on (SD 5 4.3). Reliable and valid bilingual imentation and/or last-30-day use was January 10, 2005. 14,15 4. Centers for Disease Control and Prevention. tools measured demographic and prevalent for both Arab and non-Arab Cigarette use among high school students – th cultural information (DCI), family and Americans in the 9 grade. However, the United States, 1991–2005. Morb Mort Wkly. peer tobacco use, Rosenberg’s self- type of tobacco smoked differed. One 2006;55(26):724–726.

S3-20 Ethnicity & Disease, Volume 17, Summer 2007 TOBACCO AND HEALTH - Rice et al

5. Johnston LD, O’Malley PM, Bachman JG, www.aaiusa.org/demographics.htm. Last ac- 12. Wolfram RM, Chehne F, Oguogho A, Schulenberg JE. Monitoring the future: national cessed September 27, 2005. Sinzinger H. Narghile (water pipe) smoking results on adolescent drug use—Overview of key 9. Centers for Disease Control and Prevention influences platelet function and (iso-)eicosa- findings. (NIH Publication No. 04-5506). (CDC). (2004). Global Tobacco Use Survey. noids. Life Sci. 2003;74:47–53. Bethesda, Maryland: National Institute on Available at http://www.cdc.gov/tobacco/global/ 13. Tamim H, Terro A, Kassem H, et al. Tobacco Drug Abuse; 2004. GYTS/GYTS_intro.ht. Last accessed July 9, use by university students, Lebanon, 2001. 6. Johnston LD, O’Malley PM, Bachman JG, 2005. Addiction (England). 2003;98:933. Schulenberg JE. Monitoring the future: nat- 10. US Department of Health and Human 14. Maziak W, Ward K, Soweid RA, Eisenberg T. ional survey results on drug use, 1975–2003: Services. (USDHHS). (1994). Preventing Tobacco smoking using a waterpipe: A re- Volume I, Secondary school students. Tobacco Use among Young people: A Report of emerging strain in a global epidemic. Tobacco (DHHS Publication no. (NIH) 04-5507). the Surgeon General. Washington DC: U.S. Control. 2004;13:327–333. Bethesda, MD: National Institute on Drug Govt. Printing Office No. S/N 017-001- 15. Rice VH, Templin T, Kulwicki A. Arab Abuse; 2003. 00491-0. Atlanta: Public Health Service, American tobacco use: Four pilot studies. 7. Abraham N, Shryock A, eds. Arab Detroit: Centers for Disease Control and Prevention, Preventive Medicine. 2003;37:492–498. From Margin to Mainstream. Detroit, Mich: Office of Smoking and Health. 1994. 16. Rice VH, Weglicki LS, Templin T, Hammad Wayne State University Press; 2000. 11. The Sacred Narghile: Hookah, Shisha, Water- A, Jamil H, Kulwicki A. Predictors of Arab 8. Arab American Institute (2005) Arab Ameri- pipe. Available at http://www.sacrednarghile. American adolescent tobacco use. Merrill- can Demographics. Available from http:// com. Last accessed on July 8, 2004. 2004. Palmer Quarterly. 2006;52(2):327–342.

Ethnicity & Disease, Volume 17, Summer 2007 S3-21 G. TOBACCO USE PATTERNS AMONG HIGH SCHOOL STUDENTS: DO ARAB AMERICAN YOUTH DIFFER?

Objective: To determine tobacco use rates Linda S. Weglicki, PhD, RN; Thomas Templin, PhD; (cigarette, water pipe smoking [WPS] or Adnan Hammad, PhD; Hikmet Jamil, MD, PhD; narghile) in Arab American compared to non- Arab youth. Sharifa Abou-Mediene, MD, MPH; Mona Farroukh; Design/Setting: A convenience sample of Virginia Hill Rice, PhD, RN 2,782 14- to 18-year-old high school students from a midwest community completed a 21- 6 item tobacco use history survey. INTRODUCTION ble diseases (eg, tuberculosis, hepatitis) and a variety of life-threatening condi- Results: Seventy-one percent of the partici- The significant progress our nation tions (eg, coronary heart disease, pul- pants were ArA. Grades 9 through 12 were equally represented. Results included ‘ever made in reducing youth cigarette smok- monary disease and pregnancy related tried cigarettes [narghile]’ (20%, 39%); ‘smoked ing since the mid-1990s has stalled, complications) similar to those caused 7 cigarettes [narghile] in the past 30 days’ (7%, according to the 2004 National Youth by cigarette smoking. The research 22%); and ‘regular smoking [narghile]’ (3%, Tobacco Survey results.1 Overall, youth conducted by Rice and colleagues is 15%) for ArA and non-Arab youths, respective- cigarette-smoking rates, based on the the only known reported research on ly. Each was significantly related to grade and WPS among adolescents, both Arab ethnicity. WPS for ArA and non-Arab youths CDC 2005 reported data, were 23% for th th was (38%, 21%); (17%, 11%); and (7%, 5%) for all 9 through 12 grade students and American and non-Arab, in the United 2 ‘ever used,’ ‘used in the past 30 days,’ and 8.1% for 6th through 8th grade middle States. The purpose of this study was to ‘regular use,’ respectively. Grade, ethnicity, and school students. While there are well- examine tobacco use, (ie, cigarette sex were significantly related to WPS. recognized differences in youth ciga- smoking and WPS in a convenience sample of adolescents (14 to 18 years of Conclusions: Cigarette smoking rates for non- rette-smoking rates for the four major Arab youth were lower than current national racial/ethnic groups, the smoking rates age) attending high school with a large youth smoking rates but significantly higher for Arab Americans is generally not immigrant Arab population in a Mid- than ArA youth. Rates for ArA youth were singled out. Arab Americans, one of the western community. Data were collect- much lower than current national reported fastest growing immigrant groups in the ed in 2004 and 2005. data. Rates of WPS for US youth, regardless of United States, number nearly 4 million race or ethnicity, are not known. Findings from this study indicate that both ArA and non-Arab with approximately 490,000 living in youth are experimenting and using WPS Michigan. Adults from the Middle East METHODS regularly. These results underscore the impor- have some of the highest reported tance of assessing novel forms of tobacco use, cigarette smoking rates in the world2; Design particularly WPS, a growing phenomenon ranging from 60% in Tunisia to 40% in This community-based, cross-sec- among US youth. (Ethn Dis. 2007;17[Suppl 3 3]:S3-22–S3-24) Iraq which may translate into higher tional survey examined current tobacco smoking rates among youth of Middle use, defined as ‘‘smoked one or more Key Words: Smoking, Arab American Youth Eastern descent. In addition, the cul- cigarette(s) and/or narghile within the tural patterns of tobacco use brought in past 30 days,’’ experimentation with from the eastern Mediterranean region tobacco, defined as ‘‘ever smoking and Middle East (particularly water pipe a cigarette and/or narghile, even a few smoking [WPS] or narghile)4 are in- puffs,’’ and regular tobacco use, defined From the Wayne State University Col- creasingly being modeled by youth as ‘‘smoked a cigarette and/or narghile 5 lege of Nursing (LSW), Wayne State Uni- regardless of race/ethnicity in the once or more per day for the last versity, Center for Health Research (TNT), United States, Brazil and European 30 days’’ in 14- to 18-year-old adoles- Arab Community Center for Economic and countries3 and are of particular interest. cents. Social Services (ACCESS), Community Research studies describing WPS among Health & Research Center (AH), Wayne State University, Department of Family United States youth are essential given Participants Medicine (HJ), Arab Community Center the novelty of this rapidly growing form Participants were 2,782 youths, 14 for Economic and Social Services (ACCESS), of tobacco use among young people. to 18 years of age, attending one of two Child & Adolescent Health Program (SAM), Recent studies, mainly conducted in local community high schools that Arab Community Center for Economic and the Middle East, have identified that agreed to participate. Ninety percent Social Services (ACCESS), Michigan Child/ 5 Health Kids Program (MF), Wayne State WPS results in a number of potential (n 2504) provided usable data. For University College of Nursing & Karmanos negative health consequences, such as this analysis, excluded were 632 stu- Cancer Institute. the risk of transmission of communica- dents who had previously participated

S3-22 Ethnicity & Disease, Volume 17, Summer 2007 TOBACCO AND HEALTH - Weglicki et al in a smoking prevention/cessation pro- cent of non-Arab youth reported having younger Arab American population gram. The total sample was 1872. experimented with smoking cigarettes may be the modeling of Middle Eastern Inclusion criteria were 1) between 14 (‘‘even a few puffs’’) compared to cultural tobacco use practices as one way and 18 years old, 2) able to read and 20.1% of Arab American (ArA) youth. to maintain Middle Eastern ethnic write in English or Arabic and 3) Current cigarette smoking (‘‘smoked identity.12 Another explanation may be willingness to participate. a cigarette in the past 30 days’’) was the long-held unsubstantiated belief that Information letters describing the 21.9% for non-Arab and 6.8% for ArA WPS is safe5 and therefore reporting its study were mailed to parents by the youth. Regular cigarette smoking use is not seen as being unacceptable. school administration. Parents, who did (‘‘smoking once or more per day for Even more surprising were the high not wish their child to participate, were the last 30 days’’) was 15% compared to rates of WPS for all three outcomes, instructed to contact the school; less 3.2% for non-Arab and ArA youth experimentation (21.2%), current use than 0.1% of parents refused participa- respectively. Non-Arab and ArA youth (11.3%) and regular use (5.1%) re- tion. All participants who had parental reported WPS for all three outcomes: ported by non-Arab 14- to 18 year-old consent were given a Human Investiga- ‘experimentation’, ‘current’ and ‘regular high school students participating in tive Committee (HIC) approved in- use’. WPS rates were significantly higher this study. The rates of WPS for non- formation sheet describing the study among ArA youth for experimenting Arab youth may be due to numerous prior to completing the study question- and current use (p 5,.01) but not for factors, including the rapid prolifera- naire. regular use. Thirty-eight percent of ArA tion of water pipes in ‘‘hookah’’ bars youth reported experimenting with and cafes throughout the United Tobacco Use History narghile, compared to 21.3% of non- States.13 In this large immigrant Mid- Questionnaire (TUHQ) Arab. Current WPS (‘‘smoked narghile dle Eastern community, the modeling The Tobacco Use History Ques- (water pipe) in the past 30 days’’) was of a behavior by adolescents is viewed tionnaire (TUHQ) is a 21-item survey 16.7% for ArA youth compared to as novel and perceived by youth as used to collect information on smoking 11.3% for non-Arab youth. Regular ‘awesome’ or ‘sweet,’ youth experi- history. The first five questions ask WPS (‘‘smoking narghile (WPS) once menting with adult-like behaviors (eg, about demographic information such or more per day for the last 30 days’’) smoking), and perhaps being misin- as date of birth, age, grade in school and was 6.9% and 5.1% for ArA and non- formed that WPS is a safe alternative ethnicity. The next seven items were Arab youth respectively. to cigarette smoking.13 adopted from the Youth Risk Behavior In summary, there is growing na- Survey.8 Seven parallel questions ask tional and international recognition about WPS. Four items ask about DISCUSSION about the increased rates of WPS3 but, attempts to quit smoking, one question there is limited research about the asks about desire to quit, two questions There are no known studies of WPS patterns of WPS among this age group ask about other forms of tobacco use rates for non-Arab US youth. Nor are in the United States. Evidence suggests and five questions ask about plans to there any known studies for WPS rates that WPS is a rapidly growing phenom- stop smoking based on stages of in the United States for Arab American enon among the young, regardless of change.9 youth. Therefore, we are unable to ethnicity and geographic location with- make comparisons. However, studies in the United States. This is the first Data Analysis Procedures conducted in the Middle East report known study to present data on WPS by Descriptive statistics were used to WPS rates to range from 20% to 30% US youth, in particular those who are present the sample. Prior to analysis, for adults and adolescents4,5,10 with not of Arabic ancestry. These study data were weighted so that all ages were rates as high as 40.9% for Iranian findings identify the need for further equally represented. Significance for all boys.11 Our findings for Arab American research in order to determine the analyses was set at P # .05. youth (ie, 38% for experimentation, prevalence and patterns of WPS among 16.7% for current use and 6.9% for all racial and ethnic youth as well as regular use) are fairly consistent with the college-aged young adults, its health RESULTS WPS patterns of Middle Eastern col- consequences and its relationship to lege-aged students (ie, 62.6% for boys/ cigarette smoking and other forms of Cigarette smoking rates were signif- 29.8% for girls experimentation, 25.5% tobacco use. In addition, effective broad icantly higher for non-Arab American for boys/4.9% for girls current use and and culturally based interventions, de- youth for experimenting, current, and 7% daily use by boys).5 One reason for signed to mitigate WPS and its growing regular use (P,.01). Thirty-nine per- the higher pattern of use for this use by youth in the United States, need

Ethnicity & Disease, Volume 17, Summer 2007 S3-23 TOBACCO AND HEALTH - Weglicki et al to be developed and tested before we who.int/tobacco/en/. Accessed on: 04/15/ of change. Psychotherapy: Theory, Research and begin to see an increase in the negative 2006. Practice. 1982;19:276–287. 4. Tamin H, Terro A, Kassem H, et al. Tobacco 10. Chaaya M, Awwad J, Campbell OM, Sibai A, health consequences associated with this use by university students, Lebanon, 2001. Kaddour A. Demographic and psychosocial growing phenomenon among youth Addiction. 2003;98:933–939. profile of smoking among pregnant women in and young adults. 5. Maziak W, Ward K, Soweid RA, Eisenberg T. Lebanon: public health implications. Maternal This study was supported by the Tobacco smoking using a water pipe: A re- and Child Health Journal. 2003;7:179–186. National Institute of Child Health and emerging strain in a global epidemic. Tobacco 11. Momenan AA, Etemadi A, Ghanbarian A, Azizi F. The rising prevalence of water pipe Human Development [NICHHD] Control. 2004;13:327–333. 6. Knishkowy B, Amitai Y. Water pipe (narghile) smoking among Iranian adolescents: Tehran [RO1-HD37498] smoking: an emerging health risk behavior. lipid and glucose study. Paper presented at the Pediatrics. [serial online] 2005. Available at: 13th World Conference on Tobacco or Health: REFERENCES www.pediatrics.org/cgi/doi/10.1542/peds. Building capacity for a tobacco-free world, 1. Center for Disease Control and Prevention. 2004-2173. Last accessed: September Building capacity for a tobacco-free world, Tobacco use, access, and exposure to tobacco 20, 2005. Washington, DC: July 13, 2006. in media among middle and high school 7. Maziak W. Waterpipe Smoking: Anatomy of 12. Ali Smith M. Arab Americans: In search of students – United States, 2004. MMWR. the Epidemic. Paper Presented at the 4th identity. Available at: Asharq Alawsat: The 2005;54:297–301. National Arab American Conference, Health Leading International Daily [English version] 2. Rice V, Weglicki L, Templin T, Hammad A, Issues in the Arab American Community, Dear- http://aawsat.com/english/print.asp?artid5 Jamil H, Kulwicki A. Predictors of Arab born, MI: May 11, 2006. id5800. Last accessed: August 18, 2006. American adolescent tobacco use. Merrill- 8. Brener ND, Kann L, Kinchen S, et al. 13. O’Hegarty M. Emerging trends and usage of Palmer Quarterly. 2006;52(2):327–342. Methodology of the Youth Risk Behavior water pipes among the United States popula- 3. World Health Organization Tobacco Free Surveillance System. MMWR. 2004;53:1–13. tion. Poster presented at the 2003 National Initiative. Why is tobacco a public health 9. Prochaska JO, DiClemente CC. Transtheore- Conference on Tobacco or Health, Boston, priority. 2005. Available at: http://www. tical therapy: Toward a more integrative model MA.

S3-24 Ethnicity & Disease, Volume 17, Summer 2007 H. ABSTRACT:PATTERNS OF SMOKING AMONG ALEPPO UNIVERSITY STUDENTS Nizar Akil, MD

Objective. To determine prevalence and explore the risk-influencing factors for smoking among students, as well as attitudes toward smoking. During Aleppo University’s Campaign Against Smoking, a survey of the students regarding smoking habits and attitudes toward smoking was conducted. Methods. Of the 60,208 students at Aleppo University, 5.6% (3,378) were surveyed. The survey was conducted among both male and female students. Results. The survey showed that 35.5% of students are smokers (48.5% male and 12% female). Of the students who are water pipe smokers (WPS), 80.5% are male and 19.5% are female. Despite the fact that the majority of WPS are male, there appears to be increasing numbers of female WPS due to approval of adult family members of this method over cigarette smoking. The majority of students (53.9%) started smoking at university age. Friends were the main factor promoting smoking (51.2%). Other factors promoting smoking included relatives (15.3%) and the media (7.6%). The main reasons listed for quitting smoking were health reasons (52.2%), religious reasons (26.7%), and social reasons (21.2%). Despite the large number of smokers, the study showed that the majority of students (smokers and non-smokers) were annoyed by cigarette smoke and felt that smokers should be secluded to specific areas. Many smokers (45.4%) are dissatisfied with smoking and the majority of smokers (67.8%) would like to quit. Conclusions. Interventions targeting students before they reach university age may reduce the number of smokers, since this is the age that students primarily begin smoking. These interventions should address issues such as the influence of friends, health problems associated with smoking and prevention of relapse. It also appears that the majority of students, including those who smoke, support the banning of smoking in certain public areas.

I. ACTIVE AND PASSIVE SMOKING DURING PREGNANCY IN ALEPPO,SYRIA:DOES IT AFFECT THE OUTCOME? Moujahed Hammami, MD; Maed Ramamdan, MD; Ali Sereo, MD

Background. Smoking during pregnancy is known to be associated with premature births and low birth weights. However, limited data is known about the attitude and beliefs regarding smoke exposure or the effect of active and passive smoking during pregnancy on newborn babies in Aleppo, Syria. Methods. Three thousand pregnant women who delivered at Aleppo University Hospital for Obstetrics and Gynecology were studied. Each woman answered a questionnaire about smoking and environmental tobacco exposure (ETS). Weight, length, head circumference, as well as gestational age assessment, were measured for the newborns. Subjects. Mothers were divided into four groups: non-smoking (NS) mothers (n51000), active smoking (AS) mothers during pregnancy (n5850), active smoking (ASC) mothers who quit during pregnancy (n5150) and passive smoking (PS) mothers during pregnancy (n51000). Results. Infants born to mothers in the AS and PS groups had significantly (P,.05) lower birth weight, shorter birth length and smaller head circumference in addition to a significantly higher incidence of premature birth, compared to infants born to mothers in the NS group. There was no significant difference in birth weight, birth height, head circumference or the incidence of premature birth between infants born to mothers in the ASC group and the NS group. Conclusion. Our data confirmed past reports on the negative effect of smoking during pregnancy on the newborn. In addition, it emphasized the need for education and awareness of these findings, as well as changing attitudes and beliefs related to active and passive smoking among spouses and family members of pregnant women in Aleppo, Syria.

Ethnicity & Disease, Volume 17, Summer 2007 S3-25 LIFESTYLE AND HEALTH OUTCOMES

SECTION IV: LIFESTYLE AND HEALTH OUTCOMES

Section IV has been edited by May Darwish-Yassine, PhD; Linda Jaber, PharmD

Ethn Dis. 2007;17[Suppl 3]:S3-26–S3-46 A. OVERVIEW factors to male infertility based on this clinic-based, epidemiological investiga- Key Words: Lifestyle, Health Outcomes, In- fertility, Mental Health, Asthma, Depression, This session offered discussions on tion. Cardiovascular Disease, Diabetes risk factors related to cardiovascular One presentation of a comprehen- disease, with particular emphasis on sive, community-wide assessment of the relatively higher prevalence of di- mental health needs among communi- abetes and tobacco use in Arab Amer- ties of Middle Eastern and East African icans and the possible higher prevalence descent in the San Diego, California of hypertriglyceridemia. Presentations region included a look at the relation- focused on barriers including: lack of ship between psychological symptoms effective communication between and history of trauma, levels of accul- healthcare providers and Arab American turation and other social factors. Expe- patients, socioeconomic conditions, cul- riencing racial/ethnic discrimination by tural myths and misconceptions related adopted society, history of torture and to treatment and prevention, insurance harassment in country of origin and coverage, and the complexity of in- language barriers were commonly re- corporating preventive services into ported. Difficulty in revealing and a typical office visit. seeking help for these stressors were Evidence of increased risk for car- observed and resulted in various psy- diovascular disease associated with ge- chological problems, including anxiety, netic predisposition and with lifestyle anger and aggressiveness in students. factors such as tobacco use, nutrition The need for improving cultural com- and obesity has been established. The petency within the healthcare system to link between depression and cardiovas- enable it to reach out, identify and cular diseases is emerging as an area of manage these conditions was discussed. investigation. One presentation focused Utilization of glucose-lowering on summarizing the evidence for the agents and aspirin in Arab American role of depression or depressed affect in patients with diabetes was compared to the etiology and in the prognosis of the national utilization rate of these heart conditions. agents as measured by national surveys. Findings of an original investigation The study site was the city of Dearborn, from Lebanon reviewed the association the major hometown for Arab Amer- between male infertility as a chronic icans in Michigan. Patterns of utiliza- condition and a series of culturally tion were found to be different between specific risk behaviors, such as consan- Arab American diabetics in the Dear- guinity in marriage, a common practice born area who were less likely to be in Arab countries. Other possible risk treated with insulin and more likely to factors, such as war-related stress, smok- receive oral hypoglycemic medications ing, reproductive infections, caffeine when compared to the general popula- consumption, and occupational expo- tion. Arab Americans remarkably un- sures, were also reviewed. War-related derutilize aspirin. Better diabetic control From the Michigan Public Health In- trauma, episodes of sexually transmitted is indicated for Arab American patients stitute (MDY), Okemos, Michigan and Wayne or reproductive illness and consanguinity in order to prevent diabetic complica- State University (LJ), Detroit, Michigan. were suggested as contributing risk tions and to reduce the incidence of

S3-26 Ethnicity & Disease, Volume 17, Summer 2007 LIFESTYLE AND HEALTH OUTCOMES - Darwish-Yassine and Jaber adverse health outcomes such as cardio- Arab Americans with asthma had a higher and patients with indicators of lower vascular disease. prevalence of mental health-related acculturation. Language barrier was not- The interaction between quality asth- symptoms compared to their non-asth- ed as a risk factor for mental distress ma control in Arab Americans of Detroit matic counterparts. This association was including symptoms of anxiety, fear and and psychological distress was discussed. more marked for foreign-born patients mood disorder.

Ethnicity & Disease, Volume 17, Summer 2007 S3-27 B. MANAGING CARDIOVASCULAR RISK BARRIERS TO OPTIMAL HEALTH OUTCOMES IN THE ARAB AMERICAN PATIENT

Heart disease accounts for 38% of all deaths in Walid A. Harb, MD the United States. The American Heart Asso- ciation identified cardiovascular disease (CVD) as the most common cause of hospitalization cans, have a tendency to use an indirect in 2002. Direct and indirect costs of CVD have BARRIERS TO OPTIMAL reached a total of $393.5 billion in 2005.1 OUTCOMES communication approach, similar to Despite great advances in the treatment of that found in their country of origin. CVD, high mortality rates and poor clinical Optimal outcomes for patients with Arab American patients answer a direct outcomes persist. It has been estimated that cardiovascular disease present a challenge question by telling an introduction and a 17-year gap exists for research to reach 2 to healthcare providers. Arab American a story, often without ever addressing clinical practice. More than half a million Americans of Arab patients and other ethnic minorities face the initial question. It is usually left to ancestry live in Michigan. Similar to other significant barriers due to their relative the listener to formulate a conclusion. ethnic groups, Arab Americans face challenges isolation in our society and lack of This communication approach leaves within the US healthcare system that hinder scientifically reliable studies and evi- physicians unclear about patients’ main optimal clinical outcomes. Evidence-based dence-based strategies to overcome these ailment and treatment expectations. studies targeting the Arab American population do not exist. Small observational studies pro- barriers. The barriers in clinical practice The lack of clear communication hin- vide limited data of questionable value. (Ethn have been classified into issues related to ders optimal care. Dis. 2007;17[Suppl 3]:S3-28–S3-30) the patient, the physician, and the healthcare system. Socioeconomic Issues Key Words: Barriers, Health Outcomes, Two diametrically opposed popula- Cardiovascular Disease Patient barriers tions of Arab Americans exist – the highly educated, financially strong Risk factors group and the poorly educated, often The major cardiovascular disease risk illiterate, financially limited and isolated factors dominating the health of the Arab group. The educationally disadvantaged American patient include the high prev- group lacks the knowledge about the alence of diabetes and tobacco use. Many symptomatology and complications of clinicians equate diabetes mellitus with CVD. Financial burdens limit the coronary artery disease. A recent study group’s access to health care. Their first sponsored by the American Diabetes contact with health care is usually the Association documented a 15.5% preva- hospital emergency room in the late lencerateofdiabetesamongtheArab stages of disease. Additionally, the American population, compared to 5%– ability to followup or to fill prescrip- 8% found in the general population.4 tions remains limited. In addition, this Genetic, environmental or dietary causes group is ineligible for any type of remain to be explored. medical assistance until they obtain Michigan has the 14th highest citizenship. smoking rate in the nation, and tobacco use among Arab Americans is higher Compliance Issues than the general population of Michi- Several studies have shown that, as gan.5 Factors contributing to this high the number and frequency of medica- prevalence include perceptions such as: tion regimen increase, compliance rate tobacco use confers maturity status to decreases. Physicians caring for CVD the smoker; offering tobacco is an employ a multitude of evidence-based expected hospitality gesture; and the effective medications. Aside from the water pipe is considered a non-tobacco financial barriers to compliance, many product. Arab Americans believe the more medications they take, the poorer the out- From the Department of Medical Edu- Communication Issues comes they will experience. They regard cation, Oakwood, Health System, Dear- Arab Americans, especially those multiple medications as poisonous to born, Michigan. who are first-generation Arab Ameri- their body. They also believe that many

S3-28 Ethnicity & Disease, Volume 17, Summer 2007 LIFE STYLE AND HEALTH OUTCOMES - Harb cardiac drugs interfere with their sexual Some physicians lack expertise in pointments per hour, resulting in poor function. certain disease management either be- ratings to the healthcare system and Although Arab Americans have had cause of lack of training, certification, or providers. a low interest in exercise and diet failure to keep up-to-date with the latest (possibly linked to lack of role models research advances. Furthermore, pub- Medical Records, Education Efforts, in their country of origin), this seems to lished medical practices lack standardi- and Translations be slowly changing. The traditional zation. Multiple publications of the Nationally, the disastrous and dis- diets are healthy with plenty of grains, same subject with many conflicting organized medical records system is fruits and vegetables in the countries of recommendations add to the confusion a huge challenge. The great majority origin; however, the abundance of meat of physicians regarding the best ap- of physician offices and hospitals lack and sweets nullify any healthy advantage proaches for treatment. electronic medical records. There is no of these diets. In general, physicians harbor poor interface between hospital and clinic Another observed phenomenon is enthusiasm toward prevention because records. For optimal patient care, it is doctor shopping. Many physicians rely of lack of emphasis in medical schools important to develop systems of evi- on follow-up feedback of proposed and residency training. Furthermore, dence-based practices and to electroni- treatment in order to modify treatment insurance reimbursement favors proce- cally prevent medical errors, drug inter- plans. Doctor shopping delays im- dures at the expense of prevention. actions and reminders for better proved outcomes and it adds to the Physician reimbursement for patient preventive management. cynicism of both doctors and patients. education and counseling is virtually We lack well-coordinated educa- Possible explanation to this issue is the non-existent, compared to performing tional efforts to teach the general patient’s expectations of cure and the simple medical procedures. Even the population about CVD, diabetes melli- lack of differentiation between chronic HMO claim to advocate prevention tus or smoking cessation. The attempts and acute diseases. Poor communication fails to correct this tendency because by pharmaceutical companies at some of and limited educational efforts between reimbursement is too meager to cover these topics are often inadequate and patients and physicians contribute to overhead expenses, let alone teaching or have often resulted only in prompting this phenomenon. counseling. patients to ask for specific drugs, thus driving healthcare costs even higher. Physician Barriers Healthcare System Issues We have a paucity of high-quality, up-to-date translated materials to help Communication, Time, Medical Coverage educate Arab American patients. The Knowledge/Expertise, Attitude The United States is experiencing an prospects are even worse for those Many physicians caring for Arab explosion in the number of uninsured unable to read or write. Audiovisual American patients do not speak Arabic. and the under-insured patients. Arab materials are nonexistent. Translated Those who speak the language struggle American patients with financial diffi- materials, both in print and audiovisual with the multitude of different dialects. culties tend to belong to this group. formats, are essential communication Doctors and patients with differing Those awaiting citizenship are not tools for better health outcomes. dialects can exchange words but lack eligible for any medical assistance. Un- a complete and clear communication. In der-insured patients tend to have low- addition, Arabic-speaking physicians paying jobs, thus limiting the diagnostic CONCLUSION learned medicine and medical terminol- and therapeutic options. It also limits ogy in English. If not careful, the Arabic the patients’ access to certain hospitals, Although Arab Americans are pre- words for gallbladder or liver can easily physicians and sub-specialists. For many sented with unique barriers, they share be confused with words for pancreas or HMOs, the lowest medical cost con- many issues with the American public. kidneys. tinues to be the leading incentive for Great strides must be undertaken to In general, the decreased rates of healthcare delivery. Many HMOs limit overcome such barriers. Suboptimal care reimbursement and the increase in choices to medications of least effective- is associated with higher morbidity and documentation requirements have ness, highest profile of side effects, and mortality and hence with decreased forced many physicians to see more most drug-drug interactions simply productivity and a higher financial patients in less allotted time. As a result, because of lowest cost. In addition, as burden on the society. Solutions must educational time regarding disease treat- our healthcare system moves toward be comprehensive and effective. Al- ments, complications or prevention has more and more discounted care, doctors though individuals may have some been compromised. are responding by making more ap- impact on improving the healthcare

Ethnicity & Disease, Volume 17, Summer 2007 S3-29 LIFE STYLE AND HEALTH OUTCOMES - Harb system, the financial burden of the N Our healthcare system must create Texas: American Heart Association; 2005: change requires a legislative mandate a demand for patient and provider 63. 2. Balas E, Boren S. Managing clinical knowledge and support. education on most effective prac- for healthcare improvement. In: Haux R, ed. Our healthcare system must assure tices. Yearbook of Medical Informatics: Patient-Cen- basic medical coverage for all citizens. To N We must improve healthcare promo- tered Systems. Heidelberg, Germany: IMIA. achieve this, we recommend the following: tions through community campaigns 2000:464. using variety of learning methods 3. Jaber L, et al. The prevalence of the metabolic syndrome among Arab Americans. Diabetes N and formats to include audiovisual Electronic medical records should be Care. 2004;27:234–238. available to all practices, hospitals and print materials in multiple 4. Kulwicki A, Rice VH. A case study of and pharmacies. These records initi- languages. environmental tobacco smoke reductions. Pub ate prompts for preventive and Health Nurs. 2003;20(6). 5. Kulwicki A, Hill Rice V. Arab American better-coordinated services, thus REFERENCES adolescent perceptions and experiences with minimizing potential drug errors 1. American Heart Association. Heart Disease smoking. Public Health Nurs. 2003 May– and saving lives. and Stroke Statistics – 2005 Update. Dallas, Jun;20(3):177–83.

S3-30 Ethnicity & Disease, Volume 17, Summer 2007 C. DEPRESSION AND CARDIOVASCULAR DISEASE

Manuel E. Tancer, MD; Alireza Amirsadri, MD

Ethn Dis. 2007;17[Suppl 3]:S3-31–S3-32 INTRODUCTION each increase in score on the Beck Depression Inventory. Key Words: Depression, Cardiovascular Dis- ease Mounting evidence of a relationship Other types of studies have been between depression and cardiovascular conducted, such as the Northwick Park disease exists.1–3 This brief report Heart Study. This study included 1,408 summarizes evidence for this relation- White males, between the ages of 40 ship and describes two possible mech- and 64. At the time of enrollment, none anisms for the relationship. of the subjects had suffered from a MI. Although many risk factors for Psychological state was measured by the coronary artery disease – genetic factors, Crown-Crisp Experiential Index diabetes, hypertension, clotting abnor- (CCEI). One of the major components malities, hyperlipidemia, smoking and of this index is obsessionality. While obesity – have been recognized for many systolic blood pressure had the largest years, the role depression or depressed impact on the likelihood of fatal affect plays has only recently gained ischemic heart disease (28% and relative attention. risk [RR] of 8.7–46.8), the obsession- In this paper, we explore: research ality factor also significantly contributed studies supporting the increased rate of to the increased risk (20% and RR, 3 depression in ischemic heart disease; the 20–37.3). concept that depression or depressed or Another way of looking at the re- negative affect is a risk factor for lationship between depression and car- morbidity/mortality following myocar- diovascular disease is to examine hospi- dial infarction; and whether depression talized cardiac-risk patients diagnosed or depressed affect is a risk factor for the with major depression. Pratt et al looked development of coronary artery disease.2 at the Baltimore cohort of a national In a groundbreaking study in 1995, epidemiological sample to determine the Frasure-Smith and colleagues measured role of major depression in MI risk, as multiple variables at the time of a myo- well as to examine possible role of cardial infarct and identified those psychotropic medications in risk. The associated with mortality. Major de- study participants included 64 with MI pression, smoking status or whether an and 1,551 without heart disease. The individual received thrombolysis was odds ratio for MI in patients with not associated with mortality at depression was highly significant at 18 months. Previous myocardial infarc- 4.54. The use of tricyclic antidepressants tion (MI) and a Beck depression in- (then the standard of care for depression) ventory of .10 were highly associated was not associated with the risk of 16 with mortality (previous MI [CI, 1.9– myocardial infarction risk. 17] and elevated Beck depression in- The relationship was also supported 9 ventory (CI, 2.4–25). This work has by the Johns Hopkins Precursors Study. recently been replicated4, 5 and has been This study was a prospective, longitudi- extended beyond myocardiac infarction nal study of 1,190 medical students with to include studies of patients following a 40-year followup. The cumulative valve replacement6, 7 or coronary artery incidence of clinical depression was bypass grafting.8 Lesperance et al and 12%. Men developing depression drank Frasure-Smith and Lesperance extended more coffee than those who did not, but did not differ in terms of baseline blood From the Department of Psychiatry, the finding of a relationship between School of Medicine, Wayne State Universi- depressive symptoms and MI, demon- pressure, serum cholesterol levels, smok- ty, Detroit, Michigan. strating increased risk of mortality with ing status, physical activity, obesity or

Ethnicity & Disease, Volume 17, Summer 2007 S3-31 LIFE STYLE AND HEALTH OUTCOMES - Tancer and Amirsadri family history of coronary artery disease. creased measures of platelet activation cardial infarction. Arch Gen Psychiatry. In multivariate analysis, the men who compared with placebo treated pa- 2003;60:627–636. 5. Lesperance F, Frasure-Smith N, Talajic M, reported clinical depression were at tients.15 Bourassa M. Five-year risk of cardiac mortality significantly greater risk for subsequent Beat-to-beat heart rate variability in relation to initial severity and one-year changes coronary artery disease (RR, 2.12; CI, reflects a balance between vagal tone in depression symptoms after myocardial in- 1.24–3.63) and myocardial infarction and sympathetic activity. Altered heart farction. Circulation. 2002;105:1049–1053. (RR, 2.12; CI, 1.1–4.06). The increased rate variability has been reported in 6. Ho PM, Masoudi FA, Spertus JA, et al. risk associated with clinical depression both psychiatric disorders such as panic Depression predicts mortality following cardi- 14 ac valve surgery. Ann Thorac Surg. 2005;79: was present even for myocardial infarc- disorder and major depression and in 1255–1259. 13 tions occurring 10 years after the onset of patients with cardiovascular disease. 7. Hata M, Yagi Y, Sezai A, et al. Risk analysis for the first depressive episode (RR, 2.1; CI, Some psychotropic medications, such at depression and patient prognosis after open 1.1–4.0). The authors concluded that tricyclic antidepressants, decrease heart heart surgery. Circ J. 2006;70:389–392. clinical depression appears to be an rate variability and might lead to sudden 8. Mallik S, Krumholz H, Liu Z, et al. Patients with depressive symptoms have lower health independent risk factor for incident cardiac death, while serotonin drugs 14 status benefits after coronary artery bypass coronary arterial disease (CAD) for have the opposite effect. surgery. Circulation. 2005;111:271–277. several decades after the onset of the 9. Ford DE, Mead LA, Chang PP, Cooper- clinical depression. Patrick L, Wang NY, Klag MJ. Depression is Not all studies have confirmed the ONCLUSIONS a risk factor for coronary artery disease in men: C the precursors study. Arch Intern Med. 1998; association between depression and in- 10 158:1422–1426. creased cardiac mortality. Differences In summary, diagnosis of major 10. Stewart RA, North FM, West TM, the Long- in methodology, particularly when the depression or dimensional measures of term Intervention with Pravastatin in Ischae- depression is diagnosed (before the MI, depressed mood or negative affect is mic Disease (LIPID) Study Investigators. in the hospital during the MI, or several a risk factor for cardiovascular disease. Depression and cardiovascular morbidity and mortality: cause or consequence? European weeks after the MI) all lead to different Major depression or depressive symp- Heart J. 2003;24:2027–2037. results. In addition, it appears that toms are risk factors for poor outcome 11. Nemeroff CB, Musselman DL. Are platelets the negative or depressed affects are more following cardiac events. Major depres- link between depression and ischemic heart powerful predictors of the relationship sion is associated with several defects in disease? Am Heart J. 2000;140(4 Suppl:57–62. than are operationalized diagnoses of the clotting cascade (increasing the 12. Musselman DL, Tomer A, Manatunga AK, et major depression. likelihood of thrombus formation). al. Exaggerated platelet reactivity in major depression. Am J Psychiatry. 1996;153: What factors might mediate the Treatment with selective serotonin re- 1313–1317. relationship? At least two possible uptake inhibitors, such as sertraline, 13. Carney RM, Freedland KE, Stein PK, et al. mechanisms have been proposed that reverses many depression-associated ef- Effects of depression on QT interval variability might provide the pathophysiological fects on the clotting cascade. Finally, after myocardial infarction. Psychosom Med. link between depression and the rate of altered heart rate variability might in- 2003;65:177–180. 14. Yeragani VK, Roose S, Mallavarapu M, increased cardiac mortality. The two, crease the chance of fatal arrhythmias. Radhakrishna RK, Pesce V. Major depression which are not mutually exclusive, are with ischemic heart disease: effects of parox- 11,12 exaggerated platelet reactivity, and REFERENCES etine and nortriptyline on measures of non- reduced heart rate variability.13,14 1. Glassman A, Shapiro PA, Ford DE, et al. linearity and chaos of heart rate. Neuropsycho- Patients with major depression have Cardiovascular health and depression. biology. 2002;46:125–135. J Psychiatr Pract. 2003;9:409–421. been found to have increased activation 15. Serebruany VL, Glassman AH, Malinin AI, 2. Wulsin LR, Singal BM. Do depressive symp- the Sertraline Anti-Depressant Heart Attack of the thrombotic pathway, in particu- toms increase the risk for the onset of coronary Randomized Trial Study Group. Platelet/ 11,12 lar, exaggerated platelet reactivity. disease? A systematic quantitative review. endothelial biomarkers in depressed patients Selective serotonin reuptake inhibitors, Psychosomatic Med. 2003;65:201–210. treated with the selective serotonin reuptake currently the most widely used anti- 3. Shah SU, White S, White A, Littler WA. inhibitor sertraline after acute coronary events: depressants, appear to unstick the sticky Heart and mind 1. Relationship between the Sertraline Antidepressant Heart Attack cardiovascular and psychiatric symptoms. Post- Randomized Trial (SADHART) Platelet Sub- platelets, at least in vitro. In one study, graduate Med J. 2004;80:683–689. study. Circulation. 2003;108:939–944. the selective serotonin re-uptake inhib- 4. Frasure-Smith N, Lesperance F. Depression 16. Pratt AG, Norris ER, Kaufmann M. J Vasc itor sertraline led to significantly de- and other psychological risks following myo- Nurs. 2005;23(4):123–127.

S3-32 Ethnicity & Disease, Volume 17, Summer 2007 D. MALE INFERTILITY IN LEBANON:ACASE-CONTROLLED STUDY

Objective. The impact of risk factors, such as Loulou Kobeissi, DrPH; Marcia C. Inhorn, PhD consanguinity and familial clustering, reproductive infections, traumas, and diseases, lifestyle factors and occupational and war out epidemiological infertility research exposures on male infertility, was investigated INTRODUCTION in a case-controlled study conducted in in the developing world. Conducting Lebanon. Infertility affects more than 80 mil- sound studies on infertility, in general, lion people around the globe, with one and male infertility, in particular, is Study Design. One-hundred-twenty males in 10 couples experiencing primary or significantly controversial in male patri- and 100 controls of Lebanese, Syrian or archal societies, which relate fertility Lebanese-Palestinian descents were selected secondary infertility. Infertility is more from two in-vitro fertilization (IVF) clinics prevalent in those countries defined as with masculinity. Many cases of male located in Beirut, Lebanon. All cases suffered the infertility belt, namely the central infertility in those societies remain un- from impaired sperm count and function, and the southern African countries, identified. As such, the accurate estima- according to World Health Organization where as many as one-third of the tion of the prevalence of this condition guidelines for semen analysis. Controls were and its contributing factors or causes is the fertile husbands of infertile women. Data couples in some populations are unable 1 1,7 were collected using a semi-structured in- to conceive. Globally, the overall an issue of major uncertainty globally. terview, laboratory blood testing and the prevalence ranges between 8%–12%, This is especially true in the Middle results of the most recent semen analysis. with a core prevalence of primary East, where 10%–15% of all married Univariate, bivariate and multivariate logistic infertility of about 5%.1,2 The causes couples are estimated to have infertility regression analyses were used for data analysis, problems.8 along with checks for effect modification and of infertility have been attributed to control of confounders. a variety of anatomical, genetic, endo- This case-controlled study seeks to crinological and immunological fac- assess the underlying factors of this Study Results. Consanguinity and the familial tors.3 condition in a Middle Eastern society. clustering of male infertility cases, as well as The majority of the gynecological It specifically aims to investigate the reproductive illnesses and war exposures were impact of various risk factors on male independently significant risk factors for male workload in the developing world is 4 infertility. The odds of having infertility prob- attributed to infertility problems. In- infertility – consanguinity, reproductive lems in the immediate family were 2.6 times fertility problems are understudied at all infections, traumas and illness, lifestyle higher in cases than controls. The odds of biological, clinical and epidemiological and occupational and war exposures. reproductive illness were 2 times higher in Lebanon is a country characterized with cases than controls. The odds of war exposures perspectives; up to 30% of the causes of 5 were 1.57 times higher in cases than controls. infertility are idiopathic. Prevention both westernized and traditional life- Occupational exposures, such as smoking and and appropriate treatment of infertility styles. It has high rates of consanguin- caffeine intake, were not shown to be in terms of concrete strategies of actions eous marriage (11%–17%), 15 years of important risk factors. are lacking. civil war, and high rates of smoking and caffeine intake. Conclusion. This case-controlled study high- Infertility poses severe ramifications lights the importance of investigating the at the cultural, social and emotional etiology of male infertility in Middle Eastern levels. It directly affects the lives of communities. It suggests the need to expand married couples resulting in distress, MATERIALS AND METHODS research on male reproductive health in the anxiety, blame and marital and sexual Middle East in order to improve the prevention 6 and management of male infertility and other problems. This is compounded by the Study Design and Population male reproductive health problems. (Ethn Dis. limited availability of infertility treat- A total of 220 cases and controls 2007;17[Suppl 3]:S3-33–S3-38) ments especially in the poorest and most (120 cases and 100 controls) of either affected developing countries.1,4 Lebanese, Syrian, or Lebanese-Palesti- Key Words: Male Reproductive Health, In- Epidemiological studies assessing the nian men were selected from two of the fertility prevalence of, and risk factors for, busiest and most successful infertility infertility are relatively scarce in the clinics located in Beirut. The American developing world. On one hand, there is University of Beirut-Medical Center international community neglect, as (AUB-MC) is a private, university- infertility is considered a natural check based teaching hospital catering to a re- on population growth in countries with ligiously mixed patient population of ` From the Department of Epidemiology, high fertility levels. On the other hand, Muslims (Sunni and Shiite), Christians, University of Michigan, Ann Arbor, Michi- a range of logistical and methodological Druze and various immigrant and gan. problems exists pertaining to carrying refugee populations. The FIRST IVF

Ethnicity & Disease, Volume 17, Summer 2007 S3-33 LIFE STYLE AND HEALTH OUTCOMES - Kobeissi and Inhorn is a stand-alone private infertility clinic Table 1. Distribution of sociodemographic factors among cases and controls catering primarily to southern Lebanese Shi`ites and occasionally Muslim Sunnis Male Infertility and Christians coming from either Variables Cases Control Lebanon or neighboring Syria. A total Age Mean (SD) 38.6 (6.7) 39.30 (5.9) of 146 cases and controls were selected P value5.538 from AUB-MC and 74 cases and Years of education Mean (SD) 13.5 (4.2) 14.2 (5.5) controls from the FIRST IVF. P value5.589 Salary (US$) Mean (SD) 1721 (2435) 1885 (2230) There were no major exclusion P value5.380 criteria regarding the demographic, N (%) N (%) socioeconomic characteristics or history Current residence of reproductive infections. Cases and Beirut 42 (35.3%) 46 (46.0) South 25 (21.0%) 8 (8.0%) controls were tested for comparability Mount Lebanon 14 (11.8%) 10 (10.0%) and no remarkable differences in base- Else where in Lebanon 13 (10.9%) 8 (8.0%) line characteristics were observed. The Outside Lebanon 25 (21.0%) 28 (28.0%) X25 9.39 P value5.052 inclusion criteria for the cases were: 1) Religion inability to conceive a child during at Christian 30 (25%) 29 (29.0%) least the past 12 months; and 2) Muslim 86 (71.0%) 66 (66.0%) confirmed semen results of one or more Druze 4 (3.3%) 5 (5.2%) X25 .949 P value5.622 of these conditions: oligospermia (low- Profession sperm count, less than 20 million per Blue collar 16 (13.3%) 6 (6.3%) mm3), asthenospermia (low motility, , Clerical related 19 (15.8%) 21 (21.2%) than 40%, teratozoospermia (bad mor- Business/teaching 42 (35%) 37 (37.4%) Doctor/lawyer/diplomat/professor 29 (24.2%) 28 (28.3%) phology), and azoospermia (no sperm in Government employee 14 (11.7%) 6 (6.1%) the ejaculate). The inclusion criteria for X25 5.19 P value5.268 the controls were: 1) confirmed semen results of the absence of these afore- mentioned conditions; and 2) con- Data Management and Analysis tween the cases and the controls (Ta- firmed results of an infertile spouse or Data were coded and entered, using ble 1). The average age in both groups unexplained infertility. the FoxPro version 2.6, and were analyzed was 39 years of age, with the average using the Statistical Package for Social years of education being 14 years. The Data Collection Sciences (SPSS-v12, Chicago, Ill.). Uni- average monthly reported income in Upon obtaining informed consent, variate and bivariate analyses, utilizing chi- both groups was approximately data were collected using a combination square Fisher’s exact test were used to test US$1,800. The majority of the subjects of methods including structured inter- the association between the main outcome resided in Beirut and South Lebanon. view technique, blood testing for toxic variable (male-infertility) and the different The religious backgrounds were simi- metal analysis and semen analysis results. exposure and confounding variables. The larly heterogeneous between the two The interview questionnaire collect- Multivariate Backward Logistic Regres- groups. The controls were slightly more ed information on demographics, so- sion model was used where odds ratios, P- likely to be in higher-status professions; cioeconomic parameters, reproductive values and confidence intervals (CI) were yet, the professional background of both history, presence of chronic diseases, computed at type I error,alpha of 5%. The the cases and the controls was relatively lifestyle factors, and occupational and final model incorporated the independent similar. war exposures. The laboratory data variables that displayed the most signifi- provided blood analysis for the follow- cant odds ratios. Consanguinity and Infertility ing heavy elements: lead, arsenic, vana- Twenty-four percent of the controls dium, manganese, copper, molybde- reported being married to a cousin as num, zinc, and selenium. The most RESULTS opposed to 16% of the cases; however, recent semen analysis was reported; the this difference was not significant. The semen analysis results were processed at Sociodemographic cases were more likely to report cousin the time the interview was being con- Characteristics marriages among their parents and ducted or within a few hours following There were no significant differences grandparents. The odds of infertility its completion. in sociodemographic characteristics be- problems in the immediate family

S3-34 Ethnicity & Disease, Volume 17, Summer 2007 LIFE STYLE AND HEALTH OUTCOMES - Kobeissi and Inhorn

among the cases was 2.6 times higher Table 2. Bivariate analysis of the various risk factors among cases and controls than that among the controls, suggest- Male Infertility ing a familial clustering of male in- Cases Controls fertility that may be related to consan- N (%) N (%) guinity and possibly a resultant of genetic mutations of the Y-chromosome Familial clustering of infertility via consanguinity Kinship to wife micro-deletions. (Tables 2 and 3) Wife closely related 19 (16.2) 24 (24.0) Wife not closely related 98 (83.8%) 76 (76.0) Reproductive History X252.04 P value5.153 Relationship between parents/grandparents No major differences between the None are related 64 (53.8%) 62 (62.6%) cases and the controls existed in the age Parents or grandparents are related 34 (28.6%) 28 (28.3%) at marriage, number of sexual partners Both parents and grandparents are related 21 (17.6%) 9 (9.1%) and age of sexual activity initiation. The X253.61 P value5.165 Reported infertility problems in immediate family cases and the controls had an average Yes 49 (41.2%) 17 (17.0%) age of 32 years upon the first marriage, None 70 (58.0%) 83 (83.0%) and an average of 34 lifetime sexual 2 X 515.085 P value5.0000 partners for the controls and 38 for the Reproductive histories, infections and illnesses cases. The cases were slightly older than Age at marriage Mean (SD) 32.1 (6.4) 32.3 (6.7) P value5.875 the controls upon their sexual activity Wife’s age at marriage Mean (SD) 25.7 (5.5) 27.5 (6.4) initiation. The history of reproductive P value5.024 illnesses and infections was shown to be No. of sexual partners Mean (SD) 38.8 33.5 a highly significant independent risk P value5.752 Age of sexual activity Mean (SD) 22.5 (6.8) 20.7 (5.35) factor. The odds of suffering from one P value5.036 reproductive event were 2.4 times higher among the cases than controls; Reproductive health index* the odds of suffering from two or more No event 21 (17.8%) 49 (49.0%) One event 51 (43.2%) 33 (33%) events were 4.8 times higher among Two events 31 (26.3%) 14 (14.0%) cases than controls (Tables 2 and 3). Three events 15 (12.7%) 4 (4.0%) X25 26.54 P value5.000 Lifestyle factors Lifestyle Practices Coffee intake (cups/day) Mean (SD) 3.2 (4.7) 2.9 (4.7) Both the cases and the controls P value5.574 reported similar rates of caffeine con- Soft drink intake (bottles/day) Mean (SD) 2.6 (12.6) 1.09 (1.4) sumption. Similarly, there were no P value5.221 Smoking significant differences in the smoking Years of smoking Mean (SD) 19.66 (6.8) 20.4 (8.9) habits and practices. Both cases and P value5.621 controls reported similar exercise habits, No. of cigarettes per day Mean (SD) 27.1 (19.8) 27.7 (16.0) with 27% engaged in regular exercise. P value50.868 On the other hand, cases were slightly Water pipe smoking more likely to report that they have Yes 32 (27.1%) 26 (26.0%) stress in their lives; this difference (35% No 86 (72.9%) 74 (74.0%) vs 32%) was not significant. (Tables 2 X250.035 P value5.852 Exercise and 3) No 37 (31.1%) 26 (26.3%) Used to 41 (34.5%) 33 (33.3%) Occupational Exposures Yes 33 (27.7%) 27 (27.3%) Not regularly 9 (7.4%) 12 (12.5%) Both cases and controls were equally X252.764 P value5.429 likely to report some type of occupa- Self-reported stress tional exposure. The most common Stressed 39 (35.1%) 31 (31.3%) exposures reported were those associated Not stressed 72 (64.9%) 68 (68.7%) X25.344 P value5.558 with chemicals used in agriculture or manufacturing. These were followed by driving-related exposures to gasoline and high heat, and construction-related

Ethnicity & Disease, Volume 17, Summer 2007 S3-35 LIFE STYLE AND HEALTH OUTCOMES - Kobeissi and Inhorn

Table 2. Continued illness were 2 times higher in cases than controls, and the odds of war exposures Male Infertility were 1.57 times higher in cases than Cases Controls controls. Occupational exposures, smoking practices and caffeine intake N (%) N (%) were not shown to be important risk Occupational exposures factors in this case-controlled study. None 50 (42.0%) 55 (55.0%) Chemical exposure 25 (21.0%) 16 (16.0%) A significant proportion of the study Agricultural-related exposures 8 (6.7%) 6 (6.0%) sample reported consanguineous mar- Driving-related exposures 18 (15.1%) 13 (13.0%) riage patterns, in terms of either having Construction-related exposures 11 (9.2%) 6 (6.0%) married to a relative or having their More than one occupational exposures 7 (5.9%) 4 (4.0%) X25 3.98 P value5.553 parents and/or grandparents married to War exposures** a relative. Male infertility tended to No event 45 (39.5%) 51 (51.0%) cluster strongly in families often with One event 44 (38.6%) 32 (32.0%) Two or more exposures 25 (21.9%) 17 (17.0%) several male relatives affected by in- X25 2.89 P value5.236 fertility. This familial infertility could

* Reproductive health index is a non-weighted index of the summation of the presence of one of these self- serve as an important proxy of the reported conditions: adult onset mumps, varicoceles, testicular injuries, sexually transmitted diseases, spinal cord genetic disposition in the etiology of injuries, impotence, premature ejaculation. male infertility. Major studies in the ** War exposure index is a non-weighted index of the summation of the presence or absence of one of these self-reported events: close residential proximity to violence, self injury, family injury, taking part in the war as literature relate the micro-deletions along a fighter, being displaced, and being subject to kidnap or torture. the Y-chromosome to azoospermia, the potential of cystic fibrosis gene mutations among azoospermic men with exposures to cement and dust. Occupa- cases were exposed to two or more war congenital absence of the vas deferens tional exposures were not shown to be events as opposed to 17% of the and seminal vesicles, as well as germ cell a significant risk factor in the etiology of controls. The odds of exposure to war alterations associated with inadequate male infertility in this study (Tables 2 events is 57%, borderline significantly DNA repair that is associated with and 3). higher among cases than controls (Ta- increased frequency of DNA mutations bles 2 and 3). 9–12 resulting in meiotic arrest. The War Exposures rates of such mutations substantially War exposures were reported by the increase among consanguineous com- study subjects in terms of exposure to ISCUSSION D munities. one or more of the following war- Reproductive illnesses, traumas and related events: close residential proxim- This study demonstrated that con- infections are important risk factors in ity to violence; self-injury; family injury; sanguinity, reproductive illnesses and the etiology of male infertility. The taking part in the war as a fighter; being war exposures are important risk factors study showed a gradient increase in the displaced; and being subjected to kid- for male infertility. The odds of having odds ratio as the number of reported nap or torture. This exposure was infertility problems in the immediate reproductive disorders increased. Cases shown to be a significantly independent family were 2.6 times higher in cases were significantly more likely to report risk factor. Twenty-two percent of the than controls. The odds of reproductive more than one reproductive problem than controls, including varicoceles, Table 3. Multi-variate analysis-logistic regression sexually transmitted infections, spinal Variable Adjusted OR P value (95% CI) cord injuries, adult-onset mumps and testicular injuries. Infertility problems in immediate family (yes/no) 2.58* .057 (.971–6.8) Kinship between parents and/or grandparents (yes/no) .865 .756 (.34–2.17) Various studies have shown the Reproductive Health Index (No. of events) 1.98* .009 (1.18–3.1) adverse impact of sexually transmitted Intake of coffee (cups/day) 1.05 .288 (.96–1.14) diseases, mumps, delayed treatment of Intake of soft drinks (bottles/day) 1.07 .677 (.77–1.47) undescended testes, repair of inguinal Cigarette smoking (cigs 3 years/day) .999 .183 (.998–1) Occupational exposures (yes/no) 1.32 .556 (.527–3.29) hernia and endocrine disorders in the 10,13 War exposures (No. of events) 1.57* .056 (.989–2.49) etiology of male infertility. Varico- R2 5 29.5% P value5 .001. celes have also been implicated in causing direct effect on the testes via

S3-36 Ethnicity & Disease, Volume 17, Summer 2007 LIFE STYLE AND HEALTH OUTCOMES - Kobeissi and Inhorn causing ipsilateral testicular damage semen as a result of an inflammatory might overshadow the ability to gener- resulting in reduced testicular volume reaction triggered by the smoking alize the overall population. A larger resulting in a reduction in spermato- metabolites in the male genital tract.21 sample size is also needed for increasing genesis and semen counts, as well as Other studies failed to confirm this the power of this study; this problem is poor sperm morphology. These effects mechanism and postulated that smok- difficult to correct, owing to the fact are attributed to a decrease in the germ ing impacts on male infertility could be that the actual reporting on male cell/steroli cell ratio, where by the attributed to the coexistence of other infertility is compromised due to the percentage of germ cells in their late etiological factors mediating the associ- negative social connotations associated stage, (ie, spermatids and spermatozoa) ation such as caffeine and alcohol with this condition. For every man who are reduced. The impact of varicoceles intakes.22,23 This study did not find agreed to participate in this study tend to be bilateral on both testes, even a significant independent association of during an 8-month period in 2003, at in men with unilateral varicoceles.14–16 smoking on male infertility. Both cases least one man refused to participate for Varicoceles have also been implicated by and controls tended to be heavy smok- unspecified reasons. In addition, the having indirect effects on the spermato- ers of both cigarettes and water pipes quality of the measures is high, due to genesis process by causing hypothermia, and had approximately the same num- employing multiple validation tech- hormonal dysfunction, production of ber of years of exposure to smoking. niques. No major problems existed for anti-sperm antibodies, and release of This suggests the importance of other adjusting for missing and non-response oxidative stress.16,17 etiological factors that could be affecting data. This study demonstrated the impor- the condition and the need for addi- In summary, the current case-con- tance of war-related exposures in the tional studies to be conducted among trolled study suggests the importance of etiology of male infertility. There was heavy smokers. consanguinity, reproductive illnesses a significant gradient increase in the In terms of occupational hazards, and war-related exposures as risk factors odds of male infertility as exposure to both cases and controls had similar for male infertility. Unlike some studies, war-related events increased. This as- levels and durations of such exposures. no observed associations were made in sessment relied on objective measures of Many studies documented the negative terms of lifestyle factors and occupa- exposures, such as close residential impact of chemical and pesticides tional exposures. This suggests the importance of investigating the etiology proximity to violence, self and family exposures, radiation, and heat on sper- of this condition in the context of the injury, taking part in the war, being matogenesis resulting in alterations in communities where it arises. It also displaced or subject to kidnap or sperm quantity and quality.24–27 On the highlights the need for expanded re- torture, that are less likely to be subject other hand, some studies suggest that search targeting male infertility in the to recall bias. This finding suggests the the association of certain occupations Middle East and the development of importance of conducting more com- and male infertility is highly dependent constructive strategies to alleviate this prehensive studies specifically in this on the organ susceptible and the condition and to resolve social dispari- region of the world, which has been individual’s age at exposure. According- ties arising from this condition. undergoing extensive periods of war ly, an observed negative association turmoil and political instability. The could either mean that the concentra- ramifications of war-related exposures tion of a specific chemical may have not on male infertility and developmental reached its latency period for the in- REFERENCES disorders can not be taken lightly, as the curred damage to take place or it could 1. Inhorn M. Global infertility and the globalization of new reproductive technologies: use of various chemicals with long half- simply reflect a true negative associa- illustrations from Egypt. Soc Sci Med. lives will not only affect the fertility of tion. Additional studies are needed to 2002;56:1837–1851. current generations but could extend to further understand the etiology of 2. Irvine DS. Epidemiology and aetiology of futures generations.18–20 different occupational exposures in male infertility. European Society for Human The impact of smoking on male terms of toxic effects, dose and dura- Reproduction & Embryology. 1998;13:33–44. 3. Vayena E, Patrick J, Rowe PJ, Griffin D, eds. tion.24, 27 infertility is debatable. Cigarettes con- Current Practices and Controversies in Assisted tain a range of chemical toxins such as The major limitation of this study Reproduction. Geneva: World Health Organi- nicotine, carbon monoxide, cadmium relates to its external validity, since zation; 2001. and other mutagenic compounds, which a clinic-based convenience sample was 4. Sundby J, Mboge R, Sonko S. Infertility in the can impair the sperm function, motility used in contrast to a population-based Gambia: frequency and health care seeking. Soc Sci Med. 1998;7:891–899. and morphology. A proposed mecha- random sample. However, the fact that 5. Huynh T, Mollard R, Trounson A. Selected nism for such impairment is the increase the study population was selected from genetic factors associated with male infertility. in seminal leukocyte infiltration into the two major infertility clinics in Lebanon Hum Reprod Update. 2002;8(2):183–198.

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6. Lee TY, Sunn GH, Chao SC. The effect of an 13. Purvis K, Christiansen E. Infection in the male men: a prospective study. Fertility and Sterility. infertility diagnosis on the distress, marital and reproductive tract. Impact, diagnosis and 2002;78(3):491–499. sexual satisfaction between husbands and treatment in relation to male infertility. 21. Wong WY, et al. New evidence of the wives in Taiwan. Hum Reprod. 2001;16(8): Intl J Andrology. 1993;16:1–13. influence of exogenous and endogenous factors 1762–1767. 14. Jarow JP. Effects of varicocele on male in- on sperm count in men. Euro J Obstet Gynecol 7. Inhorn M. Middle Eastern masculinities in fertility. Hum Reprod Update. 2001;7(1):59– Reproduct Bio. 2003;110:49–54. the age of new reproductive technologies: 64. 22. Buiatti E, Barchielli A, Geddes M, et al. Risk Male infertility and stigma in Egypt and 15. Jones MA, et al. The adolescent varicocele. factors in male infertility: a case-control study. Lebanon. Med Anthropol Q. 2004;18(2):162– Am J Clin Pathol. 1988;89:321–328. Arch Environ Health. 1984;39(4):266–270. 182. 16. Marmar JL. Varicocele and male infertility: 23. Kenkel S, Rolf C, Nieschlag E. Occupational 8. Serour GI. Bioethics in reproductive health: Part II- The pathophysiology of varicoceles in risks for male fertility: an analysis of patients a Muslim’s perspective. Middle East Fertility the light of current molecular and genetic attending a tertiary referral centre. Int J Androl. Society J. 1996;1:30–35. information. Hum Reprod Update. 2001;7(5): 2001;24:318–326. 9. Inhorn M. Infertility and Patriarchy: The 461–472. 24. Apostoli P, Bellini A, Porru S, Bisanti L. The Cultural Politics of Gender and Family Life in 17. Maconochie N, Doyle P, Carson C. Infertility effect of lead on male infertility: A time to Egypt. Philadelphia, Penn: University of Penn- among male UK veterans of the 1990–1991 pregnancy (TTP) study. Am J Indust Med. sylvania Press; 1996. Gulf war: reproductive cohort study. BMJ. 2000;38:310–315. 10. Forti G, Krausz C. Clinical review 100: 2004;329(7459):196–201. 25. Strohmer H, et al. Agricultural work and male Evaluation and treatment of the infertile 18. Ghanei M, Rajaee M, Khateri S, Alaeddini F, infertility. Am J Indust Med. 1993;24:587–592. couple. J Clin Endocrin & Metab. 1998; Haines D. Assessment of fertility among 26. Sharpe RM. Lifestyle and environmental 83(12):4177–4188. mustard-exposed residents of Sardasht, Iran: contribution to male infertility. Brit Med Bull. 11. Hoyer PB. Reproductive toxicology: current a historical cohort study. Reprod Toxicol. 2004; 2000;56(3):630–642. and future directions. Biochemical Pharmacol- 18(5):635–639. 27. Oldereid NB, Thomassen Y, Attramadal A, ogy. 2001;62(12):1557–1564. 19. Safarinejad MR. Testicular effect of mustard Olaisen B, Purvis K. Concentrations of lead, 12. Shah K, Sivapalan G, Gibbons N, Tempest H, gas. Urology. 2001;58(1):90–94. cadmium and zinc in the tissues of reproduc- Griffin DK. The genetic basis of infertility. 20. Ramadan S, et al. Effect of cigarette smoking tive organs of men. Reprod & Fertil. 1993; Reproduction. 2003;126(1):13–25. on levels of seminal oxidative stress in infertile 99(2):421–425.

S3-38 Ethnicity & Disease, Volume 17, Summer 2007 E. PROJECT SALAAM:ASSESSING MENTAL HEALTH NEEDS AMONG SAN DIEGO’S GREATER MIDDLE EASTERN AND EAST AFRICAN COMMUNITIES

Joachim O. F. Reimann, PhD; Dolores I. Rodriguez-Reimann, PhD; Mehboob Ghulan, MD; Mohammed F. Beylouni, PhD

Ethn Dis. 2007;17[Suppl 3]:S3-39–S3-41 INTRODUCTION Calls to meet the mental health needs of Middle Eastern and East Key Words: Mental Health Greater Middle Eastern and East African origin communities in the African communities in the United United States have been made for two 10 States face multiple challenges. First, decades yet these populations remain many are immigrants and refugees who poorly understood. Little information find themselves in unfamiliar environ- exists on the psychological correlates of ments. Acculturating to a new country harassment and accumulated stressors in (eg, learning a new language and these groups. Project Salaam assessed different societal rules, changes in social such issues among San Diego, Califor- status) is often stressful.1 In Middle nia’s Greater Middle Eastern and East Eastern communities, as in other cul- African groups. It identified relation- turally and linguistically distinct groups, ships between psychological symptoms related problems can be handed down and history of trauma / adverse experi- to second and third generations.2 ences, acculturation stresses, and socio- Secondly, many Middle Eastern and demographics. It further assessed per- East African immigrants have experi- sonal coping skills, attitudes toward enced adverse circumstances such as mental health services, and general war, persecution, imprisonment and healthcare preferences. torture in their countries of origin. The 2004 World Refugee Survey, for example, lists Palestinians, Afghans, METHODS Iraqis and Iranians as constituting some of the largest refugee groups in the Data came from 360 written sur- world.3 Not surprisingly, people in such veys, 10 structured focus groups (79 circumstances can encounter multiple, adults / 50 adolescents) and 20 key severe and sustained stressors. stakeholder interviews. All participants Third, harassment and discrimina- were of Greater Middle Eastern or East tion aimed at greater Middle Eastern African origin or descent. They were communities increased after the 9/11 recruited through local community- and terrorist attacks.4 Anti-Muslim and faith-based organizations, schools, fliers, anti-Middle Eastern biases in the Unit- businesses serving the study’s popula- ed States are nothing new.5,6 But given tions, and word-of-mouth. Activities the constant and ongoing public focus were conducted in English, Arabic, on US–Middle Eastern conflicts, it Farsi, Somali or Russian as needed by seems unlikely that a heightened nega- a fully bilingual / bicultural Project tive focus on these groups will abate in Salaam staff. the near future. Harassment has in- The survey asked about demograph- cluded overt hate crimes (eg, beatings, ics, experiences with adverse events, vandalism, murder) and more subtle attitudes toward mental health services, forms of discrimination.7,8 These reac- personal coping efforts, healthcare pref- From the Center for Behavioral & tions have not been limited to erences and encounters with healthcare Community Health Studies, Graduate Arabs and Muslims, but have extended systems in the United States. It also School of Public Health, San Diego State University (JOFR, DIRR) and the Islamic to anyone with features similar to those included the Traumatic Event Sequelae 11 Center of San Diego, San Diego, California of a Middle Easterner (eg, Indian Inventory and acculturation measures (MG, MFB). Sikhs).9 adapted from the literature.12,13 Struc-

Ethnicity & Disease, Volume 17, Summer 2007 S3-39 LIFE STYLE AND HEALTH OUTCOMES - Reimann et al tured interviews also asked about par- Table 1. Standard Multiple Regression: Predictors of Psychological Symptoms ticipants’ experiences with any adverse incidents. If such events were reported, Predictors b tp respondents were asked to comment on Adverse Event in Country of Origin .27 3.56 ,.0001 why they believed the events happened, Adverse Event in the US .31 4.11 ,.0001 their emotional reactions, and if/how Adverse Event in both Home Country & US (Interaction) .18 2.06 .04 Limited English Proficiency .17 2.51 .01 the events affected day-to-day life. Gender (Female) .15 2.77 .006 Focus group and stakeholder transcripts Acculturation Stress .25 4.56 ,.0001 were reviewed for primary themes. US Mainstream Orientation 2.12 21.67 .09 Descriptive statistics provided an over- Home Country Orientation .08 1.27 .21 Age .06 1.13 .26 view of survey response patterns. Stan- Education .06 1.00 .32 dard multiple regression then identified Monthly Income 2.09 21.49 .14 predictors of psychological distress. Generational Status 2.04 20.78 .43 Qualitative and quantitative results were Ethnic or National Origins / Descent* .04 0.48 .63 integrated by identifying consistencies (R2 5.40; F58.39, P,.0001); N5360 * Variable was dummy coded. across data types.

ranged from subtle discrimination to origin was especially linked with RESULTS violent confrontations. Harassment and thoughts of death and difficulties ex- discrimination in public, at the work- pressing feelings. Adolescents who had Participants in all study groups were place, near home, at school (among been harassed tended to describe in- largely immigrants (eg, 93% of the adolescents), and by governmental enti- creased nervousness, frustration, anger, survey and 83% of the focus group). ties was most frequently mentioned. In and acting out (eg, fighting with other Most self-identified as Muslim; but addition, 56% of immigrants recounted students at school). those from Christian denominations being persecuted in their home country. Standard multiple regression analy- (eg, Chaldeans) and the Baha´’ı´ faith Seventeen percent of these described sis identified being female (P5.006), were also represented. Ethnic / national being tortured. Similar patterns were limited English proficiency (P 5.01), background among survey respondents noted among focus group participants acculturation stress (P,.0001), coun- included Somali (22%), Afghan (21%), and key stakeholders. Almost all partic- try-of-origin persecution (P,.0001), Arab (17%), Kurdish (7%), Iranian ipants concurred that adverse experi- US-based harassment (P ,.0001), and (5%), and a variety of other nationalities ences in country of origin and/or in the the interaction between adverse experi- (eg, Sudanese, Ethiopian, Lebanese, United States were common problems ences in the United States and country Turkish, Palestinian, Algerian, Moroc- in their respective communities; yet of origin (P5.04) as predicting distress. can, Egyptian and Jordanian). Similarly, 64% of those experiencing US-based The full regression model is presented focus groups and key stakeholder inter- incidents had not reported them to any in Table 1. Fifty-four percent of those views included those from Lebanese, authorities. Among those who made reporting adverse United States and Iraqi, Egyptian, Syrian, Sudanese and such reports, only 12% were satisfied home-country experiences had symp- other Greater Middle Eastern / East with the outcome. Primary reasons for tom profiles similar to those diagnosed African backgrounds. While a majority not reporting were: 1) not knowing with post-traumatic stress disorder in of participants across activities described procedures for doing so; 2) belief that it the general population. This was also having limited economic means, would be ineffective; and 3) not want- true for 49% of persons reporting a broader spectrum of education and ing to draw attention to themselves. home-country persecution only, 35% income was also represented. Adults most often described person- of those reporting adverse US experi- Thirty-seven percent of survey real difficulties, including: problems ex- ences only, and 14% of those describing spondents described encountering ha- pressing feelings (57%); trouble work- no adverse events. rassment or discrimination in the Unit- ing (55%); helplessness (52%); Despite such difficulties, respon- ed States. They attributed such events to impaired concentration (52%); nervous- dents described professional mental reactions to the 9/11 terrorist attacks ness (52%); and detachment (51%). health services as unavailable to them. and to the continuing public focus on Adverse experiences in the United States They discussed social stigmas and the US-Middle East conflicts. Muslims, were most often connected with anger, lack of culturally, religiously knowledge- Arabs and those in traditional clothing loneliness and interpersonal (eg, family) able providers as barriers. Other barriers appeared most at-risk. Circumstances problems. Persecution in country of included lack of health insurance,

S3-40 Ethnicity & Disease, Volume 17, Summer 2007 LIFE STYLE AND HEALTH OUTCOMES - Reimann et al language difficulties and poor treatment Given the project’s partnership with 5. Perry B. In the Name of Hate: Understanding by providers and support staff. Among a mosque, the sample is skewed toward Hate Crimes. New York: Routledge; 2001. 6. Abraham N. Anti-Arab racism and violence in survey respondents, 16% had stopped Muslims with strong religious adher- the United States. In: McCarus E, ed. The going for care because of poor treatment ence. In addition, it is primarily made Development of Arab-American Identity.Ann by providers. up of immigrants. Consequently, results Arbor: University of Michigan Press. 1994; may have limited generalizability to 155–204. DISCUSSION persons with no religious convictions, 7. Ibish H, Stewart A. 2003 Report on Hate Crimes and Discrimination against Arab Amer- those born in the United States and icans: September 11, 2001 to October 11, 2002. Results show mental health needs those from Middle Eastern/East African Washington DC: American-Arab Anti-Dis- among the studied groups as substantial. backgrounds not in this sample. Despite crimination Committee Research Institute Those who have experienced adverse these limitations, the identified number (ADCRI); 2003. events in the United States and in their of people in need of mental health care 8. Federal Bureau of Investigation. Hate Crime Statistics – 2003. Washington DC: US De- country of origin are particularly affected. is noteworthy. Overall, the study serves partment of Justice. Thisresultsupportspreviousfindings that as one empirical effort to bring needed 9. Gerstenfeld PB. A time to hate: Situational vulnerability to new trauma is increased attention to the circumstances faced by antecedents of intergroup bias. Analysis of by past trauma.14 At the same time, Middle Eastern and East African com- Social Issues and Public Policy. 2002;61–67. culturally effective care is often lacking. munities in the United States. 10. Young RF, Bukoff A, Waller JB, Blount SB. Health status, health problems, and practices Adequate service development will re- among refugees from the Middle East, Eastern quire education of community members, REFERENCES Europe, and Southeast Asia. The International providers and other stakeholders. 1. Berry JW, Kim U. Acculturation and mental Migration Review. 1987;21:760–782. health. In: Dasen P, Berry JW, Sartorius N, Project Salaam’s long-term goal is to 11. Christopher R, Reimann JOF. The Traumatic eds. Health and Cross-Cultural Psychology: implement a systematic approach that Event Sequelae Inventory: Administration, Scor- Towards Application. Beverly Hills, CA: Sage; ing, and Procedures Manual. Sparks, NV: The includes: 1) professional training to in- 1988:207–236. College of Clinical Sciences; 2000. crease cultural competence among 2. Ghanem-Ybarra GJ. The acculturation process 12. Cue´llar I, Arnold B, Maldonado R. Accultur- healthcare providers, educators, social and ethnic self identification of second-generation ation rating scale for Mexican Americans-II: A service workers, policy makers and other Christian Palestininan American women. Disser- revision of the original ARSMA scale. tation Abstracts International: Section B: The stakeholders; 2) education of broader Hispanic J Behav Sciences. 1995;17:275–304. Sciences & Engineering. US: University Micro- 13. Mena FJ, Padilla AM, Maldonado M. Accul- society to reduce misconceptions and films International. 2003;63(12-B):6093. turative stress and specific coping strategies stereotypes about persons of Greater 3. US Committee for Refugees. World Refugee among immigrant and later generation college Middle Eastern and East African back- Survey 2004. Key Statistics.Washington DC. students. Hispanic J Behav Sciences. 1987;9: ground; and 3) psycho-educational activ- United States Committee for Refugees and 1183–1192. Immigrants, Jan 2004. ities for community members that expand 14. Breslau N, Chilcoat HD, Kessler RC, Davis 4. American Arab Anti-Discrimination Commit- GC. Previous exposure to trauma and PTSD their ability to access health and social tee. 1991Report on Anti-Arab Hate Crimes. effects of subsequent trauma: results from the services and enhance their personal means Washington, DC: ADC Research Institute; Detroit Area Survey on Trauma. Am J Psychi- to cope with stressors. 1992. atry. 1999;156:902–907.

Ethnicity & Disease, Volume 17, Summer 2007 S3-41 F. THE USE OF GLUCOSE-LOWERING AGENTS AND ASPIRIN AMONG ARAB AMERICANS WITH DIABETES

Objective. Little is known about the health Helen D. Berlie, PharmD; Adnan Hammad, PhD; outcomes or the quality of care among Arab Linda A. Jaber, PharmD American patients with diabetes. The objective of this study is to examine the use of glucose- lowering agents and aspirin therapy in this population compared to the drug utilization INTRODUCTION The purpose of our study was to patterns reported in nationally representative examine and compare the use of aspirin surveys. Patients with diabetes have a two- to and glucose-lowering agents in Arab four-fold increased risk of developing Americans with diabetes to national Research Design and Methods. A random trends in the United States. sample of adult Arab American patients with cardiovascular disease (CVD). Death self-reported diabetes was selected. Complete from cardiovascular disease accounts for medication histories were recorded during 65% of all diabetes-related deaths, a face-to-face interview. Medication utilization rendering CVD the number one cause METHODS of the glucose-lowering agents and aspirin of mortality in the United States.1 were compared to data from the Third National Health and Nutrition Examination Several mechanisms contribute to the This was a cross-sectional, popula- Survey (NHANES) and the Behavioral Risk link between diabetes and CVD. Hyper- tion-based study conducted in Arab Factor Surveillance System (BRFSS). glycemia is independently associated Americans. The methods for this study with an increase in diabetes-related have been described in detail elsewhere.7 Results. The study sample consisted of 53 complications including CVD. Progres- Briefly, non-pregnant adults, 20 to participants (20 males, 33 females) with mean age 6 SD of 59.4 6 12 years and A1C levels of sive loss of beta cell function leads to the 75 years of age, and with a self-reported 8.0 6 2%. Compared to US adults, Arab deterioration of glycemic control in ancestry of Arab descent were chosen via American patients with diabetes were less patients with diabetes over time.2 To random sample in two areas of Dear- likely to be treated with insulin (27% vs 17%) achieve and maintain glycemic targets, born, Michigan. Subjects were consid- and more likely to receive oral hypoglycemic combination therapy with two or more ered to have diabetes if they reported agents (65% vs 81%). Similar proportions of participants were maintained on insulin-oral oral hypoglycemic agents are often re- a previous medical diagnosis of the 3 hypoglycemic-combined therapy (10% US quired. In patients with longstanding disease and/or they were using oral adults vs 9% Arab Americans). Aspirin use diabetes who have sustained significant anti-diabetic agents or insulin. For the was significantly lower among the study decline in beta cell function and endog- purpose of this study, only individuals participants (23%) compared to the reported enous insulin secretion, insulin therapy with previously diagnosed diabetes were national prevalence of aspirin intake (64%). remains the most effective treatment. included. Conclusion. The therapeutic management of Additionally, aspirin therapy reduces the Trained bilingual interviewers ad- diabetes in the Arab-American patients with risk of CVD in diabetic patients with and ministered standardized questionnaires, diabetes is suboptimal. The use of insulin and without existing CVD.4–6 Therefore, the translated into Arabic, to capture self- aspirin was lower than that reported by prevention of diabetes-related cardiovas- reported information, such as demo- participants in the NHANES and BRFSS cular complications requires aggressive national databases. More aggressive ap- graphics, medical diagnoses and medi- proaches for the management of hyperglyce- use of glucose-lowering agents and anti- cations. The use of medications was mia and the prevention of cardiovascular platelet therapy. further documented by examining all diseases are needed to improve health out- Arab Americans have a high preva- prescription and over-the-counter med- comes in the Arab-American community. (Ethn lence of diabetes and other cardiovascu- ication containers during the scheduled Dis. 2007;17[Suppl 3]:S3-42–S3-45) lar risk factors such as obesity and home visits. Interviewers recorded the 7–9 Key Words: Diabetes, Glucose, Aspirin dyslipidemia. Similar to other mi- names and the dosages of all prescribed norities, Arab American individuals are medications. often faced with cultural barriers, which Medication utilization patterns for may hinder their ability to receive aspirin and glucose-lowering agents in recommended medical care and atten- Arab Americans with diabetes were tion. Given the youthfulness of this compared to nationally representative From the Department of Pharmacy community, the burden of diabetes and population-based reports. The use of Practice, Wayne State University Detroit, its associated cardiovascular conse- aspirin in these patients was compared Michigan (HDB, LAJ); and the Community Health Center, Arab Community Center for quences will increase as the population to the 2003 database of the Behavioral Economics and Social Services, Dearborn, ages, imposing a substantial public Risk Factor Surveillance System Michigan (AH). health challenge. (BRFSS).10 The BRFSS is an annual

S3-42 Ethnicity & Disease, Volume 17, Summer 2007 LIFE STYLE AND HEALTH OUTCOMES - Berlie et al

40 years or above, were receiving aspirin Table 1. Demographics and characteristics of Arab Americans with diabetes therapy. In comparison, the prevalence Total Men Women of aspirin use among Arab Americans N 53 20 33 was 22.6% (Table 2). Arab American Age (yrs) 59.4 6 12 53.7 6 12.4 62.9 6 10.2 men were more likely to receive pre- Duration of diabetes (yrs) 9.2 6 7.4 7.8 6 7.3 10.0 6 7.5 ventative therapy with aspirin than HbA1C 8.0 6 2.2 7.8 6 2.4 8.1 6 2.1 Cardiovascular History (n) women were. Furthermore, two of the Hypertension 23 9 14 subjects received anti-platelet therapy Dyslipidemia 24 12 12 with Plavix, while no combination CHF 6 3 3 therapy with aspirin and Plavix was Angina 6 1 5 Stroke 1 0 1 reported. MI 2 1 1 The NHANES survey reported that PVD 7 2 5 65.3% of those with diabetes were being CHF: congestive heart failure, MI: myocardial infarction, PVD: peripheral vascular disease. treatedwithoralglucose-lowering agents, 27.4% were on insulin alone and 10.4% were on combination therapy with oral agents and insulin togeth- random state-based telephone survey of glycemic agents use among Arab Amer- er. In comparison, 81.1% Arab Amer- participants aged $ 35 years. Partici- ican patients with diabetes compared to ican participants were receiving oral pants who reported using aspirin were the reported national surveys. Mean glucose-lowering agents, 43.4% received then asked whether aspirin was being andstandarddeviations(SD)were monotherapy and 37.7% were on used for pain relief or for the prevention calculated. combination oral agent therapy (Ta- of a cardiovascular event. Participants ble 2). Insulin use was reported in 17% were also asked whether they had a di- of Arab Americans and only 9.4% were agnosis of diabetes. ESULTS R on combination therapy with oral The utilization of glucose-lowering agents and insulin. The use of oral agents in Arab Americans was compared Among the random sample of 542 agents as monotherapy, as well as in to a database of The National Health Arab Americans, 53 individuals had combination with other oral agents was and Nutrition Examination Survey a previous diagnosis of diabetes. De- similar in Arab American men and (NHANES), collected from 1999– mographic characteristics for the study women. Insulin use, however, was 2002.11 This survey was conducted by population are presented in Table 1. higher in women than men. the National Center for Health Statis- According to the 2003 BRFSS survey, tics of the Centers for Disease Control 25,549 of the 84,538 participants and Prevention and included partici- surveyed reported taking aspirin daily pants $ 18 years of age. Household or every other day and diabetes was DISCUSSION interviews were conducted and patients present in 10.5% of participants. The The present study demonstrates an were identified as having diabetes if they 1999–2002 NHANES survey reported underutilization of aspirin therapy reported being previously diagnosed 998 of the 11,441 subjects surveyed as among Arab American patients with with the disease. having diabetes. diabetes. The observed aspirin use in this Statistical analysis was performed to According to the BRFSS sample, population is considerably lower than the estimate the rates of aspirin and hypo- 64% of participants with diabetes, reported prevalence of aspirin intake among general US patients with diabetes. Table 2. Results: Use of insulin and OHA in Arab Americans with diabetes Additionally, the use of insulin was also lower in Arab Americans with diabetes Total N (%) Men n (%) Women n (%) compared to national estimates. The Aspirin therapy 12 (22.6) 8 (40.0) 4 (12.1) mean HbA1C level of 8.0% was above Oral agents 43 (81.1) 16 (80.0) 27 (81.8) Monotherapy 23 (43.4) 9 (45.0) 14 (42.4) the American Diabetes Association Combination therapy 20 (37.7) 7 (35.0) 13 (39.4) (ADA) recommended goal of ,7% and Insulin therapy 9 (17.0) 2 (10.0) 7 (21.2) reflected the underutilization of combi- Insulin alone 4 (7.5) 1 (5.0) 3 (9.0) nation therapy of glucose-lowering Insulin + oral agent 5 (9.4) 1 (5.0) 4 (12.1) No glucose-lowering therapy 6 (11.3) 3 (15.0) 3 (9.0) agents in this population. Arab American men were more likely to be treated with

Ethnicity & Disease, Volume 17, Summer 2007 S3-43 LIFE STYLE AND HEALTH OUTCOMES - Berlie et al aspirin, whereas women were more likely majority of patients in this survey were the NHANES data were collected during to be treated with insulin. not treated with an anti-platelet agent, one-on-one interviews. Second, the study The increased risk of cardiovascular thereby increasing their risk of cardio- participants were exclusively immigrant disease in patients with diabetes is the vascular events and death. and therefore may not be representative of result of a pro-coagulant state, which The United Kingdom Prospective US-born Arab Americans. can be attributed in part to increased Diabetes Study (UKPDS) demonstrated In conclusion, the use of aspirin and platelet aggregation.12 The production that intensive glycemic control prevents glucose lowering pharmacological strat- of thromboxane A2 (TXA2) is elevated or delays the progression of diabetes egies in Arab American patients with in patients with diabetes and is re- complications.16 In addition, the study diabetes is unacceptably suboptimal sponsible for promoting platelet aggre- provided compelling evidence that the compared to the nationally representa- gation.13 TXA2 is also a potent vaso- progressive loss of functioning beta cells tive surveys and does not conform to the constrictor. Aspirin therapy prevents the resulted in the gradual increase in ADA recommendations. Targeted ef- synthesis of TXA2 and irreversibly HbA1C levels over time and that the forts to increase aspirin use in Arab inhibits the activity of platelets.14 A effective normalization of hyperglyce- American patients with diabetes are large meta-analysis of 145 randomized mia would slow down the decline of needed. In addition, more aggressive controlled trials conducted by the Anti- these beta cells. Therefore, one of the glucose-lowering strategies that incor- platelet Trialists’ Collaboration includ- key messages of the UKPDS was to porate combination oral agents and ed patients with pre-existing cardiovas- institute and continually reassess effec- early use of insulin are required. Given cular diseases. This analysis demonstrat- tive hypoglycemic strategies. In order to the high prevalence of diabetes and ed that anti-platelet therapy in these maintain the targeted HbA1C goal, cardiovascular risk factors in Arab high-risk individuals was effective in aggressive use of combination therapy Americans, strategies focusing on opti- preventing recurrent cardiovascular with oral agents and/or insulin is often mization of aspirin and glucose-lower- events in those patients with or without required in the majority of patients. ing therapies are imperative for the diabetes.4 Studies involving patients Combination therapy with oral agents reduction of cardiovascular burden and with diabetes without a prior history was used by 37.7% of the study other diabetes-related complications. of cardiovascular disease have also participants. The use of insulin was demonstrated the protective effects of lower in Arab Americans compared to REFERENCES aspirin in lowering the incidence of national US data. Insulin and oral agent 1. American Diabetes Association. All About Diabetes: Diabetes Statistics. 2005. Available cardiovascular endpoints, such as myo- combination therapy was also under- from http://diabetes.org/diabetes-statistics.jsp. 5,6 cardial infarction and stroke. It was utilized in the present study. Last accessed 2 May 2006. further estimated that increasing the The under-utilization of aspirin, 2. UK Prospective Diabetes Group. U.K. pro- prevalence of aspirin intake to 90% insulin and combination therapy in this spective diabetes study 16. Overview of from the current 66% in diabetic population may be attributed to a num- 6 years’ therapy of type 2 diabetes: a progressive disease. Diabetes. 1995;44:1249–1258. patients receiving care from the De- ber of factors, namely linguistic, cultur- 3. American Diabetes Association. Standards of partment of Veterans Affairs heathcare al, social and health belief barriers. medical care in diabetes -2006. Diabetes Care. systems could potentially prevent System impediments including accessi- 2006;29:S4–S42. 11,000 myocardial infarctions and save bility and availability of culturally 4. Anti-patelet Trialists’ Collaboration. Col- over 8,000 lives.15 These studies appropriate healthcare and lack of laborative overview of randomized trials of prompted the recommendation by the resources may also exist. The high anti-platelet therapy. Prevention of death, myocardial infarction, and stroke by pro- ADA for the use of aspirin therapy in all prevalence of diabetes in the Arab longed antiplatelet therapy in various cate- patients with previous CVD for second- American population has been attribut- gories of patients. BMJ. 1994;308:81–106. ary prevention and in those greater than ed in part to a lack of acculturation in 5. Physicians’ Health Study Research Group. 40 years of age or who have additional this group of minorities.17 Whether or Final report on the aspirin component of the risk factors, for primary prevention. not the lack of acculturation has an ongoing Physicians’ Health Study Research Group. N Engl J Med. 1989;321:129–135. While the mean age of Arab American effect on sub-optimal pharmacologic 6. Hansson L, Zanchetti A, Carruthers SG, et al. participants in the present study was therapy is not known. Effects of intensive blood-pressure lowering 59.4612 years, only 22.6% were re- There are some limitations to the and low dose aspirin on patients with ceiving aspirin. In addition, only 3.78% present study. First, different population- hypertension: principal results of the Hyper- of participants reported receiving alter- based surveys with different methodolo- tension Optimal Treatment (HOT) randomized trial. Lancet. 1998;351:1755–1762. native anti-platelet therapy with Plavix, gies were used for data comparisons in 7. Jaber LA, Brown MB, Hammad A, et al. which is also recommended by the ADA this study. The BRFSS was a phone Epidemiology of diabetes among Arab Amer- if patients cannot tolerate aspirin. The survey, whereas the Arab-American and icans. Diabetes Care. 2003;26(2):308–318.

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8. Hammad A, Herman WH, Jaber LA. Cardio- 11. Resnich HE, Foster GL, Bardsley J, Ratner 15. Krein SL, Vijan S, Pogach LM, Hogan MM, vascular risk factors in an Arab American RE. The achievement of American Diabetes Kerr EA. Aspirin use and counseling about population in southeastern Michigan. Ethn Association Clinical Practice Recommenda- aspirin among patients with diabetes. Diabetes Dis. 2005;15:S1–S29. tions among US adults with diabetes, 1999– Care. 2002;25:965–970. 9. Hatahet W, Fungwe TV. Obesity and cardio- 2002. Diabetes Care. 2006;531–537. 16. UK Prospective Diabetes Study (UKPDS) vascular disease risk factors are ethnicity based: 12. Colwell JA, Nesto RW. The platelet in Group. Intensive blood-glucose control with A study of women of different ethnic back- diabetes. Diabetes Care. 2003;26:2181– sulphonylureas or insulin compared with grounds in southeastern Michigan. Ethn Dis. 2188. conventional treatment and risk of complica- 2005;15:S1-23–S1-25. 13. Davi G, Catalano I, Averna M, et al. tions in patients with type 2 diabetes (UKPDS 10. Ajani UA, Ford ES, Greenland KJ, Giles Thromboxane biosynthesis and platelet func- 33). Lancet. 1998;352:837–853. WH, Mokdad AH. Aspirin use among US tion in type 2 diabetes mellitus. N Eng J Med. 17. Jaber LA, Brown MB, Hammad A, et al. Lack adults, Behavioral Risk Factor Surveil- 1990;322:1769–1774. of acculturation is a risk factor for diabetes in lance System. Am J Prev Med. 2006;30: 14. Patrono C. Aspirin as an anti-platelet drug. Arab immigrants in the United States. Diabetes 74–77. N Eng J Med. 1994;330:1287–1294. Care. 2003;26:2010–2014.

Ethnicity & Disease, Volume 17, Summer 2007 S3-45 G. ABSTRACT: ASTHMA, ENVIRONMENTAL RISK FACTORS, AND HYPERTENSION AMONG ARAB AMERICANS IN THE METRO DETROIT AREA Mary Johnson, PhD; Jerome Nriagu, PhD; Adnan Hammad, PhD; Kathryn Savoie, PhD; Hikmet Jamil, MD, PhD. From the U.S. Environmental Protection Agency, Research Triangle Park, North Carolina (MJ); Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan (JN), Department of Family Medicine, Wayne State University, Detroit, Michigan (HJ); and ACCESS Community Health & Research Center, Dearborn, Michigan.

Background. The importance of environmental risk factors in asthma etiology has been well documented, and certain environmental risk factors have also been associated with hypertension. However, few previous studies have examined the relationship between hypertension and asthma. Study Population. This study explores the relationships between hypertension, asthma and environmental risk factors in a population of 600 Arab American adults in the metropolitan Detroit area. Methods. An Environmental Risk Index (ERI) was used to quantify household environmental risk factors associated with asthma; physician-diagnosed hypertension was self-reported. Asthma status was determined using responses to a validated symptoms checklist and self-reported diagnosis by a physician. Results. Hypertension was significantly associated with asthma after adjusting for age, sex, healthcare access, socioeconomic status (SES) and marital status. The prevalence of asthma and hypertension was not significantly different among men and women in the study population. Comparing the relationship between environmental risk factors and asthma revealed that ERI was significantly associated with asthma among participants with and without hypertension; however, the relationship between environmental risk factors and asthma was stronger among participants with hypertension. This interaction was stronger among women in the study population and was statistically significant adjusting for age, healthcare access, SES and marital status. These results are consistent with the disproportionate asthma risk associated with obesity among women. Specific risk factors implicated in this relationship will be discussed. An additional consideration was the impact of other potentially mediating factors, such as age and time spent at home. Age was positively associated with asthma and hypertension in the study population; however the relationship between ERI, hypertension and asthma did not vary significantly by age. Using full-time employment as a surrogate for time spent outside the home showed that the relationship between ERI, asthma and hypertension was stronger among study participants who spent more time at home. This effect modification was statistically significant controlling for age, healthcare access, SES and marital status. Conclusion. Results suggest that hypertension may impact asthma not only through shared risk factors, but also through an increased vulnerability to environmental stressors. These findings also suggest that household risk factors may have a stronger adverse effect among individuals who spend more time at home, possibly due to prolonged duration of exposure or a greater degree of vulnerability among those individuals. This is an abstract of a proposed presentation and does not necessarily reflect EPA policy.

S3-46 Ethnicity & Disease, Volume 17, Summer 2007 REPORT:HEALTH-RELATED POLICY, ENVIRONMENTAL HEALTH, AND CHRONIC DISEASE

SECTION V. REPORT:INTERACTIVE PANEL DISCUSSION ON HEALTH-RELATED POLICY, ENVIRONMENTAL HEALTH, AND CHRONIC DISEASE

Summarized by session moderators David J. P. Bassett, PhD; May Darwish-Yassine, PhD

Ethn Dis. 2007;17[Suppl 3]:S3-47–S3-49 The session opened with introduc- velopment of effective intervention tion of the panelists: Kimberlydawn strategies. Through efforts such as Key Words: Environmental Health, Chronic Disease, Health Policy Wisdom MD, Michigan Surgeon Gen- these conferences, programs, especially eral; Joseph Harford PhD, director, those that promote better lifestyles for Office of International Affairs of the sustained health, are in development. National Cancer Institute, Bethesda, These programs must consider the MD; Sabri Belgacem MD, director, mental stress due to differences in Health Systems Policy and Develop- culture and language, accessibility to ment, World Health Organization – health care and the immigration pro- Eastern Mediterranean Regional Office, cess itself. Cairo, Egypt; Ali Mokdad, PhD, Cen- In his remarks, Joseph Harford, ter for Disease Control and Prevention, PhD recalled comments from John Atlanta, GA; and Adnan Hammad, Seffrin, PhD on his global perspectives PhD, director, ACCESS Community that addressed growing concerns about Health and Research. an inability to deal with chronic diseases In introducing the discussion ses- in the developing world. He noted sion, David J.P. Bassett, PhD, noted a dramatic increase in cancer in Middle how the early Arab American Health East countries and a general prediction conferences identified a need to collect of a future overload of the healthcare and collate previously unavailable data systems, because such systems have on disease prevalence in the Arab previously focused on short-term treat- American community. An integral part ment of communicable diseases. Har- of these biennial conferences has been ford also noted the establishment of the ACCESS-based research conducted a regional consortium of seven regional in collaboration with local universities NCI cancer registries in the Middle East and healthcare organizations in south- to prepare for this epidemic. In addi- eastern Michigan. At each new meeting, tion, the importance of community- a greater participation of health profes- based programs to address the increas- sionals and academics from the Middle ing use of tobacco among young Arabs, East brought many new perspectives to in general, and Arab Americans, in these endeavors. particular, was stressed. A lively di- The 4th National Conference suc- alogue between the audience and pane- cessfully recruited a wide range of lists rounded out the discussion. speakers not only from the Arab world, A recurring theme was the discon- but also from Michigan, as well as nect between policymaking and the lack From the Eugene Applebaum College national and international health orga- of resources and political inclination to of Pharmacy and Health Sciences (DJPB), nizations. Therefore, a unique combi- address many chronic disease condi- the School of Medicine (DJPB), Wayne nation of experiences from non-Arab, tions, including the provision of pro- State University, Detroit, Michigan, and the Michigan Public Health Institute Arab American and Middle East po- grams to promote healthy lifestyles and (MDY), Okemos, Michigan. pulations helped to promote the de- increase health screening. The audience

Ethnicity & Disease, Volume 17, Summer 2007 S3-47 PANEL DISCUSSION - Bassett and Darwish-Yassine first raised the need to promote safe health care to manage chronic diseases is derstanding the context and conse- environments that allow people to walk also limited in the United States for quences of what is being offered, and as well as participate in other exercise- many individuals, especially refugees. most importantly to make choices in- related activities. First to respond, Wisdom announced a new initiative dependent of media and peer pressure. Kimberlydawn Wisdom, MD, encour- designed to assist 550,000 Michigan Based on previous experience with aged the organizers to invite more residents who do not have ready access programs to reduce substance abuse, policymakers to future conferences. to health insurance from either govern- he explained that such intervention She then described how the state of ment or employer supported programs. programs provide inexpensive ways to Michigan uses teams that include archi- Other members of the audience com- combat the promotion of tobacco use in tects, engineers and public health pro- mented on the lack of resources to schools worldwide. fessionals to design safe places to walk support research and programs to Ibrahim Kira, PhD, of ACCESS and promote exercise in the develop- modify behaviors that include helping initiated a discussion on the mental ment of new living communities and in individuals to stop smoking, exercise health aspects of dealing with chronic the remodeling of older ones. more, and deal with metabolic syn- diseases, emphasizing how depression Discussions also focused on the dromes associated with obesity and becomes a major barrier to effective development of programs to address cardiovascular disease. intervention and improvement. He lifestyle changes, including exercise, and Ali Mokdad, PhD, continued the noted the importance of an integrative pointed out how the cultural strengths discussion on the disconnect between approach in treating the whole person of a community might be used to make policymaker actions and the actual in the context of the family and such programs attractive and sustain- needs of society by noting the influence community, a model used by ACCESS able. The panelists stressed the need for and control the tobacco industry exerts to translate research into evidence-based early involvement of communities in on policy decisions for marketing their practice in the Arab American popula- the design of environments and the products. He also noted the power of tion. Harford followed by emphasizing establishments of such intervention the media, illustrating how the intro- the need for a similar holistic approach programs. duction of satellite TV networks in the to treating cancer, recognizing the The audience raised issues concern- Middle East sparked a rapid increase in mental health needs of cancer survivors ing lack of access to early screening water pipe use not only in the Arab and terminally ill patients and the programs and long-term management world but also in Arab communities support needed by their respective programs for chronic conditions. In the across Europe and North America. He families. Middle East, political expediency of emphasized the need to focus on the A member of the audience noted the short-term administrations appears to social determinants of health in trying importance of seeing cultural differences drive the establishment of new hospitals to prevent the increases in ill health. He not as barriers but as opportunities to rather than investment in such pro- noted the relative inability of health develop innovative sustainable programs grams. Such facilities were important in professionals to influence behavior and to affect dietary changes, decrease and the past when treatment of infectious reduce the mental stress of their patients prevent tobacco use and enhance exer- diseases was the health priority. In andclients.Healsoindicatedthat cise. Adnan Hammad, PhD, closed this addition to a relative lack of suitable health professionals have failed to lobby part of the panel discussion by empha- screening programs, Harford commen- effectively to change health policies and sizing the high numbers of immigrants ted on the stigma of cancer that delays to promote research and training in entering Michigan each year. He de- its early presentation, leading to an these areas. scribed the transitions and challenges inability to apply modern intervention Paul Shaheen, who serves on the they experience, especially if they come strategies. He indicated that, in com- steering committee of the Michigan from rural areas in their country of parison with the United States and Council for Maternal and Child Health, origin. Many go from living a life filled Europe, a reluctance to seek help still addressed the worldwide increase in with much exercise to sitting in a factory, exists in the Middle East and most likely tobacco usage, citing ongoing difficul- driving instead of walking to work, and carries over into the older Arab Amer- ties in getting political action against the switching from eating a healthy diet to ican population. Sabri Belgacem, MD, tobacco industry. He described the need one that is rich in red meat and fat. At noted that this stigma and barrier to to work with health professionals and the same time the immigrants must deal early treatment also applies to other schools to develop suitable educational with the stresses of language, cultural chronic conditions, including diabetes programs for all grade levels. Such change, and the immigration adminis- and cardiovascular disease. Two mem- programs would help students learn tration process that sometimes can take bers of the audience noted that access to how to make decisions based on un- several years.

S3-48 Ethnicity & Disease, Volume 17, Summer 2007 PANEL DISCUSSION - Bassett and Darwish-Yassine

May Darwish-Yassine, PhD, led his need for nicotine at the price of remove tobacco from the market even a discussion on how to reduce tobacco being exposed to a greater amount of though it causes so much chronic use and introduce effective smoking cancer causing tars. disease and death. Harford indicated prevention programs. She emphasized The recognition of the addictive that lung cancer deaths over time were the role of family members in influenc- effects of tobacco smoking was dis- decreasing in California, an unfriendly ing children’s use of tobacco and the cussed, commenting on the adolescent state for smokers, compared with Ken- fact that the very high usage and social misperception that it is easy to quit and tucky where tobacco use is promoted. acceptability of narghile (water pipe) on the observation that a majority of He emphasized the need for communi- smoking in the Middle East is perpet- smokers actually want to quit but have ty-based group action to lobby local uated by the immigrant population in great difficulty doing so. In discussing government and national congressional the United States. approaches to cessation and prevention, leaders. A participant requested advice on conference participants familiar with Closing remarks by Wael Sakr, MD how to deal with patients who use the Arab American immigrants in Califor- and the panelists pointed to the need to water pipe. Harford stressed that the nia raised the possibility that the in- focus efforts on preventing children message from the medical community fluence of sustained cultural practices from smoking and to apply methods should be that there are no safe levels for and beliefs in the relatively dense used for treating other addictions to smoking and that regular and infre- community in southeastern Michigan those wishing to quit. The need for quent use of tobacco in any form is risky might differ considerably from more health professionals to educate politi- behavior. He also noted that infrequent dispersed Arab American groups in cians by providing data on effective water pipe smoking most likely would other metropolitan areas. They also smoking-cessation program expendi- not have much effect on appetite noted that, although California is un- tures and long-term savings in health- suppression. Another participant indi- friendly to cigarette smokers, the estab- care costs was discussed. Emphasis cated that some water pipe sessions last lishment of narghile lounges in Arab was made on the need for health- as long as an hour and involve greater restaurants in San Francisco is on the care professionals to continue to work depths of breathing of around 500 mL increase. with community leaders in promot- per puff compared with 50 mL per puff The failure of health policies to ing administrative control of tobacco for a cigarette. He also said that research control tobacco was illustrated by an at the state and local levels by encour- suggests that the water used in the water audience member who compared the aging tax increases on tobacco, denying pipe removes some of the nicotine; rapid removal from the market of useful tobacco access to minors, and banning therefore a dependent smoker would drugs with relatively low incidents of smoking in public places and restau- need to increase usage in order to satisfy adverse health effects to the failure to rants.

Ethnicity & Disease, Volume 17, Summer 2007 S3-49 GLOBAL HEALTH FROM ARAB AND DEVELOPING WORLD PERSPECTIVES

SECTION VI. GLOBAL HEALTH FROM ARAB AND DEVELOPING WORLD PERSPECTIVES

Section VI has been edited by Wael A. Sakr, MD; Nizar Akil, MD

Ethn Dis. 2007;17[Suppl 3]:S3-50–S3-56 A. OVERVIEW growing rates of mortality due to chronic diseases where 80% of these deaths Key Words: Global Health, Public Health, The presentations in this section Chronic Disease occurred in low- and middle-income provided an account for the current countries compared to 20% share for the status and the trends of major public high-income countries. He suggested health issues in the Arab world at large, that the findings of a study in the Sousse with data from specific countries in the region showing the three risk factors of region. The effects of socioeconomic and tobacco use, diet, and physical inactivity educational status and the transforming as the dominant and often synergistic lifestyle factors including tobacco con- role in the development of these chronic sumption, dietary habits and the lack of diseases to be applicable to trends in the physical activity on the incidence of Arab world. He also emphasized that the noncommunicable diseases were ad- importance of developing population- dressed by the invited speakers. While wide prevention programs that are the major themes were similar, different community-based and are inclusive, (ie, areas of emphasis along with country- all age brackets; especially the youth and specific data, predictions and statistics both the symptom-free and the high-risk were offered in the papers presented. individual). Sabri Belgacem, MPA, MD, director Ali Mokdad, PhD, chief, Behavioral of Health Systems & Services Develop- Surveillance Branch at the Centers for ment, WHO-EMRO, Cairo, Egypt Disease Control and Prevention out- addressed the steadily growing risk for lined the differences in the approaches noncommunicable diseases in the Arab adopted by the clinical vs public health world with the increasing prevalence of disciplines. The clinical world believes high blood pressure, diabetes and obe- in reductionism, which is the basis of sity due to poor eating habits and medicine, whereby the larger phenom- changes in economic and social statuses. ena are studied by looking at the smaller He emphasized the alarming increase in tobacco consumption among adults and components and the concept is that the youth in countries across the region. more-specialized a service or a hospital Combating these challenges is compli- is, the better it will serve its people. The cated by the major financial hardships public health philosophy, on the other faced by Arab countries to provide hand, believes in interconnectedness, quality healthcare services. A key factor whereby the large phenomena are visible in these efforts involves increasing and can only be studied when they are knowledge and awareness of risk factors in the presence of their smaller compo- to alleviate the impact of the rising rates nents. He presented the results of CDC of noncommunicable diseases. surveys in Jordan on the epidemiology In his presentation, Hassen Ghan- of diabetes, hypertension and other risk factors as they relate primarily to the From Wayne State University, Detroit nem, MD, chief, Epidemiology, Univer- Michigan (WAS) and Aleppo University, sity Hospital Farhat Hached, Sousse, changes in the behavior and life style of Damascus University (NA). Tunisia, focused on the worldwide the Jordanian population.

S3-50 Ethnicity & Disease, Volume 17, Summer 2007 B. COMMENTARY:THE GROWING RISK FACTORS FOR NONCOMMUNICABLE DISEASES IN THE ARAB WORLD

Sabri Belqacem, MPA, MD

Ethn Dis. 2007;17[Suppl 3]:S3-51–S3-52 The Arab population is estimated to increase in its use. Egypt leads the be about 280 million. The majority are region in tobacco consumption, with Key Words: Noncommunicable Diseases, Risk Factors in the younger age brackets, although in an estimated 8% increase consumption some countries, the aging population is annually and a growing number of increasing due to changing living stan- children starting the habit between 10 dards and demographic transitions. The to 15 years of age. Estimates show region is quite diverse with respect to a fivefold overall increase in tobacco social and economic determinants of consumption in Egypt from 1970 health. While these countries are at (12 billion cigarettes/year) to 2003 different stages of development and (62 billion cigarettes/year). In Syria, their economic classification includes 50% of males and 10% of females many within low-income status, some consume cigarettes, with alarming within the middle-income and few smoking rates among medical profes- within the high-income categories, the sionals (40% males, 11% females). In total income of the entire Arab world Morocco, tobacco commerce repre- according to the Human Development sents2.1%ofGDPandaccountsfor Report of 2003 and 2004 is less than about 2.5% of total per capita expen- that of Spain. ditures. In the GCC countries, 45 Allcountriesintheregionfacethe daily deaths are attributed to smoke- burden of growing risk factors for related illnesses. Overall, the increase noncommunicable diseases (NCD), in smoking in the Arab world has been with statistical evidence documenting more pronounced in the rural areas a rise of the major risk factors for these (fourfold), compared to twofold in the diseases such as tobacco, obesity, lack urban areas of the region. of physical activity and high blood The overall burden of morbidity in pressure. Unhealthy lifestyles are also the low- and middle-income countries growingamongyoungpopulations of the region is accounted for mostly and are exacerbated by globalization by NCD (57.1%) compared to in- and extended communication particu- fectious diseases (25%) and injuries larly through satellite channels, which (17%). are becoming very popular in the As countries of the region work on region. Ischemic heart and vascular developing strategies and programs to diseases, as well as cancers, represent control the rise in NCD, their efforts the major causes of morbidity and are hampered by the limited financial mortality. Obesity is also increasing in resources to address risk factors for the Arab world, ranging from 16%– NCD, which is costly and needs long- 50% and more than 50% in the term commitment. The emphasis needs higher-income countries of the Gulf to be on health promotion, starting at Cooperative Council (GCC). The lack school and in work settings in line with of, or the very limited, physical activity the cultural heritage and religious reported in these countries is also practices. Implementing school health a contributing factor to the rise in programs for youth is essential. Some NCD. regional attempts have been made to Statistics related to tobacco use, in integrate NCD control activities within From the Health Systems and Services particular, are worth emphasizing as the primary healthcare settings and we Development, WHO-EMRO, Cairo, Egypt. the Arab world has seen a steady have seen an increased awareness for the

Ethnicity & Disease, Volume 17, Summer 2007 S3-51 GLOBAL HEALTH PERSPECTIVES - Belqacem need of partnerships with academic the burden of NCD in the Arab world. mendations for managing risk factors institutions, professional associations, WHO is a major partner in these efforts and noncommunicable diseases, and NGOs, the food industry, and the and provides technical support, pro- promotes national and regional NCD media to support strategies to reduce motes established guidelines and recom- registries.

S3-52 Ethnicity & Disease, Volume 17, Summer 2007 C. GLOBAL HEALTH FROM THE ARAB AND DEVELOPING WORLD PERSPECTIVES

Hassen Ghannem, MD, MSc

Ethn Dis. 2007;17[Suppl 3]:S3-53–S3-54 INTRODUCTION chronic diseases. Despite the new interest and emphasis on public health Key Words: Global Health, Arab World Thirty-five million people died in and prevention, it appears that the 2005 from chronic diseases mainly from challenge of chronic disease control in cardiovascular disease, stroke, cancer developing countries remains before us. and diabetes mellitus.1 The worldwide Urbanization is expected to raise the epidemic of chronic diseases resulted in level of chronic diseases risk factors as more than 60% of all deaths, at least a result of the adoption of new dietary half of which were considered prema- habits, lack of physical activity, and ture deaths. Only 20% of these deaths stressful work conditions in the urban have occurred in high-income countries area. while 80% occurred in low- and mid- Many myths about chronic diseases dle-income countries. The projected have serious consequences for the health number of chronic disease deaths will and welfare of people in low- and increase from 35 million in 2005 to middle-income countries. In these 41 million in 2015, in the same time countries, the costs of chronic disease the disability adjusted life years are often born by patients as out-of- (DALYs) will rise from 725 to 808 mil- pocket payment leading to more family lion.2 (Table 1) poverty. From another side, the envi- The Arab world is currently facing ronment and economic pressures in the epidemiological transition phenom- developing world may result in poor enon that leads to the extension of diet choices and limited physical activ- chronic diseases. For example, in Tuni- ities, which constitute the unhealthy sia, a country in transition,3 we have behaviours that lead to chronic disease observed a hypertension prevalence rate morbidities. of 28.8% (BP $ 140/90 mm Hg) among a representative sample of individuals of Sousse (N 5 957). History of PREVENTING AND diabetes was found among 10.2%, CONTROLLING obesity (BMI . 30) among 27.7% CHRONIC DISEASES (significantly higher among women: 34.4%), android obesity among 36%, Fortunately, many of these diseases and smoking habits among 21.5% are amenable to successful intervention (significantly higher in men: 61.4%). as is clearly demonstrated in developed The epidemiological situation is mostly countries.4,5 Evidence indicates that similar for the rest of the Arab countries a small number of risk factors and with respect to chronic diseases risk conditions are common to major chron- factors. ic diseases. This means that integrated Three common and highly prevent- actions against selected risk factors able risk factors – tobacco use, diet, and implemented within the social context physical inactivity – play a dominant can lead to the reduction of major and often synergistic role in the de- chronic diseases.6,7 Low- and middle- velopment of these chronic diseases. For income countries should follow these developing countries, the problem is proven concepts of integrated preven- more serious because many have not yet tion of chronic diseases as an essential From the Community and Preventive component of existing health systems Medicine Division, Department of Epide- conquered communicable diseases and miology; University Hospital Farhat Ha- their health systems are ill-prepared to and should focus on health promotion ched, Sousse, Tunisia. provide the costly care required for these at a general level.

Ethnicity & Disease, Volume 17, Summer 2007 S3-53 GLOBAL HEALTH PERSPECTIVES - Ghannem

The prospects of preventing and Table 1. Projected global deaths and DALYs from chronic disease by age from 2005 to 2015 controlling risks for chronic diseases are relatively very slowly improving.11 Deaths (millions) DALYs (millions) Sustained progress to bridge the gap will 2005 2015 2005 2015 occur only when governments, relevant 0–29 years 1, 7 1, 5 220 219 international agencies, non-governmen- 30–59 years 7 8 305 349 tal agencies and civil societies acknowl- 60–69 years 7 8 101 125 edge that the promotion of public $70 years 20 24 99 116 health should include the prevention All ages 35 41 725 808 of chronic diseases and their risk factors. The challenges of chronic disease pre- Available evidence supports the fea- ments would lead to a reduction in the vention are enormous and their control efforts must be scaled up proportionally sibility and effectiveness of population- burden of chronic disease risk factors to the increasing burden.11 wide prevention directed toward in- behaviors and consequently to chronic creasing the proportion of people at disease burden. The integrated preven- 8,9 REFERENCES low-risk of chronic diseases. In addition programs for chronic diseases 1.WorldHealthOrganization.Preventing tion, chronic disease, and particularly should target the young, as well as the Chronic Diseases: A Vital Investment. WHO cardiovascular disease (CVD), risk fac- adults, by the implementation of lifestyle Global Report. World Health Organization; tors can be linked directly to social, modification and educational activities 2005. economic and environmental determi- in the context of a community mobili- 2. Strong K, Mathers C, Leeder S, Beaglehole R. nantsofhealth.Factorsthathave zation perspective. The improvement of Preventing chronic diseases: how many lives can we save? Lancet. 2005;366(9496):1578–82. a major impact on the development of the preventive practices of health profes- 3. Ghannem H, Hadj Fredj A. Prevalence of chronic disease include: education, sionals at the different levels of care must cardiovascular risk factors in the urban availability and affordability of healthy be central to the programs. population of Soussa in Tunisia. J Public foods, access to health services, and This approach addresses all sectors Health Med. 1997;19:392–396. infrastructures that support a healthy of the community (from symptom-free 4. Farquhar JW, Wood PD, Breitrose H, et al. 7 Community education for cardiovascular lifestyle. Advances in etiological re- individuals to high-risk persons) and health, Lancet. 1977;1:1192–1195. search of CVD have resulted in numer- proposes interventions centered on the 5. Puska P, Salonen JT, Nissinen A, et al. Change ous intervention projects and programs promotion of healthy habits (smoking in risk factors for coronary heart disease during through the developed world. The scope abstinence promotion and control of 10 years of a community intervention pro- of these activities is broad, from pre- tobacco addiction, balanced food, sus- gram (North Karelia Project). BMJ. 1983; 287:1840–1844. ventive action on a single risk factor tained physical activity) and the pre- 6. World Health Organization. Protocol and such as tobacco or a disease such as vention of the main underlying risk Guidelines: Countrywide Integrated Noncom- coronary heart disease (CHD) to a more factors (arterial hypertension, smoking, municable Diseases Intervention (CINDI) Pro- comprehensive approach involving sev- obesity, diabetes, hypercholesterolemia). gramme. Copenhagen: WHO Regional Office eral risk factors common to several The ultimate goal is to reduce (or to for Europe; 1996. 6 7. World Health Organization. The World Health chronic diseases. In fact, there is delay) the occurrence of chronic diseases Report 2002. Reducing the Risks, Promoting scientific evidence of the effectiveness and their related risk factor behaviors Healthy Life. Geneva: WHO; 2002. 8 of such strategies, but, at the same (smoking, physical inactivity and un- 8. Rose G. The Strategy of Preventive Medicine. time, a lack of commitment to pre- healthy diet). Oxford: Oxford University Press; 1992. vention may undermine the launching The program employs interventions 9. Beaglehole R, Magnus P. The search for new risk factors for coronary heart disease: occupa- of these initiatives. targeting the internal factors under the tional therapy for epidemiologists? Int J Epi- We can hypothesize that communi- control of the individual, but also demiol. 2002;31(6):1117–11122. ty-based intervention programs designed targets environmental factors not under 10. Ghannem H. The challenge of preventing for the whole population of developing the individual control. The effectiveness cardiovascular disease in Tunisia. Prev Chronic world, where everyone would have access of interventions with regard to behavior Dis. 2006;3(1):A13. 11. Beaglehole R, Yach D. Globalisation and the to positive healthy living, smoke free air, modifications constitutes the main chal- prevention and control of non communicable healthy nutrition, regular physical activ- lenge to the integrated program de- disease: The neglected chronic diseases of 10 ity and supportive working environ- signed to control chronic diseases. adults. Lancet. 2003;362:903–908.

S3-54 Ethnicity & Disease, Volume 17, Summer 2007 D. CHRONIC DISEASES AND THE POTENTIAL FOR PREVENTION IN THE ARAB WORLD: THE JORDANIAN EXPERIENCE

Ali H. Mokdad, PhD

Ethn Dis. 2007;17[Suppl 3]:S3-55–S3-56 In this report, we present data Self awareness of chronic disease summarizing patterns of chronic dis- (Source: CDC 2004 Survey) reflects poor Key Words: Chronic Disease, Arab eases in Jordan as found through studies screening practices, especially for cancer, conducted by the US Centers for including low awareness of mammo- Disease Control and Prevention gram and Pap smear procedures. (CDC). Data indicated that chronic Of the 26.4% (760,000) adults with disease was accountable for .50% of hypertension, 67% are uncontrolled deaths in the country during 2003, with (Source: He J, Whelton PK. Am Heart J, cardiovascular diseases at 38.2% and 1999;138:211–219) and presents a major cancer at 14.3%. risk factor for heart disease and stroke. A Trends in chronic diseases were 12–13 point reduction in blood pressure evaluated based on these CDC surveys would help reduce heart attacks by 21%, conducting during 1996, 2002 (actual strokes by nearly 40%, and deaths from household surveys) and 2004. Diabetes cardiovascular disease by 25%. mellitus incidence doubled from 6.8% Nearly 20% (580,000) Jordanians in 1996 to 15.3% in 2004. The have high blood cholesterol levels increase is attributed to behavioral (.240 mg/dL) and 26% (,770,000) changes rather than genetic or family have borderline high levels (200– history factors (Source: CDC 2004 239 mg/dL) (MMWR. 2000;49(33): Survey). Among the risk factors cited 750–755). These facts are important were: poor diet with 28.3% reporting for the Ministry of Health and should no daily fruit or vegetable consump- assist in guiding programs for people tion from the day before their survey; who have borderline hypercholestere- physical inactivity at 63.7%; and mia. Of those with high or borderline a smoking rate of 23% for individuals high levels of cholesterol, ,65% are ages $18 years. uncontrolled, which, again, is a major While 26.4% of Jordanian adults risk factor for heart disease and stroke. A have high blood pressure, the surveys 10% decrease in total cholesterol levels indicate that 14.9% suffer from un- may result in an estimated 30% re- diagnosed hypertension. High choles- duction in the incidence of coronary terol levels increased from 9.1% in 1996 heart disease. to 19.9% in 2004 with undiagnosed Diabetes statistics from Jordan are hypercholesteremia estimated to be at also alarming, with 440,000 (15.3%) 6.4%. Of particular concern were the with diabetes and an additional 350,000 numbers for diabetes: 7.8% of Jorda- (12.3%) having pre-diabetes as indicat- nians knew they had diabetes (were told ed by the intolerance glucose test (IGT). by physicians) vs an actual 15.3% who High glucose levels are a major risk were found to be diabetic with blood factor for heart disease and stroke. tests conducted during the survey. The Clinical trials in the United States reported obesity rate increased by 50% have shown that diabetes is also pre- to a rate of 34.9% in 2004. The ventable by changing behaviors, in- problem is further complicated by creasing physical activity, and eating weight awareness (ie, not perceiving a balanced healthy diet. These changes From the Behavioral Surveillance being obese for 19.2% in 2002 and are known to be more effective than Branch, Centers for Disease Control and 34.9% in 2004). medications. Prevention, Atlanta, Georgia.

Ethnicity & Disease, Volume 17, Summer 2007 S3-55 GLOBAL HEALTH PERSPECTIVES - Mokdad

Finally, 23% of the Jordanian pop- In summary, public health pro- leading causes of morbidity and mor- ulation .18 years of age are smokers, grams in place in Jordan are impor- tality include an emphasis on commu- which accounts for 720,000 adults with tant to the long-term health of the nity involvement and political commit- a high morbidity and mortality cost. nation; additional plans to address these ment.

S3-56 Ethnicity & Disease, Volume 17, Summer 2007 INTEGRATED HEALTH CARE DELIVERY: PAST,PRESENT AND FUTURE

SECTION VII. INTEGRATED HEALTH CARE DELIVERY:PAST,PRESENT AND FUTURE. ASSESSMENT OF LOCAL MODELS OF INTEGRATING PHYSICAL AND MENTAL HEALTH CONCERNS

Edited by Wael Sakr, MD and R. Michael Massanari, MD, MS

Ethn Dis. 2007;17[Suppl 3]:S3-57–S3-69 A. OVERVIEW from the medical/health system where it belongs, to the patients and their families Key Words: Arab Medicine, Integrated Health Care This session provided a historical who are not equipped to fulfill this task. perspective of the philosophy and Three presentations of this session practice of an integrated approach for outlined the approach adopted by two the evaluation and management of hospital-based systems, (Henry Ford disease during the golden era of Arabic and Oakwood) and one community- civilization. Samir Yahia, MD, a rheu- based system (ACCESS), for integrating matologist by specialty and a student of the mental health component, depres- the history of Arab medicine, highlight- sion in particular, into the assessment ed the numerous contributions in and management of patients seen within medicine from a large number of these facilities and their outpatients physicians and scientists across several satellite and affiliated physicians offices centuries and vast geographic terrain of in the Detroit, Michigan area. The first the Arabic/Islamic empire. Yahia em- speaker, Edward Coffey, MD, concen- phasized the need for the integration of trated on the effects of depression on variousfieldsofknowledgeinthe cardiovascular and central nervous sys- education and training of future physi- tem morbidity by presenting mounting cians in order to prepare them to adopt data confirming the negative impact, a comprehensive approach with consid- particularly of long-standing untreated eration for the mental and social depression, on these systems. He also background of each patient. outlined a Ford Health system plan that Bringing the concept into contem- was implemented to facilitate screening porary frame, Michael Massanari, MD fordepressionintheprimarycare offered a general assessment for the setting. The essence of the plan is to ability of the medical delivery practice identify an effective way for the clinician in the United States to account for to diagnose depression for treatment to relevant mental, behavioral and logistical begin in a timely fashion. considerations when doctors attempt to Issam Khraizat, MD, from the Oak- manage patients. His report illustrates wood Health Care System, addressed real life examples of the failure of the the issue of depression and women’s current medical practice system to com- health. Women have a 25% lifetime risk prehensively address patients’ needs. The of developing depression with a high environment of ‘‘reductionism’’ that likelihood of recurrence once diagnosed. focuses on studying, specializing and In addition, pregnancy, delivery, post- practicing within increasingly narrowing delivery period and peri-menopause are areas of sub-specialties, results in frag- events that can often trigger depression mented care, competition for resources in some women. Khraizat also high- From Wayne State University, Detroit and worse, passing the responsibility of lighted programs at the Oakwood Michigan. ensuring the delivery of coordinated care Health Care Systems designed to in-

Ethnicity & Disease, Volume 17, Summer 2007 S3-57 INTEGRATED HEALTH CARE DELIVERY - Sakr and Massanari corporate screening for depression at within the system to address the needs with physical and mental health care. both the general practice and specialized of this population. His data demonstrated the paradigm levels. For Arab Americans, in particu- Finally, the presentation by Ibrahim shift that resulted from the advances in lar, Khraizat acknowledged the bilingual Kira, PhD from ACCESS emphasized this area including primarily data from capabilities of the healthcare profession- the importance of integrating research ACCESS but also with reference to al, social workers and supportive services programs within a community network national research.

S3-58 Ethnicity & Disease, Volume 17, Summer 2007 B. INTEGRATED CARE IN THE HISTORY OF ARAB MEDICINE –AHISTORICAL PERSPECTIVE

Samir Yahia, MD

This presentation featured the high- Omayyad and especially the Abbasid science can offer the sick and the ly developed medical knowledge, prac- phase of the Arabic rule, institutions injured.’’ tices, medical writings, textbooks and devotedtoknowledgeandcareflour- Mac Eachern’s editorial on hospital institutions (libraries, hospitals and ished. Of a particular note, is Dar Al standardization, 1936. pharmacies) that existed during the Hikma, an extensive multi-specialty enlightened days of the Arabic/Islamic library established in Baghdad and It is appropriate to mention a leader civilization spanning the 8th to 12th housed numerous books initially trans- of early Arab medicine. He was both centuries. lated to Arabic; the library books grew a great physician and a believer in Ar-Razi and Ibn Sina, two of the rapidly with the numerous contribu- psychosomatic medicine. Abu Ali al- great physicians renowned in Arab tions from Arabic scholars as the new Husayn bin Abdallah bin Sina (980– medicine, were known for a comprehen- culture moved from the absorption 1037) studied and wrote The Canon of sive approach to medical care based on into the creation phase. This monu- Medicine, the most important textbook th th a vast knowledge from sophisticated ment was indeed an integrated center of medicine until the 15 or 16 writings in a variety of fields and of learning that continued growing for centuries. The five-book text was struc- disciplines. They were referred to as centuries. tured in distinct sections: Al-Hakim, a term, which means ‘‘the Also of interest is to learn about the N Book I: On ‘‘universals,’’ a systematic wise’’ and was bestowed on scholars early Arab hospitals, which were docu- survey of medical theory, etiology, who were recognized as teachers, scien- mented as having staffs of dozens of hygiene, therapy and surgery tists, philosophers, travelers, linguists, specialists including physiologists, ocu- N Book II: Simple drugs and artists; they were charitable and lists, surgeons and bonesetters. N Book III: Diseases arranged from held the highest moral and ethical values They had special wards for the head to toe and of course, also medically qualified mentally ill and separate wings for N Book IV: Some general conditions and licensed. The wide exposure to men and women. These hospitals were N Book V: Compound drugs these disciplines in addition to medicine often incorporated into large charitable expanded the perspectives of evaluating foundations and were supported by Gerard of Cremona translated the patient’s physical ailments and helped endowments made by powerful and book into Latin; the Canon became th to place them into the wider context of wealthy individuals. It is indeed in- required reading up to the 17 century the mental and social framework of triguing to read the dedication state- for the European world. patients and their families. ment of hospitals as articulated by one In closing, Yahia told an anecdote Many deserving an Al-Hakim title of the Abbasid Khalif 1200 years ago told about Ibn Sina with respect to his believed and practiced an integrated and compare the text to a 20th century psychosomatic medicine skills. He was approach to patients’ evaluation and hospital: asked to examine a young man who care and have also been acknowledged became increasingly sick and had lost for their achievements and discoveries in ‘‘I dedicate this hospital to my peers weight without an apparent physical medicine. They were also visionaries in and inferiors, and constitute this wakf to illness. As Ibn Sina examined the pulse term of establishing key medical institu- the benefit of the king and the mamluk; of the patient, he talked to him about tions and medical systems that formed the soldier and the prince; the great and women and love and monitored the the foundation of today’s counterparts. the small; the freeman and the slave; for acceleration of his pulse as the conver- The hospital and the pharmacy are men and for women.’’ sation became more specific with neigh- examples of the former while posi- Al-Mansur borhood locations and finally, with the tions/functions such as the chief physi- house of the young lady with whom the cian who administers qualifying exams ‘‘The 20th century hospital is char- patient was in love. Ibn Sina diagnosed for aspiring physicians and the inspector acterized today as an institution in him with ‘‘love sickness’’ and suggested who ensures the validity and safety of which every man, woman and child, that the only remedy was to unite him chemicals and drugs sold in pharmacies regardless of race, color, creed or social with his loved one. Of course, the story are examples of the latter. During the status, gets the best care that medical ends happily and he is cured.

Ethnicity & Disease, Volume 17, Summer 2007 S3-59 C. INTEGRATED HEALTH CARE DELIVERY –AMANDATE FOR SYSTEMS TRANSFORMATION

R. Michael Massanari, MD, MS

INTRODUCTION ity, the teacher requested an appoint- the responsibility of the patient and her/ ment with a neurologist at a renowned his family to coordinate care? Does the Claims that ‘…the US healthcare Midwestern clinic only to discover that patient serve the system or does the system is the best healthcare system in there were no available appointments in system serves the patient? In the scenar- the world….’ are not unusual, at least the foreseeable future. io described above, the family member among those who have little reason to Through personal persistence, she was an articulate individual who had seek the services of the system. On the finally obtained an appointment in the more than a passing knowledge of the other hand, observations of those who neurology department of a prominent healthcare system. How would someone need and depend on the services of the medical school located more than from a different culture or someone for healthcare system portray a much dif- 100 miles from her home. While satis- whom English is a second language ferent view. The following scenario fied with the quality of care and services navigate the disjointed health system? provides a stinging indictment of health received in the department of neurolo- To be sure it can be argued that this care in the United States and the gy, several sophisticated diagnostic stud- scenario is but a single, isolated example implications for patients and consumers ies were requested by the neurologist. of poor coordination and integration of when integration and cooperation are Because the diagnostic services were not health care. Unfortunately, evidence lacking. It suggests that describing US immediately available in the school of suggests that the experience of the health care as a ‘system’ is little more medicine or in her home community, teacher is as likely to be the rule as the than an oxymoron. the teacher had to schedule the services exception. at a medical center located approximately 80 miles in the opposite di- CASE STUDY rection from the school of medicine. WHAT CAN BE DONE? A preliminary assessment of the An intelligent, articulate, private sophisticated scans revealed that the In a recent survey of US citizens, music instructor described her frustra- ventricles of the brain were enlarged, The Commonwealth Fund reported tion and anxiety trying to obtain care and the radiological interpretation sug- that 40% of respondents complained for her middle-aged husband who re- gested that her husband might be of inefficiencies and lack of coordina- cently developed progressive difficulties suffering from normal pressure hydro- tion of care during recent encounters with ambulation and early dementia. cephalus. This is a serious, but poten- with the health care system.1 Seventy- The teacher and her husband live in tially treatable disorder if intervention five percent of respondents agreed that a mid-sized, Midwestern city that is the occurs before permanent brain damage theUShealthcaresystemrequires home of a large state university. It is ensues. At the time of our discussion, fundamental changes or complete re- a sophisticated community serviced by the teacher was trying, on her own structuring. The observations of the lack two competing health systems. In her initiative, to obtain her husband’s of integration of physical health care are first attempt to obtain assistance for her medical records and information from equally true for behavioral health ser- husband, the teacher sought care the diagnostic center, to transmit the vices. And, if the consumer requires through her primary care provider in information to the neurologist in the both physical and behavioral health one of the large health systems. school of medicine, and to arrange services, issues of poor coordination The primary care physician was a followup appointment with the neu- are compounded. unable to provide a satisfactory expla- rologist. In the meantime, the husband’s Russell Ackoff, professor emeritus nation for her husband’s evolving symptoms were slowly progressing and from the Wharton School at the problems. Even more distressing was their economic well-being was evermore University of Pennsylvania and an the physician’s inability to obtain a neu- compromised because of the time that expert in operations and systems theory, rological consultation. The explanation must be devoted to coordinating her has described the US healthcare system for this barrier was that the health husband’s care. as a ‘mess’ where a mess is a system of system does not include a neurologist Is this the ‘best’ that the best problems.2 The complex and disjointed in its professional services. Unwilling to healthcare system in the world can offer health system is the product of re- accept this opinion as the final author- to patients and consumers? Should it be ductionist thinking, a paradigm that has

S3-60 Ethnicity & Disease, Volume 17, Summer 2007 INTEGRATED HEALTH CARE DELIVERY - Massanari motivated intellectual thought and in- digm of reductionism to a paradigm of will have to include: 1) cooperation and quiry since the Enlightenment in the synthesis and systems thinking. integration among clinicians who pro- 17th Century. The Institute of Medicine, in its vide care; 2) proper alignment of services In brief, we seek to expand knowl- series of reviews and recommendations and incentives in health systems in which edge by focusing our inquiry on smaller on the Quality Chasm, has recognized clinicians practice and provide services; and smaller components of the whole. the issue of integration and coordina- and 3) alignment of policies and eco- In the case of health care, knowledge of tion as a major barrier to optimal care. nomic incentives among organizations the human body and disease has been The Institute has formulated a list of 10 responsible for reimbursing care. While advanced by studying smaller and new rules for redesigning and improving efforts to promote integration at any one smaller parts of the whole. From this care including the following rule that of the three levels of the system are paradigm of reductionism has emerged addresses coordination and integration. essential, changes will not be sufficient to a complex array of clinical specialties achieve the broader vision without ‘‘Cooperation: Those who provide and sub-specialties, eg, cardiac electro- comprehensive systems transformation. care will cooperate and coordinate physiology, with little attention to the Will the teacher’s husband receive a di- their work fully with each other and individual patient or to the synthesis of agnosis and appropriate intervention with you (patient, consumer). The the multiple parts of the healthcare before neurological damage is irrevers- walls between professions and institu- process. In this morass of sub-special- ible? For the present, the outcome will tionswillcrumble,sothatyour ties, each entity is competing for limited depend on the teacher’s dogged persis- experiences will become seamless. resources with little attention devoted to tence to coordinate care in a system that You will never feel lost.’’3 the larger enterprise and its engagement can best be described as a ‘mess.’ with the individual patient. In short An enormous gap still exists between REFERENCES the current health delivery system and there is no system, but rather a potpourri 1. Schoen C, How SKH, Weinbaum I, et al. of entities that have few incentives to the vision for the ideal system set out in Public Views in the Shaping of the U.S. Health coordinate and integrate services. In- the Institute of Medicine’s recommenda- System. Commonwealth Fund. August, 2006. deed, in some circumstances, reimburse- tions. Achieving the vision for coordi- 2. Gharajedachi J, Ackoff RL. Mechanisms, or- ment mechanisms promote competition nated, integrated health services will ganisms, and social systems. Strategic Manage- ment J. 1984;289–300:5. require a transformation of thinking rather than cooperation across provid- 3. Institute of Medicine. Crossing the Quality Chasm. ers. Ackoff argues for a new paradigm in and practices at multiple levels of the The New Health System for the 21st Century. thinking. We must move from a para- health system. Systems transformation Washington, DC: National Academy Press; 2001.

Ethnicity & Disease, Volume 17, Summer 2007 S3-61 D. INTEGRATING MENTAL AND GENERAL MEDICAL HEALTH CARE -THE HENRY FORD HEALTH SYSTEM EXPERIENCE

C. Edward Coffey, MD

INTRODUCTION best predictor of mortality after a heart companies would not pay the physician attack is the presence of depression. The for the visit. While this situation has been A brief overview of medical and same is true for a stroke. The relationship changed, it is a good example of mental integration within the Henry works the other way also. Having de- fragmentation that occurs in the health- Ford Medical System was presented in pression increases the risk of having care system in this country. Dealing with this presentation. The model focused on a heart attack, vascular disease or stroke and managing depression is also very depression. (IHD 1.6, cardiac arrest 1.9, post-MI time consuming. Primary care physicians Depression in the medically ill is mortality 3, acute & 1-yr, stroke 1.7, and may not be prepared to respond to long-standing. It affects the functional stroke mortality 3). a patient’s feelings of depression. status of the individual and has a very The point is, the brain and the heart At HFHS, a system was implemented serious effect on morbidity and mortal- communicate with each other. A major that would facilitate the evaluation and ity. Most professionals are aware that goal is to understand and leverage that treatment of depression in the primary 10% of patients with depression will die two-way communication within the care setting. The strategy was simple. from suicide. Another 10% will die from body to improve the health and well Develop and implement an easy way for a variety of other medical conditions at being of the patients at Henry Ford. the clinician to diagnose depression and a rate much higher than they would have Scientists have investigated the relation- make it as easy as possible for treatment had, had they not been depressed. ship between depression and vascular to begin at that point in time. Previously, Depression has a significant impact disease; findings have emerged. Possible when patients were referred and made on cardiovascular disease, both ischemic mechanisms include platelet function appointments to go to a psychiatry heart disease (IHD) and stroke. De- abnormalities (sticky and clot a bit specialist, only one third of those patients pression is present in about 10% of the easier), increased plaque inflammation showed up. The unappealing extra general population. In the general (worsened plaque inflammatory re- appointment, extra time off work and medical setting though, depression is sponse), altered cardiac autonomic tone extra co-pay were reasons for not present in 30% to 50% of patients with in the autonomic nervous system, appearing for the appointment. We general medical or neurological illness. altered hypothalamic pituitary (HPA) developed and implemented an electron- Depression is recognized in approxi- axis, which is maintained for weeks and ic depression screening tool that takes mately 33% of patients who have been months, and information on how about 10 seconds to fill out, either on diagnosed with stroke and other chronic psychological stress-induced ischemia paper, online, or in the physician’s office. illness and is effectively treated in about and ventricular instability can result in Results of the assessment are scored one third of these patients. One main patients without plaque disease. immediately and provided to the clini- focus at the Henry Ford Medical System cian. Algorithm values above a certain in Detroit, Michigan is focusing on the number indicate a patient could be relationship between depression and DEPRESSION IN THE ILL: depressed; A few extra questions were general medical illness. THE HFHS PLAN added to the screening tool to help ensure the clinicians were not missing the How should professionals recognize emergencies, which include suicide, psy- DEPRESSION IN THE ILL: depression in patients with medical chosis, and bipolar disorder. DEPRESSION AND VASCULAR illness? In surveys that were conducted In terms of enabling treatment, DISEASE through the Henry Ford Health System HFHS has established clinical guide- (HFHS), many professionals were not lines in the management of depression If a patient has a heart attack and he comfortable in diagnosing mental dis- and have the guidelines electronically develops depression in the post-heart orders in general, either because of lack of available. The HFHS received a grant attack setting, his risk of dying from that training or the thought that the patient(s) from the Flint Foundation to develop heart attack is increased two- or three- would die of suicide under their care. these guidelines on an IT platform that fold, everything else being equal, blood Reimbursement was also an issue. If will be available for all clinicians in the pressure, cholesterol, ejection fraction, or primary care providers coded the primary state of Michigan within the next year. anything that can measure. The single diagnosis as depression, the insurance In all of HFHS’s clinics, there is always

S3-62 Ethnicity & Disease, Volume 17, Summer 2007 INTEGRATED HEALTH CARE DELIVERY - Coffey a nurse practitioner and psychiatrist see that the HFHS has some impressive difficult to get the remaining third of the who are available for clinical consulta- clinical values to share both before and patients back for consistent care. Some tive support in diagnosis or treatment after the initiation of the screening system. patients have difficulty in accepting the issues for those clinicians who seek help Before 2005, little was known about the idea of depression, possibly due to poorly for their patients in this area. rates of depression screening, prevalence understood cultural barriers. In all, how- and treatment. During the first year of its ever, our results have helped us improve implementation (2006), almost 100% of health care within a year of using this PLANNED CARE MODEL all patients are screened for depression; it is approach and technology. The HFHS is prevalent in about 30% of those patients; very optimistic that care in this area will One year after the new screening and, about two thirds of those patients are continue to significantly improve over mechanism was implemented, one can treated for the disease. It is still very time.

Ethnicity & Disease, Volume 17, Summer 2007 S3-63 E. THE OAKWOOD HEALTHCARE SYSTEM EXPERIENCE

Issam Khraizat, MD

A relationship exists between general a baby or fetus having anencephaly, serve to better serve their patients. To women’s health issues, depression, and trisomy-18 which is not compatible with address the patients’ cultural back- aspects of the obstetrics and gynecology life, genetic or chromosomal disorders, grounds, the hospital system has taken care. The prevalence of depression in etc. Often, the delivery, as harsh as it may these steps: women is reported to be a 25% lifetime sound, is the easy part because the long- N tripled the numbers of their bilingual risk of developing the disease, with term need to deal with the results of the and bicultural employees; a high likelihood of recurrence once delivery for the mother, father and other N instituted a very intense program of a woman has been diagnosed. If a wom- family members can be the harder part. cultural competence, awareness and an is diagnosed more than twice, she FMS works with patients in the intensive sensitivity training for those who are may need some type of maintenance care unit, if end-of-life decisions are residents, staff, physicians, nurses, therapy for a prolonged period of time needed. To address this situation, FMS ancillary providers; or possibly for a lifetime. In the developed a ‘‘My Voice, My Choice’’ N made lectures mandatory, including specialty of obstetrics gynecology, wom- brochure that talks to patients about the Health Literacy; en go through menarche, pregnancy and rights they have for their end-of-life deci- N made cultural competence training delivery, and then through menopause. sions. FMS has also presented ethics and interpretation service available During these times, some will be at risk lectures on how to recognize the different on every floor in every hospital; for depression when compared to their ethics that are involved in obstetrics N conducted a series of lectures, in- male counterparts. Pregnancy and the gynecology and other specialties as well. cluding: Patient Safety; Decreasing end of pregnancy, including the days, Other services that are available at Medication Errors; Delivering Bad weeks and months that follow, pose Oakwood Hospital include chaplains, News to Families; Patient-Specific major risks for depression. Many pa- imams and other religious figures who Populations. tients who report for obstetrics and are on call for the loss of a loved one or gynecology services are, in fact, seeking fetus (viable or pre-viable). Bereavement Presently, as mandated by federal primary care. Therefore, primary care services has a bereavement nurse who law, the Oakwood Hospital System is physicians need to be able to screen for follows up with telephone calls in hiring competent medical interpreters to depression and need to have access to conjunction with a physician, an Oak- translate for non-English speaking pa- a system that facilitates timely manage- wood Garden for women who lose tients. Bilingual literature is provided, ment for both depression and the fetuses and can grieve their loss at this including consent forms; an Obstetrics increased risk associated with it for garden free of charge. Resource Guide is available in Arabic and heart disease, stroke and co-morbidity. Government programs for Medicaid English, both on hard copy and online The Oakwood Hospital Healthcare patients like Moms and Babes II, where and talks about everything from the time System has been actively implementing bilingual (Arabic, Spanish and English the pregnant patient arrives to the time plans to integrate mental health care speaking) nurses and social workers she delivers and helps patients learn utilizing system resources and national follow up with patients from the time where to go, where to get information programs with emphasis on expanding they are pregnant (referred to by ob-gyn and where to seek help. A committee was bilingual, bicultural and culturally sen- physician) to try to determine: what formed that talks (available in Arabic and sitive and trained employees with its programs are needed for the women and English) about ectopic pregnancy, a very increasing Arab American patient pop- babies; what baby products will be serious, often fatal condition when not ulation. We believe this approach to be needed when the baby is born; trans- detected and managed on a timely basis. very important because depression in portation to and from the physician Community outreach services help Western medicine may be defined and office; and other services that may be patients cope with other conditions, such understood differently in other areas of needed. Without this type of support, as cancer, which is a very feared medicine and other cultural back- anxiety and depression can result, condition in the Arabic world and can grounds and may be treated differently. especially if a woman cannot speak the lead to depression. Oakwood has im- In our system, Family Matters language, does not know how to and/or plemented outreach to the community to Services (FMS) screens and follows cannot get to the doctor’s office. educate them about cancer prevention pre- and post-partum women for de- Oakwood’s Hospital system has and screening for various cancer types. livery complications associated with identified the ethnic communities they Helping them try to prevent cancer will

S3-64 Ethnicity & Disease, Volume 17, Summer 2007 INTEGRATED HEALTH CARE DELIVERY - Khraizat ultimately help them avoid depression Clinicians in obstetrics and gynecol- pression assessment (Edinburgh Post arising from this disease as well. Videos ogy focus on prenatal assessments, family Partum Depression Survey) is available on breast cancer and simple procedures crisis intervention for domestic violence/ in 12 languages including Arabic and were made to alleviate fear and to abuse, sexually transmitted diseases, and includes physician scoring, follow-up, familiarize patients on procedures. 24-hour psychiatry. A post-partum de- treatment, etc, from medical staff.

Ethnicity & Disease, Volume 17, Summer 2007 S3-65 F. MODELS OF HEALTH AND MENTAL HEALTH INTEGRATION: ACCESS COMMUNITY HEALTH AND RESEARCH CENTER MODEL

Ibrahim Kira, PhD; Adnan Hammad, PhD; Sharifa Abou-mediene, MD

INTRODUCTION separates mental health from physical develop healthy lifestyles and treatment health and from scientific progress. Un- adherence. Integrated physical and mental health der these circumstances, we experience Another promising development is care and research in a community net- higher healthcare costs and negative the revolution of information technology work represents a paradigm shift that effects on healthcare access and out- and computer-based systems for unified resulted from the revolutionary advances comes, and slower translation of scien- records for health and mental health. in our theoretical and applied research. tific advances. Integrated care is a new Telemedicine technology is yet another Further, integration highlighted the im- paradigm shift in how we view health development that can enhance the process portance of cross-fertilization between and provide care; it changes the way we of integration and consumer outreach. research and practice and translation of conduct research, develop programs and Still another revolutionary outcome research findings to practice and the provide education and training to health is the alliance between community and clinical insights and observation into new and mental healthcare professionals. university to develop, provide, and advanced research. Integrative health care Ecological and multi-systemic wrap- promote an evidence-based integrative with research has ecological validity. In around holistic and integrated models system of care, which enhances both this paper, we briefly discuss the evolving of care are emerging.2 Healthcare pro- cost-effective care and science. The models of integration and present the viders increasingly recognize the need to development of a scientist/practitioner Calgary model and the ACCESS Com- address behavioral, emotional and envi- multidisciplinary model in both medi- munity Health and Research Center ronmental effects on physical health to cine and psychology is one of the (ACHRC) model, which is evidence- provide effective and efficient services. outcomes of such integration. based and ecologically valid. The environmental or ecological factors Developing an integrated primary include social, political, physical and care delivery system requires collabora- cultural environments. tion between mental health professionals, BACKGROUND primary care providers, community leaders, environmentalists, and medical and Health and behavior are determined ELEMENTS AND BENEFITS behavioral scientists. Integrating practice by the interaction of human genetics, OF INTEGRATIVE and research in health and mental health culture and environment. A significant HEALTHCARE DELIVERY care is another promising development body of evidence refers to the validity of SYSTEM that enhances discovery and application this interaction paradigm.1 One result of of evidence-based models of treatment, this paradigm is the integration of genes, Elements of an integrative healthcare prevention and integration. One such health and behavior problems, and envi- delivery system include: development is the design and imple- ronmental stressors as one system with mentation of brief screening tools for N Early detection by primary screening different circuits or sub-systems. The health and mental health that can be used for both health and mental health direct effects of environmental stressors in primary care and mental health clinics disorders; on health and mental health, as well as the for mutual referrals. Integration must be N Identification of the root cause of the loop of reciprocal effects between them evidence-based. Research found positive disorders; mandate integrating all these elements effects of integration in productivity and N Networking, communication and (environmental stressors or risks, health, in fewer and less costly healthcare coordination between different dis- 3,4 mental health etc.) in managing, service visits. ciplines that are involved in direct planning and provision. care treatment plans and delivery. Scientific advances in medicine and behavioral sciences and the translation Multi-disciplinary health care is THE EMERGING MODELS of these advances to practices are slow more effective and cost-efficient. Prima- AND MOVEMENTS OF due to lack of integration between ry, secondary and tertiary prevention INTEGRATED CARE science and practice. will be more effective and efficient if it Unfortunately, the current system of addresses all risk and protective factors. Varied integration models are emerg- health care in the United States usually Prevention is important in helping to ing. One example is the model from

S3-66 Ethnicity & Disease, Volume 17, Summer 2007 INTEGRATED HEALTH CARE DELIVERY - Kira et al

University Hospital (in Detroit, Michi- more time with the patient than is The ACHRC continues to be the gan) where research is integrated into typical. most comprehensive Arab American practice in an academic setting and This model increases accessibility community-based health and mental managed care models combine health and decreases the stigma associated with health center in North America. and mental health care, for example Blue mental illness. However, participating Through our 36 health and mental Cross/Blue Shield, Kaiser and Henry FPs indicated the need for concurrent health programs we have provided Ford Health System, in a clinic setting. training for skill acquisition and main- 83,000 services to 26,000 clients be- Another model is the Calgary model tenance and noted the additional in- tween June 2003 and July 2004. used in a primary care setting. Another vestment of their time.6 ACHRC delivers one-stop services integrative model is known as the Pre- to the community that include medical, scribing Psychologists Movement.5 This public health, mental health, environ- model, which is now followed in the ACCESS COMMUNITY ment, research, immigration, social army as well as in New Mexico and MODEL OF INTEGRATIVE services, employment and legal services. Louisiana, is gaining acceptance. The CARE: ACCESS We deliver holistic, community-based, ACCESS Model of Community Health COMMUNITY HEALTH AND wraparound services. We conduct health and Research Center, which takes place RESEARCH CENTER and mental health prevention and in- in a community setting, is an evolving (ACHRC) tervention outreach to community model. This paper describes two of these members in their natural environment. emerging models: The Calgary model On the administrative level, Michi- The outreach includes home-visits, and the ACCESS model of Community gan supports an integrated health and partnering and coordinating with other Health and Research Center. mental health approach; however, the community organizations, eg, schools, approach has not yet carried down to cultural centers, faith-based organiza- the service delivery level. At ACCESS, tions, and other community agencies. THE CALGARY MODEL: health and mental health began to be PRIMARY CARE PHYSICIAN integrated administratively in one unit ACHRC Integration of Health AND SHARED MENTAL of operation with the appointment of and Mental Health Prevention HEALTH CARE a director of the community health and and Research research center five years ago. Since Prevention of health and mental In this model the family physician then, the ACCESS Community Model health is currently fully integrated; (FP) has the initial responsibility of of Integrative Care from the ACCESS intervention is still in the process of identifying those patients in need for Community Health and Research Cen- integration development. An example of mental health interventions. The FP ter (ACHRC) is multi-systemic and prevention integration projects is de- discusses the case with the mental health ecological approach that includes pression screening and prevention clinician (psychologist, psychiatric nurse health, mental health and environment among youth in schools, which is an or psychiatrist) prior to the mental and research components in a commu- ongoing integrated project by mental health clinician’s interview of the pa- nity setting. This model is still de- health, health and Dearborn schools. tient. Either the physician or the veloping within the primary care prac- The project is funded by Blue Cross/ clinician conducts the patient interview tices. Blue Shield. in the physician’s office. Usually care is taken to work within the context of the ACHRC Mission ACHRC Integration of Health FP’s relationship with the patient. The mission of ACHRC is to pro- and Mental Health Intervention A summary of the mental health mote the physical, mental and social Current integration of health and clinician’s opinion is given to the FP health of the community, utilizing mental health interventions includes with the patient present. This consulta- a holistic, multicultural approach and screening for health while providing tion is designed to allow the FP or respecting the dignity and diversity of mental health services and screening for patient to reframe symptoms in terms those we serve. We believe that a co- mental health while providing health compatible with the patient perceptions, operative relationship, which fosters services and cross-referrals. In this beliefs and resources. When needed, good healthy living at all levels, can model, psychiatry and case management family assessment, referral and brief best be achieved by an interdisciplinary are integral parts of mental health. interventions are conducted. Severe outreach strategy using high quality Referrals to neurologists and other family disturbances are referred out. healthcare services, educational pro- needed health services are routinely This model requires the FP to invest grams, research, and advocacy. considered. This includes networking

Ethnicity & Disease, Volume 17, Summer 2007 S3-67 INTEGRATED HEALTH CARE DELIVERY - Kira et al and coordination with other communi- Predictive Scales (DPS), which is a com- N Increasing knowledge of HIV seros- ty agencies, eg, schools and hospitals. puterized tool for mental health screening tatus in Arabic-speaking high-risk Procedures require primary care physi- of youth; it also measures for post- population. This research was cian notification of mental health ser- traumatic stress disorder (PTSD), de- funded by the US Centers for vices and psychotropic medication repression, anxiety and complex PTSD. Disease Control and Prevention. commended and continuous contact We refer clients to ACCESS physi- N Development/evaluation of Arab with primary care physicians and other cians and other community physicians American cancer awareness. This specialists in ACCESS and in the and neurologists and followup on our research was conducted with Wayne community. The model includes sys- referrals. Primary physician notification State University and was funded by tematic, ongoing data collection to for each client is routinely delivered Blue Cross Blue Shield of Michigan. develop a database for health and upon opening the case or changing N Environmental impacts on Arab mental health that aids in gathering medication, as noted earlier. In the Americans in metro Detroit. This the statistics required for grants and youth health center, we use the Colum- project is funded by the National funding agencies as well as for outcome bia University screening tool for mental Institutes of Health. and community research. health as well as a newly developed N Arab American youth: tobacco use and checklist for traumas, risk and protective intervention. This study is conducted Integrating Research and factors. Accordingly, youth health cen- with Wayne State University and Practice in Health and Mental ter refers to mental health those who are funded by National Institute for Child Health and Human Development. Health at risk after consent has been obtained N The scientist practitioner model in from parents. Further, we are develop- The epidemiology of diabetes and its the community setting includes conducting a database for mental health and risk factors among Arab American coming research on community health and health screening information; data anal- munity of Dearborn, Michigan. This mental health needs, as well as program ysis will be conducted using SPSS. study has been conducted with Wayne evaluation and outcome research in State University and funded by Amer- ican Diabetes Association. collaboration with area universities. The Examples of Research Projects in N focus is on discovering community needs Mental Health Expanding cancer prevention through to better address them, to evaluate Examples of mental health research translation and training. This research program effectiveness and efficiency, projects conducted by ACHRC are: was conducted with Michigan State and to determine which interventions University and funded by Susan G. N The effects of cumulative trauma on work or do not work. The end result is Komen Breast Cancer Foundation. Iraqi and African American adoles- following evidence-based, effective pre- cents’ health and mental health. This In addition, ACHRC collaborative vention and intervention, enriching basic is an ongoing collaborative research research identified, for the first-time, science by new insights and observations projected conducted by Wayne State the problem of water pipe smoking from practice, and faster translation of and ACCESS. among the Arab American community scientific advances to practice. N Two anti-stigma clinical studies to as a culturally specific health risk and ACHRC research projects are con- started to plan an intervention and assess the stigma of mental illness in ducted with collaboration with acade- prevention campaign. ACCESS clinic mental health clients. mia and are funded by local, state and N Two Iraqi refugee community stud- national funding agencies. Integrating ies. Research has been conducted on community and university efforts samples of 365 and 501 participants, CONCLUSION through the scientist practitioner model in collaboration with Eastern Michi- is essential for both developed services gan and Wayne State Universities. The service integration movement is and basic science. N Ongoing research on health and evidence-based and is here to stay, grow mental health needs assessment in and advance. There are several models Example of the ACHRC Integration: of integration and the ACHRC com- the Arabic community, in collabora- Youth Health, Mental Health and munity-based integration of health, tion with Wayne State University. Research mental health, and research may have In the children’s health program, we several advantages. It provides a promis- screen for health and mental health using Examples of Research Projects in ing model that integrates health, mental screening tools for environmental trau- Health health and research components in matic stressors in youth and their parents. Examples of health research project a community setting. The model is We use Columbia University Diagnostic conducted by ACHRC are: unique, ecologically valid and is worth

S3-68 Ethnicity & Disease, Volume 17, Summer 2007 INTEGRATED HEALTH CARE DELIVERY - Kira et al developing and disseminating nation- on Human Behavior and Development. Malwah, reduced cost of medical utilization following wide and internationally. However, the NJ: Lawrence Erlbaum Associates; 2004. mental health treatment. J Psychother Pract Res. 2. Henggeler SW, Schoenwald SK, Pickrel SG. 1998;7:68–86. ACHRC model is still in the develop- Multisystemic therapy: Bridging the gap between 5. Kinkel B, Deleon P, Mantell E, Steep A. mental stage. Continued development university- and community-based treatment. Divided no more: psychology’s role in in- and evaluation of our model is un- J Consult Clin Psychol. 1995;63(5):709–717. tegrated health care. Canadian Psychol. derway. 3. Cummings NA, Johnson J, eds. Behavior Health 2005;46:189–202. in Primary Care: A Guide for Clinical Integration. 6. McElheran W, Eaton P, Rupcich C, Basinger REFERENCES Madison, CT: Psychosocial Press; 1997. M, Johnston D. Shared mental health care: the 1. Garcia C, Bearer E, Lerner R, eds. The Complex 4. Mumford E, Schlesinger H, Glass G, Patrick C, Calgary model. Families, Systems and Health. Interplay of Genetic and Environmental Influences Guerdon T. A new look at evidence about 2004;22:424–438.

Ethnicity & Disease, Volume 17, Summer 2007 S3-69 MENTAL HEALTH

SECTION VIII. MENTAL HEALTH

Edited by: Julie Hakim Larson, PhD; Nancy Wrobel, PhD; Adnan Hammad, PhD

Ethn Dis. 2007;17[Suppl 3]:S3-70–S3-87 A. OVERVIEW migrants from Iraq and compares those who immigrated before the 1991 Gulf Key Words: Mental Health, Arab American, Substance Abuse, Posttraumatic Stress Disor- Researchers from various profession- War with those who immigrated after- der, Torture Rehabilitation al backgrounds such as health psychol- ward. Led by Jamil, this team of ogy, behavioral medicine, clinical psy- researchers designed questions to obtain chology, social work, psychiatry and data about the participants’ health status nursing have long noted the interwoven both before and after their immigration facets of the physical and mental health and administered the questionnaires in of individuals from various ethnic the participants’ native languages. Par- origins. In this section, we present ticipants who were unable to read the articles and abstracts pertinent to mental questionnaires were administered the health issues affecting Arab Americans. questionnaires verbally. Data were col- Recent efforts to include Arab Amer- lected on 29 physical and mental health icans among the ethnic groups studied medical conditions (eg, sleep apnea, have resulted in a better understanding chronic headaches, anxiety and depres- of the links between their physical and sion) and were examined by participant mental health. Clinicians have also age, sex, marital status, and specific begun considering how best to treat ethnic background. the whole person in their mental health An article by Kira et al addresses the treatment protocols for Arab Americans. physical and mental health of refugees The first paper in this session from Iraq, with particular focus on the addresses the epidemiology of Arab traumatic experiences involved in the Americans in publicly funded substance etiology of their symptoms. The avail- abuse treatment programs and was able literature on refugees, including written by a team of researchers from articles from Iraq, has suggested that Wayne State University in Detroit, this group suffers from elevated rates of Michigan. Using admissions data from physical and mental health problems. Michigan publicly funded substance The primary objective of Kira’s research abuse treatment programs, Arfken et al was to refine the description of the conducted a comparison study of intake trauma experienced by these refugees data on various ethnic groups including and explore the potential causes of their Arab Americans. Given the historically health problems. In addition to consid- high concentration of Christian (eg, ering the demographic characteristics of Iraqi Chaldean) and Muslim Arab their sample, Kira et al measured Americans in the metropolitan Detroit cumulative trauma experiences, media area and the prohibition of drug and exposure to the war in Iraq, family alcohol use by strictly practicing Mus- involvement in war, backlash after lims, the researchers wanted to describe September 11, 2001, and perceived patterns of substance abuse in this discrimination. They examined the re- community in order to help structure lationship between these variables and From the University of Windsor (JHL), future outreach, prevention and treat- various diagnostic measurement tools Ontario, Canada; University of Michigan ment efforts. (NW), Dearborn, Michigan; ACCESS Commu- that assist in identifying posttraumatic nity Health and Research Center (AH), Detroit, The second paper examines physical stress disorders and various other mental Michigan. and mental health symptoms in im- and physical health disorders.

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Thepresentationonhopeand health treatment. Hope was made the ACCESS Center for Psychosocial well-being of refugees from Iraq operational in accordance with Sny- Rehabilitation of Torture Survivors. introduces the potential promise of der’s definitions, which place emphasis Farrag and a team of clinical research- hope theory within medical settings on the person’s belief in his or her ers examined pre- and post-treatment for the treatment of individuals with own agency and capacity to generate measures of anxiety, depression and histories of trauma. As part of a larger plans of action to accomplish personal post-traumatic stress disorder in par- project on the physical and mental goals. ticipants who were survivors of tor- health of immigrants from Iraq, Ha- The final paper in this section ture. kim Larson and colleagues adminis- examines the psychosocial rehabilita- Additional mental health-related tered measures of hope, depression, tion treatment approach for survivors articles addressing specific disorders, anxiety and trauma severity to refugees of torture. This treatment is currently as presented at the conference, can be who were seeking or receiving mental used by mental health professionals at found in Sections II, III, IV, and VI.

Ethnicity & Disease, Volume 17, Summer 2007 S3-71 B. ARAB AMERICANS IN PUBLICLY FINANCED SUBSTANCE ABUSE TREATMENT

Objectives. To determine the characteristics of Cynthia L. Arfken, MD; Sheryl Pimlott Kubiak, PhD, MSW; Arab Americans receiving treatment and to Alison L. Koch, BS compare them with individuals of other ethnic groups.

Methods. We used admission data (FY2005) INTRODUCTION Barriers, such as language or denial for Michigan publicly funded substance abuse of problem, however, may impede sub- treatment (N569,989). Arab American ethnic- The Arab American community in stance abuse treatment entry for Arab 5 ity (n 224 or 0.3% of admissions) was defined the United States encompasses several Americans. Knowing the number of by codes for race, ethnicities or primary admissions by Arab Americans is a start- language of Arabic (n521). Other ethnicities waves of immigration from 22 countries examined were American Indian, Hispanic, of origin with diverse socioeconomic ing point for examining barriers. Pro- African American, and White. status, different religions and, impor- viders also need this information in tantly, reasons for migration. In general, order to respond to the need for Results. The number of Arab American however, they have a shared geographic, culturally appropriate treatment. In admissions was lower than expected for the population (RR50.25). Admissions were con- historical and cultural identity. These addition, treatment indicators comple- centrated (81%) in metropolitan Detroit as is cultural beliefs include importance of ment health needs assessment from the community (82%, RR5.99), unlike other family and honor.1,2 Another common- other sources to provide health status 1 ethnicities. Primary drugs of abuse were ality is, especially recently, heightened information about a community. alcohol (34.8%), marijuana (17.9%), heroin Knowing the descriptive epidemiology (17.4%) and crack cocaine (15.6%). Mean exposure to stigmatization and discrim- 3 duration of use (11.2 yrs) was significantly ination. Drug and alcohol use is of Arab Americans admitted to publicly lower than for other ethnicities. Arab American forbidden specifically by strict Muslims financed substance abuse treatment admissions were predominately male (76.3%), who consider misuse to bring shame to provides data to help shape outreach unemployed (62.1%) and with criminal justice the family. According to the 2000 efforts and treatment. involvement (58%), similar to other ethnicities. census, Arab Americans are concentrat- The purpose of this study is to Discussion. Using administrative database has ed in 10 states throughout the United determine the descriptive epidemiology its limits and may misclassify ethnicities. Based States, with Michigan having the largest of Arab Americans admitted to publicly upon the available data, it appears that Arab concentration of any state.4 Within financed substance abuse treatment. Americans accounted for a small percentage of Michigan, the Arab American popula- admissions to publicly funded substance abuse treatment in Michigan. Most of the admissions tion can be found in 82 of 83 counties listed English as the primary language, raising but is concentrated in the three counties METHODS concern that language may be a barrier to of metropolitan Detroit. entry. Admission profiles were generally similar Although research on immigrants We used the existing administrative across ethnicities, except that Arab Americans has found them less likely to have many database on all admissions in the state of were entering treatment after shorter duration of use. These data can inform development of chronic diseases (healthy immigrant Michigan for publicly financed sub- treatment programs and outreach efforts. (Ethn effect) due to selection of those most stance abuse treatment for fiscal year Dis. 2007;17[Suppl 3]:S3-72–S3-76) fit to migrate, this effect does not extend 2005 (N569,989). Admission data are to the mental health arena.5 For mental routinely collected and required by the Key Words: Substance Abuse, Arab Ameri- health in general and substance abuse stateofMichiganonallpublicly can specifically, the reason for migration financed substance abuse treatment. (eg, refugees) and traumatic experiences Publicly financed treatment is defined overwhelm any healthy immigrant ef- as treatment services paid by Medicaid fect. In addition, stress of migration and or from the federal substance abuse adjustment to new communities, poten- prevention and treatment block grant. It tial dissolution of protective factors such does not include self-pay or payments as employment, intact family structure from commercial insurers, criminal or religious beliefs and discrimination justice entities, other state or local may heighten the risk of substance funds, or federal programs specific for From the Department of Psychiatry and abuse or other disorders.6–8 Lafferty veterans. The data, after examination Behavioral Neurosciences (CLA); School of and colleagues present findings from for completeness, consistency and obvi- Social Work (SPK); and Department of Psychiatry and Behavioral Neurosciences community forums with Arab Ameri- ous errors, are then transmitted to the (ALK) at Wayne State University, Detroit, cans immigrants who discuss alcohol federal government as part of the Michigan. abuse as a consequence of stress.1 reporting requirement.

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Table 1. Ethnic-specific admission and population size in Michigan

I. Statewide admissions Admissions N Admissions % within total % 2000 population Relative Risk Arab American 224 0.3 1.2 0.25 American Indian 978 1.4 0.6 2.33 Hispanic 2,510 3.6 3.3 1.09 African American 18,230 26.0 14.2 1.83 Non-Hispanic White 46,774 66.8 78.6 0.85 Missing/refused/Asian/ more than one 1,273 1.9 race Total 69,989 100%

II. Within ethnicities, percentage in metropolitan Detroit Admissions % within ethnicity % 2000 population Relative Risk Arab American 80.8 82.0 0.99 American Indian 10.6 24.0 0.44 Hispanic 23.9 36.0 0.66 African American 61.2 72.0 0.85 Non-Hispanic White 30.8 35.0 0.88

NB: Asian /Pacific Islander population in Michigan is estimated to be .3%, according to the 2000 census. In fiscal year 2005 admission data for publicly funded substance abuse treatment, .3% of admissions (N5180) were coded as Asian/Pacific Islander.

As required by the state of Michi- Due to increasing interface with drug (0.3%), refused to answer (0.0%), un- gan, intake assessors located in specific courts,9 the assessors also must indicate known (0.8%) and ‘‘multiracial’’ locations around the state collect data if the admission resulted from a drug (0.9%). Because an individual admis- using appropriate state-approved forms. court referral. sion could be coded in different ethnic The assessors collect the information as Ethnicity for this analysis was de- groups, the following hierarchy was part of an intake process to assess termined using a combination of race used: admissions were coded first as eligibility for treatment, eligibility for categories, ethnic categories and prima- Arab American and if not Arab Amer- public funding, level of care required ry language spoken. The dominant ican then as Hispanic, African Ameri- (eg, outpatient, non-hospital residential) primary language was English (98.9) can, American Indian and finally White. and need for specialized services (eg, or not determined (0.2%). Admissions Analysis used admission as the unit mental health). The initial assessments listing race category of ‘‘Arab Ameri- of analysis. Multiple admissions within may be in person or over the telephone, can’’ or ethnicity of ‘‘Arab Chaldean’’ or a given fiscal year occur but typically depending on local requirements. primary language of Arabic were con- constitute a small percentage of total The intake form covers demograph- sidered Arab American. Only 21 admis- admissions. Admission, as opposed to ic information such as date of birth, sex, sions had Arabic listed as the primary individuals, has the advantage of better race, ethnicity (ie, Puerto Rican, Mex- language. Admissions with race category estimating the challenges to the system ican, Cuban, other Hispanic, Arab- of ‘‘Hispanic’’ or ethnicity of ‘‘Puerto and individual providers. Descriptive Chaldean), primary language spoken Rico’’, ‘‘Mexican’’, ‘‘Cuban’’ or ‘‘other statistics were used to summarize the (469 pre-specified categories), county Hispanic’’ or primary language of data. When comparing the proportion and living arrangement. It also covers Spanish listed were considered Hispan- of admissions to the population by primary drug of abuse (determined ic. Only 443 admissions had Spanish ethnicities, relative risk (RR) was calcu- through frequency of use and conse- listed as the primary language. Admis- lated. Due to the very large sample size quences) and age at first use of that sions with the race category of African and objective of describing the data, drug. Duration of use can then be American, American Indian or White analytical statistics were used only to determined by subtracting current age listed were considered African Ameri- examine differences in age at admission from age at first use. To assist with can, American Indian or White, re- and duration of use by ethnicities. For placement, data are collected on prior spectively. Excluded from the ethnic these analyses, univariate analysis of treatment for substance abuse, mental categories but included in total admis- variance models were constructed with issues, and criminal justice involvement. sion group were Asians/Pacific Islanders post hoc testing by Tukey’s honestly

Ethnicity & Disease, Volume 17, Summer 2007 S3-73 MENTAL HEALTH - Arfken et al

Table 2. Primary drug of abuse by ethnicities

Arab American American Indian Hispanic African American Non-Hispanic White Total Alcohol 34.8 59.9 50.8 28.4 48.3 43.2 Marijuana 17.9 13.8 19.6 18.4 16.0 16.9 Heroin 17.4 3.0 9.2 20.8 11.6 13.7 Crack 15.6 5.8 9.2 26.4 9.3 13.7 Other opiates 8.0 10.6 3.3 1.1 7.0 5.4 Powder cocaine 4.0 3.7 5.2 4.1 4.0 4.0 Benzodiazepines 1.8 0.5 0.2 0 0.4 0.3 Other drugs 0.4 2.7 2.5 0.8 3.5 2.7 Total* 100% 100% 100% 100% 100% 100%

* May not total 100% due to rounding error. significant difference. All analysis was As the Michigan Arab American Across ethnicities, admissions were conducted using SPSS 14.0 (Chicago, population is concentrated in metropol- primarily for first treatment by males Ill). itan Detroit (82%), the ethnic concen- who were unemployed (Table 3). A low As the investigators had no part of trations of admission within these three proportion of admissions were by data collection or access to identifying counties were calculated using the 2000 homeless individuals with the highest information that could be linked to census. Across ethnicities, the RRs were rate in African Americans (17.2%). individuals, the analysis was not consid- less than unity, indicating smaller pro- Mental health issues (20.1%) and drug ered human research. It was therefore portion of admissions within ethnicities court involvement (5.8%) were listed on not reviewed by the Wayne State in metropolitan Detroit than their pro- a minority of Arab American admis- University Institutional Review Board. portion of the population. The RR for sions. Criminal justice involvement (eg, Arab Americans came closest to unity probation, parole), however, was prom- (RR50.99). inent and included 58% of the Arab RESULTS The distribution of primary drug of American admissions. abuse by ethnicities is displayed in the Age at admission and duration of Arab American admissions consti- Table 2. In rank order, Arab American use differed significantly by ethnicity tuted a small percentage of the total admissions listed alcohol, marijuana, (Table 3). From the post hoc test, the admissions (0.3%) which was lower heroin, crack, other opiates (ie, pre- mean age of African-American admis- than their proportion of the population scription painkillers), powder cocaine sions (mean538.9) was significantly as measured in the 2000 census (1.2%) and benzodiazepines. The other ethni- older than that of other ethnicities. for a RR50.25. The White group was cities had admissions for other drugs, The mean duration of using the primary the only other ethnicity to have a RR of such as prescription stimulants, as drug of abuse was different and shorter less than unity (RR50.85). Table 1 primary drug of abuse, but there were for Arab American (mean511.2) com- shows the distribution of admissions no admissions for these drugs by Arab pared to each of the other ethnicities. and population by ethnicities. Americans. The Hispanic and White admissions

Table 3. Admission characteristics by ethnicities

Arab American American Indian Hispanic African American Non-Hispanic White Total Male, % 76.3 58.7 72.1 64.8 64.5 64.8 Age, mean* 31.3 32.5 31.3 38.9 32.5 34.1 Unemployed, % 62.1 60.4 50.4 66.6 54.9 57.8 Homeless, % 5.8 6.7 5.7 17.2 7.1 9.6 Mental health issues, % 20.1 35.0 24.9 16.7 32.7 28.2 Criminal justice involvement, % 58.0 62.8 65.3 39.3 60.6 55.2 Drug court involvement, % 5.8 2.1 5.1 2.9 4.4 4.0 First treatment, % 71.0 66.8 70.1 67.6 65.9 66.5 Duration of use in years, mean** 11.2 16.2 13.8 19.0 14.6 15.7

* Significantly different across ethnicities. Using Tukey’s HSD, African American admissions had higher mean age than admissions for other ethnicities. ** Significantly different across ethnicities. Using Tukey’s HSD, mean duration of use was lower for Arab American admissions, followed by Hispanic and non-Hispanic White admissions, followed by American Indian admissions, and then African American admissions.

S3-74 Ethnicity & Disease, Volume 17, Summer 2007 MENTAL HEALTH - Arfken et al had the next longer mean duration of language burden, as almost all (99.1%) sions were dominated by unemployed use, followed by American Indian and of the admissions did not list a non- men with criminal justice involvement. then African American. In stratified English primary language. The recognition of need for mental analysis, criminal justice involvement A contributing factor to the few health treatment was also low. This may had no differential impact on dura- observed admissions by Arab Americans be due to the state’s new system, which tion by ethnicities (ie, criminal jus- is the inherent limitation of using an is just beginning the process of in- tice involvement was consistently asso- administrative database. Intake assessors tegrating mental health and substance ciated with shorter duration of use are not research personnel with exten- abuse treatment. The presence of post- across ethnicities). However, there sive training and quality control super- traumatic stress disorder (PTSD), was no ethnic difference in duration vision for validly and reliability coding known to be present in recent Iraqi12 of use for admissions with residents ethnicity. Some assessors may ask for and Lebanese13 refugees, would proba- outside of metropolitan Detroit; the self-reported ethnicity while others may bly not be assessed and therefore under- mean duration was 13.2 for Arab rely upon observations. Individuals counted. Americans versus 14.7 for all other accepted for admission have limited The primary drugs of abuse reported admissions. motivation for asserting their ethnicity in the Arab American admissions are and checking the validity of coded drugs associated with high societal responses. If substance abuse is highly costs.14 They appear to reflect drugs DISCUSSION stigmatized by an ethnic group, the that are available in metropolitan areas, individual may purposively deny that as opposed to country of origin prefer- Admissions by Arab Americans con- ethnicity. The database is also limited ences.15 Unusual drugs, which would stituted a small, in absolute number and to those who were admitted to pub- necessitate new treatment plans, were relative to the population size, percent- licly funded treatment. No infor- not mentioned in the Arab American age of publicly funded substance abuse mation is available on individuals who admissions. treatment in Michigan. In addition, received treatment with other payment The Arab American admissions, their admissions were clustered in the sources. although similar in many ways, dif- same three counties where the majority An additional limitation is the use fered from other ethnicities on duration of the community lives. Interestingly, of the 2000 census, which is known of use. Arab Americans are being the concentration of admissions in to have undercounted minorities and admitted for treatment sooner after Metropolitan Detroit appeared greater does not reflect recent population initiating use of the primary drug when than that observed for other ethnicities. changes. Between 1990 and 2000, the compared to other ethnicities. These This consistency with geographic distri- Arab American population, as counted data do not elucidate the mechanism bution of the community may be a result by the census, increased 65%. Between but suggest it is related to residing in of improved outreach locally, more 2000 and 2005 additional changes a metropolitan area where better sup- skewed concentration of economically are likely. Finally, the results are port services are available. More re- disadvantaged Arab Americans or pres- limited to one state where Arab Amer- search, however, is needed on assessing ence of services in the Metropolitan icans have the largest concentration and the reasons so that it can be maintained, Detroit area. The concentration of may not generalize to the rest of the improved and disseminated to other services is supported by the finding that country. ethnicities. 9 of the 11 Michigan substance abuse Cognizant of these limitations, one In conclusion, this short descrip- treatment facilities offering treatment in can still ask why the Arab American tive epidemiology of admission to Arabic are located in metropolitan admissions were such a small percentage publicly funded substance abuse treat- Detroit.10 of overall admissions. Is it due to under- ment by Arab Americans has a number The small number of admissions, identification, language and other bar- of limitations. The results, however, especially outside of metropolitan De- riers, denial of need, seeking other care, combined with information on preva- troit, may be a result of barriers, such as or a lower burden of substance use lence of substance use disorder and language, to entering treatment. Only disorders due to cultural factors or primary drug of abuse within the 21 admissions listed Arabic as the healthy immigrant effect?11 These re- community could be used to assist primary language. The relative lack of sults raise questions but do not answer development of appropriate treatment admissions with Arabic as the primary them. programs and outreach efforts. The language may mean greater outreach Interestingly, the profile of Arab results raise important questions for efforts are needed. For the providers, American admissions was quite similar future, more-focused research. It also they may not be seeing substantial to that of other ethnicities. The admis- provides a baseline to track changes over

Ethnicity & Disease, Volume 17, Summer 2007 S3-75 MENTAL HEALTH - Arfken et al time as outreach and the community needs of Muslim communities in the 10. US Department of Health and Human changes. United States. Psych Services. 2005;562:202– Services. Substance Abuse and Mental Health 205. Services Administration. National Survey of 4. US Department of Commerce, Economics Substance Abuse Treatment Services (N- and Statistics Administration, Bureau of the SSATS) Series; 2004. ACKNOWLEDGMENTS Census. 2000 Census. 11. Erickson CD, Al-Timimi NR. Providing This work was funded in part by a grant 5. Helman CG. Culture, Health and Illness.3rd mental health services to Arab American: from the state of Michigan (Joe Young, Sr.) edition. London: Butterworth-Heinemann; Recommendations and considerations. Cul- and by a grant from the National Institute 1994. tural Diversity and Ethnic Minority Psychology. on Drug Abuse (DA014483-05). The 6. Day NL. Epidemiology of alcohol use, abuse, 2001;7(4):308–327. authors wish to acknowledge and thank the and dependence. In: Tsuang MT, Tohen M, 12. Jamil K, Hakim-Larson J, Farrag M, Kafaji T, contributions of Phil Chvojka from the Zahner GEP, eds. Textbook in Psychiatric Jamil LH. A retrospective study of Arab Michigan Department of Community Epidemiology. New York: Wiley-Liss, 1995; American mental health clients: trauma and Health. 345–360. the Iraqi refugees. Am J Orthopsychiatry. 7. Anthony JC, Helzer JE. Epidemiology of drug 2002;72(3):355–361. dependence. In: Tsuang MT, Tohen M, 13. Saab BR, Chaaya M, Doumit M, Farhood L. Pre- REFERENCES Zahner GEP, eds. Textbook in Psychiatric dictors of psychological distress in Lebanese hos- 1. Laffrey SC, Meleis AI, Lipson JG, Solomon Epidemiology. New York: Wiley-Liss, 1995; tages of war. Soc Sci Med. 2003;57:1249–1257. M, Omidian PA. Assessing Arab-American 361–406. 14. Schneider Institute for Health Policy. Sub- health care needs. Soc Sci Med. 1989;29(7): 8. Striegel-Moore RH, Dohm F, Pike KM, stance abuse: the nation’s number one health 877–883. Wilfley DE, Fairburn CG. Abuse, bullying, problem. Princeton: The Robert Wood John- 2. Hammoud MM, White CB, Fetters MD. and discrimination as risk factors for binge son Foundation; 2001. Opening cultural doors: Providing culturally eating disorders. Am J Psychiatry. 2002; 15. Arfken CL. Drug Abuse in Detroit/Wayne sensitive healthcare to Arab American and 159(11):1902–1907. County and Michigan. In: Epidemiologic American Muslim patients. Am J Obs Gyn. 9. Belenko S. Drug courts. In: Leukefeld CG, Trends in Drug Abuse: Volume II. Proceedings 2005;193:1307–1311. Tims F, Farabee D, eds. Treatment of Drug of the Community Epidemiology Work Group, 3. Ali OM, Milstein G, Marzuk PM. The Offenders. New York: Springer Publishing June 2005. Rockville, MD: National Institute Imam’s role in meeting the counseling Company, 2002;301–318. on Drug Abuse. 2006;91–95.

S3-76 Ethnicity & Disease, Volume 17, Summer 2007 C. MEDICAL COMPLAINTS OF IRAQI AMERICAN PEOPLE BEFORE AND AFTER THE 1991 GULF WAR

Hikmet Jamil, MD, PhD; Sylvia Nassar-McMillan, PhD; Richard Lambert, PhD; Adnan Hammad, PhD

Ethn Dis. 2007;17[Suppl 3]:S3-77–S3-78 INTRODUCTION residents in the metropolitan Detroit area. The participants were selected Key Words: Iraq,GulfWar,Immigrant Health Thousands of Iraqis immigrated to randomly from a list of 5,490 residents. the United States before the 1991 Gulf The random sample consisted of 350 War for a variety of reasons that were participants because of limited funding. predominately economic. Post-1991 Analysis of participants’ residences Gulf War immigration among this showed that they represent various cities group represents a new wave of immi- that differ on demographic character- gration from Iraq.1 Most post-Gulf War istics, such as socioeconomic status. Also Iraqi immigrants, many of them refu- the analysis showed that the participants gees, suffered a sequence of serious came from 55 zip code areas within 24 traumas in Iraq, either before, during cities in the metropolitan Detroit area. or after the Gulf War. These individuals Participants were verbally asked to fill appear to suffer from a host of physical out a series of questionnaires adminis- and mental health maladies, some tered in their native language. If the similar to those affecting other groups participant was unable to read, the such as US Gulf War veterans.2,3 questions were given verbally in an To date, there is no published interview format. The questionnaires scientific research about the 1991 Gulf were designed to obtain information War explaining the etiological agents regarding the subject’s medical condi- possibly responsible for such com- tions (diseases or symptoms) at the time plaints.4 Studies of Iraqi Americans are of the survey and whether that condi- very scarce, although a few recently tion was present before or after the 1991 published studies conducted with the Gulf War. Demographic information Iraqi veteran refugee population indi- was also obtained. cated high levels of medical and mental The study was conducted during disorders.2,5,6,7 However, Iraqis who 2004 and 2005. Group A consisted of immigrated after the 1991 Gulf War 206 participants who immigrated to represent a population with the highest America after 1991, and Group B potential exposure to toxic materials consisted of 144 participants who during this war. It is imperative to immigrated to America before 1991. examine closely their physical and The interview questionnaire was based mental disorders. Therefore, the objec- on an instrument from the Iowa Persian tive of the study was to compare the Gulf War Study Group, 1997.8 prevalence of medical conditions between Iraqis who immigrated after the 1991 Gulf War (Group A) and Iraqis RESULTS who immigrated before the 1991 Gulf War (Group B). From the Department of Family Med- Group A had fewer male partici- icine at Wayne State University (HJ), pants (51.5%) than Group B (62.5%). Detroit, Michigan; Department of Counsel- More participants were below the age of or Education, University of North Carolina METHODS 40 years in Group A (38.5%) than in (SNM), Charlotte, NC; Department of Group B (18.6%). There were more Educational Leadership, University of North Carolina (RL), Charlotte, NC; and ACCESS Ethical clearance was obtained from married participants in Group A Community Health and Research Center Wayne State University. The study is (85.9%) than in Group B (71.5%). (AH), Dearborn, Michigan. a cross-sectional study among Iraqi More participants had less than high

Ethnicity & Disease, Volume 17, Summer 2007 S3-77 MENTAL HEALTH - Jamil et al school education in Group A (44.7%) the study indicate that the prevalence of REFERENCES than in Group B (32.6%). Most of the 13 out of 29 medical conditions (dis- 1. Nassar-McMillan SC. Counseling Arab Amer- participants were Iraqi Americans of eases and symptoms) were significantly icans. In: Vacc NA, DeVaney SB, Brendel JM, eds. Counseling Multicultural and Diverse Arabic-speaking descent (Group A: higher (range between P,.05 and Populations.4th ed. New York: Brunner- 70.4%, Group B: 72.9%), while the P,.001) among Iraqis who immigrated Routledge, 2003;117–139. remainder were Iraqi Americans of to the United States after the 1991 Gulf 2. Jamil H, Nassar-McMillan SC, Lambert R. Chaldean descent (Group A: 29.6%; War (Group A) in comparison to Iraqis Aftermath of the Gulf War: mental health Group B: 27.1%). The occupational who immigrated to the United States issues among Iraqi Gulf War veteran refugees in the United States. JofMentHealth category with the highest percentage before the 1991 Gulf War (Group B). Counseling. 2004;26(4):295–308. of people in Group A was profes- In particular, the medical conditions 3. Jamil H, Nassar-McMillan SC, Salman WA, sional work (24.4%) when they were related to mental disorders were signif- Tahar M. Iraqi Gulf War veteran refugees: in Iraq, but this percentage declined icantly more prevalent in Group A PTSD and physical symptoms. J of Soc Work in Health Care. In press. to 9.3% when they came to the United (P,.001). The greater prevalence of 4. Knoke JD, Smith TC, Gray GC, Kaiser States. The percentage of unskilled the medical conditions among Group A KS, Hawksworth AW. Factor analysis of self- 5 workers in Group A was 5.4% when was consistent with previous research. reported symptoms: does it identify a Gulf they were in Iraq and 22.4% when Also the results were consistent with War syndrome? Am J Epidemiol. 2000;152(4): individuals immigrated to the United a number of small surveys, which were 379–388. 5. Jamil H, Hakim-Larson J, Farrag M, Kafaji T, States. Group B showed more or less conducted in Iraq comparing health Duqum I, Jamil L. A retrospective study of the reverse trend in these two occupa- data from before and after the Gulf Arab American mental health clients: trauma 9,10 tions. War. and the Iraqi refugees. Am J of Orthopsychiatry. Among the 29 medical conditions 2002;72:355–361. (symptoms and illnesses) that could be 6. Takeda J. Psychological and economic adaptation of Iraqi adult male refugees: Implica- reported, only one (thyroid problem) CONCLUSIONS tions for social work practice. J of Soc Serv Res. was more prevalent in Group B and one 2000;26:1–21. (eczema) was equal in both groups. 7. Via T, Callahan S, Barry K, Jackson C, Gerber N There were significant differences in Among the 29 medical conditions more D. Middle East meets Midwest: the new health more than half of the medical prevalent in Group A, 13 were statisti- care challenge. J of Multicultural Nurs & conditions (including mental disor- Health. 1997;3:35–39. cally more prevalent (eg, sleep apnea, ders) between the Iraqis who immi- 8. Iowa Persian Gulf Study Group. Self-reported memory loss, chronic headache, fa- grated before and after the 1991 illness and health status among Gulf War tigue). The medical conditions related veterans. J of Am Med Assoc.1997;277: Gulf War. to mental disorders (PTSD, panic 238–245. N More clinical and epidemiological disorder, anxiety and depression) were 9. El-Shihabi WM. Preliminary study on changes research among Iraqis who partici- of pattern of complaints of Iraqi patients after statistically more prevalent among par- pated in the 1991 Gulf War is the 1991 war. Paper presented at: The ticipants in Group A as compared to International Scientific Symposium on Post needed. Group B. War Environmental Problems in Iraq. Iraqi Society for Environment Protection and Improvement; December 10–12, 1994. Bagh- dad, Iraq. DISCUSSION ACKNOWLEDGMENTS 10. Al-Taha SAH. A survey of genetic clinic This research could not have been un- patients for chromosomal genetic syndromes Significant differences were found dertaken without the support of Pfizer and congenital malformations as detected by for most demographic variables between Corporation. The research team would like clinical and chromosomal studies: 1989–90 vs to thank all of the outreach health advocates 1992–93. The International Scientific Sym- Iraqis who immigrated after the 1991 who worked hard to collect the data. We posium on Post War Environmental Problems Gulf War (Group A) and those who would also like to thank all who participated in Iraq. Iraqi Society for Environment Pro- immigrated before the 1991 Gulf War in this research. This research does not tection and Improvement; December 10–12, (Group B) (P,.05). Also the results of influence Pfizer’s vision. 1994. Baghdad, Iraq.

S3-78 Ethnicity & Disease, Volume 17, Summer 2007 D. THE PHYSICAL AND MENTAL STATUS OF IRAQI REFUGEES AND ITS ETIOLOGY

Ibrahim Kira, PhD; Adnan Hammad, PhD; Linda Lewandowski, PhD; Thomas Templin, PhD; Vidya Ramaswamy, PhD; Bulent Ozkan; Jamal Mohanesh

Ethn Dis. 2007;17[Suppl 3]:S3-79–S3-82 INTRODUCTION identity trauma, (eg,‘‘discriminated against or threatened due to race or Key Words: Iraq,GulfWar,Immigrant Health Iraqi refugees who present as mental ethnicity or religion’’); 2) family trau- health clients provide an educational ma, (ie, divorce and family history of challenge due to the severity of their violence); 3) secondary traumatization problems. In a previous study,1 we or interdependence trauma; 4) personal found elevated levels of poor health identity/autonomy trauma, (ie, sexual and mental health in Iraqi refugees. The abuse); 5) survival trauma; and 6) objectives of the present study were to abandonment trauma. The measure replicate and to explore potential root was found to have reliability, construct causes of such elevation. validity and good predictive validity, as it correlated significantly with PTSD and CTD (cumulative trauma disor- METHODS ders) scales.

Participants included a quota sample Media Exposure to War in Iraq of 501 (274 males), with age ranges Scale (MEWS). between 12 and 79 years and a mean Media exposure was measured by age of 35.7 6 13.95 years. The sample one question that asked the respondent represented Iraqi refugees who came to report how many hours a day on from different channels of refuge. Sixty average the respondent watched/listened percent were married, 31% single, 4% to the news about the war in Iraq. separated, and 4% divorced. Of the sample, 5.4% were illiterate, 56% had Family/Friends Hurt in the War educational levels ranging from second Scale (FFPWS). grade to high school, and 34% were This scale measured the degree of college students or graduates. Ten the individual’s family involvement in percent had resided in the United States the war and how they were affected by for up to two years, 32% for 3–5 years, the war. Two items ask respondents if 36% for 6–10 years, and 21% for more they have a family member or friend than 10 years. Ninety percent were who has been killed, wounded or lost Shiite Muslims, 5.8% were Sunni property due to the war. The scale has Muslims and 3.2% were Christians. alpha reliability of .81. Additional measures for perceived backlash after Measures: Independent September 11 and multi-ethnic per- variable measures ceived discrimination were also used.

Cumulative Trauma Measure (CT). Measures: Dependent This measure contains 22 kinds of variable measures traumatic experiences, (eg, torture, war, rape, sexual and physical abuse, car PTSD Measure (CAPS-2). accidents, abandonment by parents and This measure was developed by natural disasters). Each participant was Blacke2 and is widely used to assess From ACCESS Community Health and Research Center (IK, AH, JM), Dearborn, asked to report the frequency of each PTSD. It assesses 17 symptoms, with Michigan; and Wayne State University (LL, kind of trauma experienced. The mea- each symptom rated on frequency and TT, VR, BO), Detroit, Michigan. sure includes 6 sub-scales: 1) collective severity on a 5-point scale. CAPS

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Table 1. Logistic regression for cumulative trauma prediction of diseases

Independent Variable Cumulative trauma Confidence intervals Dependent variables B SE Odds ratio Exp(B) Lower Upper Neurological disorders .11 .03 1.124 1.06 1.18 Blood pressure and other cardiovascular .10 .03 1.113 disorders Respiratory disorders .05 .02 1.06* 1.01 1.11 Digestive disorders .04 .02 1.04* 1.00 1.09 Urinary disorders .03 .02 1.03 .99 1.07 Musculoskeletal disorders .07 .02 1.073 1.03 1.11 Endocrine disorders .05 .02 1.05* 1.00 1.10

Findings are obtained after the effects of sex, age, marital status, education and income were controlled statistically. * P,.05. ** P,.01. 3 P,.001. 4 P5.062.10 + (close to significance). demonstrated high reliability with media exposure to Iraqi wars as in- mobility and lack of acculturation are a range from 0.92–0.99 and proved to dependent variables. We also considered some of the factors that may contribute have good convergent and discriminate various health and mental health vari- to the high level of symptoms. While validity.3 In this study, we used the ables as dependent variables controlling torture predicted poor health, it did not frequency sub-scale of CAPS-2 that is for gender, income, education, marital predict PTSD or CTD. Cumulative currently widely reported in psychiatric status and age. We conducted a sequence trauma, collective identity trauma/dis- literature. The scale in this study had of binary logistic regressions with cu- crimination and exposure to media a high reliability with an alpha of 0.97. mulative trauma and trauma types and news of the war in Iraq were the ‘‘exposure to media news about the war strongest predictors of poor health and Cumulative Trauma Disorders in Iraq’’ as independent variables and mental health (See Tables 1, 2 and 3). Measure CTD (15 items). different types of health problems as Their effects on health are direct effects, This measure has been developed in dependent variables, controlling for the independent of the effects of mental two studies on Iraqi refugees and on effects demographics. We used structur- health variables, such as PTSD. Cumu- clinic mental health clients.1 The mea- al equation modeling (AMOS 6), with lative trauma is found to be a significant sure was found to have four factors and cumulative trauma, trauma types, dis- predictor of neurological, blood pres- four sub-scales: executive function def- crimination, war in Iraq media exposure sure and other circulatory, respiratory, icits, suicidality, dissociation and de- as independent variables that have direct digestive, musculoskeletal and endo- pression/ anxiety interface. and indirect effects on health and crine disorders. mental health variables. We experimented with different Health Scale (12 items). path models that are fit to explain the Kira and associates1 developed this relationships between cumulative trau- measure in a previous study on Iraqi RESULTS ma and health problems. The model refugees. It includes questions about that was found to have a good fit self-reported health and the kinds of The results depict an even poorer (CFI5.932, RMSEA5.053) describes health problems the participant has, (eg, picture of health than what was found the central mediating effects of endo- neurological, circulatory, digestive sys- in the study we conducted with Iraqi crine disorders and neurological disor- tem and endocrine). It has an alpha refugees in 2001.1 More than 14% in ders. We also experimented with differ- index value of 0.751. this study met the full clinical criteria ent path models that fit the data to for PTSD. Adolescents have higher explain the relationships between per- Data Analysis PTSD prevalence (19.6%) than adults. ceived discrimination as a latent variable To explore the effects of potential The high rate of PTSD is accompanied explained by backlash, collective identi- factors associated with poor health and by other serious disorders in their ty trauma and multi-ethnic discrimina- mental health, we conducted multiple psychiatric profile and complex PTSD tion on health and PTSD. The model regression and path analysis with cumu- symptoms are more severe. The down- that has a good fit (CFI .96, RMSEA lative trauma, trauma types, torture, and ward social, economic and occupational .06) found significant positive effects of

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Table 2. Logistic regression for exposure to war news prediction of diseases

Independent Variable Exposure to war news Confidence intervals Dependent variables B SE Odds ratio Exp(B) Lower Upper Neurological disorders .25 .06 1.283 1.14 1.44 Cardiovascular & Circulatory disorders .24 .07 1.273 1.12 1.45 Respiratory disorders .05 .06 1.05 .94 1.17 Digestive disorders .13 .04 1.14** 1.04 1.24 Urinary disorders .03 .05 1.03 .94 1.12 Musculoskeletal disorders .20 .05 1.223 1.11 1.34 Endocrine disorders 2.03 .07 .97 .85 1.11

Findings are obtained after the effects of sex, age, marital status, education, income and previous cumulative trauma were controlled statistically. * P,.05. ** P,.01. 3 P,.001. P5.062.10+ (close to significance). perceived discrimination (.36) on poor pendence trauma are the strongest compared to other previous traumas, health. We conducted further analysis predictors of CTD. Personal identity has equal or stronger effects on health using the Structural Equation Modeling trauma is uniquely predictive of PTSD, and PTSD, after controlling for age, with the six types of traumas as pre- survival trauma is uniquely predictive of education and income, as this exposure dictor variables and PTSD, CTD and poor health and collective identity is ongoing. health as dependent variables. The trauma is a unique predictor of CTD. model has an excellent fit (CFI5 The scales accounted for 46% of the 1.000, RMSEA5.000). Illustrations of variance in PTSD, 20% of the variance DISCUSSION these models are available from the in CTD and 15% of the variance in lead author at ikira@accesscommunity. health. One of the mechanisms that has org. Exposure to war on Iraq for Iraqi been suggested to explain the direct Collective identity trauma, second- refugees predicted increasing PTSD, effects of trauma on health and mental ary traumatization/interdependence CTD and poor health, after teasing health is the effects of stress gen- trauma and family trauma are the out the effects of previous lifetime erated by the traumatic events on the strongest predictors of both PTSD and traumas and the differences in demo- human immune system and on brain poor health. Collective identity trauma, graphic variables. Path analysis indicat- structures.4,5 Besides the direct effects personal identity trauma and interde- ed that media exposure to the war news, of chronic stress on the initiation

Table 3. Logistic regression for collective identity trauma prediction of diseases

Independent Variable Collective identity trauma / discrimination Confidence intervals Dependent variables B SE Odd ratio Exp(B) Lower Upper Neurological disorders .68 .16 1.973 1.43 2.70 Blood pressure and other cardiovascular .50 .21 1.65** 1.10 2.48 disorders Respiratory disorders .50 .15 1.653 1.24 2.19 Digestive disorders .32 .13 1.37** 1.07 1.76 Urinary disorders .22 .12 1.25+ .98 1.58 Musculoskeletal disorders .48 .13 1.613 1.25 2.80 Endocrine disorders 2.40 .28 .67 .39 1.15

Findings are obtained after the effects of sex, age, marital status, education and income were controlled statistically. * P,.05. ** P,.01. 3 P,.001. P5.062.10+ (close to significance).

Ethnicity & Disease, Volume 17, Summer 2007 S3-81 MENTAL HEALTH - Kira et al and continuation of diseases, mental tion to the first author and Vidya Ramaswa- of the first ten years of research. Depress Anxiety. health conditions, such as PTSD, my’s advanced analysis of the Iraqi data. 2001;13:132–156. 4.ChiappeliF,ManfriniE,FranceschiC, have direct effects on diseases. The Cossarizza A, Black K. Steroid regulation in REFERENCES effects of trauma on mental health cytokines: Relevance for Th1 to Th2 shift? 1. Kira I, Clifford D, Wiencek P, Al-Haidar A. mediate further its effects on diseases. In de Kloet ER, Azmitia EC, Landfield PW, Iraqi Refugees in Southeast Michigan: First These results highlight the urgent need eds. Annals of the New York Academy of Report. Dearborn, Michigan: ACCESS Com- to address the health and mental health Sciences: Brain Corticosteroid Receptors: Studies munity Health and Research Center; 2001. on the Mechanisms, Functions, and Neuro- need of Iraqi refugees in the United 2. Blake DD, Weathers FW, Nagy LM, Kaloupek toxicity of Corticosteroid Action. New York: States. DG, Klauminzer G, Charney DS. A clinician New York Academy of Sciences. 1994;746: rating scale for assessing current and lifetime 204–215. PTSD: The CAPS-1. Beh Ther. 1991;13:187– 5. Segerstrom S. Miller G. Psychological stress and ACKNOWLEDGMENTS 188. human immune system: A meta-analytic study Authors acknowledge the contribution of 3. Weathers F, Keane T, Davidson J. The of 30 years of inquiry. Psych Bull.2004; a generous grant from Russell Sage Founda- clinician-administered PTSD scale: A review 130:601–630.

S3-82 Ethnicity & Disease, Volume 17, Summer 2007 E. HOPE AND FOSTERING THE WELL-BEING OF REFUGEES FROM IRAQ

Julie Hakim Larson, PhD; Mohamed Farrag, PhD; Hikmet Jamil, MD, PhD; Talib Kafaji, EdD; Husam Abdulkhaleq, MA; Adnan Hammad, PhD

Ethn Dis. 2007;17[Suppl 3]:S3-83–S3-84 INTRODUCTION OBJECTIVES Key Words: Refugees, Iraq, Immigrant Health Hope theory seems to be useful in The objectives of this article are: 1) understanding the mechanisms for to introduce Snyder’s operationalization treatment of refugees from Iraq within of the construct of hope as agency (the medical settings. Hope theory has been belief in one’s own capacity, motivation proposed by Snyder as a useful way to and self-determination) and pathways conceptualize how people adjust to (the belief in one’s own capacity to psychological and physical distress.1 generate plans that will foster goal For refugees who have histories of attainment); 2) to examine links be- trauma and torture,2,3 hope theory can tween refugees’ feelings of hope and be a way to understand the mechanisms their symptoms of anxiety, depression by which these individuals can be and trauma; and 3) to critique the effectively treated within medical set- potential promise of hope as an antidote tings. As part of a larger project on the to maladaptation and dysfunction in the health and well-being of refugees from treatment of refugees. Iraq, the purpose of the current study was to examine links between refugees’ feelings of hope and their symptoms of HYPOTHESIS anxiety, depression, and trauma.4–6 According to Snyder, hope can be It was expected that self-reports of made operational as ‘‘…a way of think- hope (SHS; Agency, Pathways)7 would be ing about your goals in which you have negatively related to symptoms of de- the perceived capacity to come up with pression and anxiety (Hopkins Symptom 8 the pathways to those goals, along with Checklist-25, HSCL-25), and post-trau- 9 the mental energy to use those path- matic stress disorder symptom severity. ways’’. To measure hope as a state, Snyder developed and validated the State Hope Scale (SHS).7 This measure can be METHODS divided into two scales: Agency and Pathways. The Agency scale assesses the After ethical clearance from Wayne belief that one has the capacity, motiva- State University and from the IRB tion and determination to act in one’s Review Board of the Detroit-Wayne own behalf. The Pathways scale involves County Community Health Depart- the belief that one has the capacity to ment, 116 adult Iraqi refugees (46 identify and generate routes along path- males, 70 females) were recruited from ways that will allow one to reach their a community mental health clinic in goals. Because refugees have often been Michigan. Participants were either seek- found to suffer from histories of de- ing or already receiving outpatient pression, anxiety and post-traumatic services (n587) or were in a partial From the Department of Psychology, stress disorder, and because optimism hospitalization program (n529). Inter- University of Windsor (JHL), Ontario, Ca- and hope are often considered antidotes views using self-report instruments were nada; ACCESS Community Health and to maladaptation and dysfunction, the conducted by two bilingual (Arabic, Research Center (MF, TK, HA, AH), Dear- born, Michigan; and the Department of study of hope in refugees offers promise English) mental health professionals. 6 Family Medicine, Wayne State University as one way that clinicians can address The State Hope Scale (SHS) was (HJ), Detroit, Michigan. their treatment needs. used to measure Agency and Pathways.

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The Post-traumatic Stress Diagnostic theory for both the client and the strengths and hope in client reports. J of Clin Scale (PDS)9 was used to assess post- clinician (eg, solution rather than prob- Psychol. 2006;62:33–46. 2. Kira IA. Torture assessment and treatment: the traumatic stress disorder symptom se- lem focus, emphasis on self-worth and wraparound approach. Traumatology. 2002;8: 10 verity based on the DSM-IV criteria. dignity, improved rapport). 25–51. The Hopkins’ Symptom Checklist 25 By focusing on hope, it is possible to 3. Takeda J. Psychological and economic adap- (HSCL-25)8 was used to assess anxiety assess the strengths in the client’s tation of Iraqi male refugees: implications for and depression. Internal consistency was psychological makeup and in the envi- social work practice. J of Soc Work Practice. 2000;26:1–21. good for each scale (alpha coefficients ronment to determine how they can be 4. Jamil H, Hakim-Larson J, Farrag M, Kafaji T, ranged from .88 to .94). utilized to take constructive action and Duqum I, Jamil L. A retrospective study of steps in achieving the client’s goals. Arab American mental health clients: trauma Being hopeful involves some feelings of and the Iraqi refugees. Am J of Orthopsychiatry. 2002;72:355–361. uncertainty as one tries to anticipate the RESULTS 5. Jamil H, Hakim-Larson J, Farrag M, Kafaji T, outcome and consequences of the Jamil LH, Hammad A. Medical complaints As anticipated, negative correlations actions that have been taken toward among Iraqi American refugees with mental were found between hope: agency and achieving a goal.11 disorders. J of Immigrant Health. 2005;7:145– anxiety, r(116)52.43, depression, In conclusion, hope is inversely 152. r(116)52.43, and trauma severity, 6. Jamil H, Farrag M, Hakim-Larson J, Kafaji T, related to anxiety and depression. In- Abdulkhaleq H, Hammad A. Mental health r(116)52.55, all Ps,.01, two-tailed. creasing hope involves helping clients symptoms in Iraqi refugees: Posttraumatic Similarly, negative correlations were clarify their goals toward personal stress disorder, anxiety, and depression. Jof found between hope: pathways and happiness and well-being, and helping Cultural Diversity. In press. anxiety, r(116)52.41, two-tailed, de- them use their personal strengths and 7. Snyder CR, Sympson SC, Ybasco FC, pression, r(116)52.36, two-tailed, and Borders TF, Babyak MA, Higgins RL. De- supports in their environment to take velopment and validation of the State Hope post-traumatic stress disorder symptom realistic steps in achieving their goals. Scale. J of Personality and Soc Psychol. 1996;2: severity, r(116)52.54, all Ps,.01, 321–335. two-tailed. 8. Mollica RF, Wyshak G, deMarneffe D, Khuon ACKNOWLEDGMENTS F, Lavelle J. Indochinese versions of the This project was funded by the Center for Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Victims of Torture, Minneapolis, Minne- DISCUSSION Am J of Psychiatry. 1987;144:497–500. sota. Special thanks to the research assistants 9. Foa E. PDS (Posttraumatic Stress Diagnostic for their work on the project and to the The results imply that clinicians may Scale) Manual. Minneapolis, MN: National clients who volunteered to participate. This Computer Systems, Inc; 1995. want to target increasing feelings of study would not have been possible without hope as an antidote to despair and the 10. American Psychiatric Association. Diagnostic their help. and statistical manual of mental disorders (4th after-effects of trauma such as anxiety 1 ed.). Washington, DC: American Psychiatric and depression. Snyder et al suggest REFERENCES Association; 1994. that clinicians may accomplish this by 1. Snyder CR, Ritschel LA, Rand KL, Berg CJ. 11. Lazarus RS. Adaptation and Emotion.New attending to the advantages of hope Balancing psychological assessments: including York: Oxford University Press; 1991.

S3-84 Ethnicity & Disease, Volume 17, Summer 2007 F. THE PSYCHOSOCIAL REHABILITATION APPROACH IN TREATING TORTURE SURVIVORS

Mohamed Farrag, PhD; Husam Abdulkhaleq, MA; Galaleldin Abdelkarim, MA, PhD; Rima Souidan, MSW; Haitham Safo, MA

Ethn Dis. 2007;17[Suppl 3]:S3-85–S3-87 INTRODUCTION psychiatric problems, such as post- traumatic stress disorder, depression Key Words: Torture Survivors, Rehabilitation 7 Organizedtorturepracticedby and anxiety. Probably the most com- oppressive regimes against political mon problems among victims of torture enemies constitutes a serious world- are post-traumatic stress disorder wide epidemic. According to Amnesty (PTSD), depressive, somatoform or International, 150 out of 215 countries anxiety disorders. Studies at the Cen- 8,9 practiced human rights abuses in ter showed that torture victims, 2005.1 The United Nations defines compared with mental health clients torture as ‘‘any act by which severe and with other refugees, have signifi- pain or suffering, whether physical or cantly more problems or needs in many mental, is intentionally inflicted on areas of life, functioning, mental health a person for such purpose as obtaining or health. In addition, victims of torture from him or a third person informa- tend to suffer from comorbidity, in- tion or a confession, punishing him for dicating that they usually have more an act he or a third person has than one mental health and health committed or is suspected of having problem at the same time. The prob- committed, or intimidating or coerc- lems also tend to be very persistent and ing him or a third person for any lead to serious disruption of their social reason based on discrimination of any skills. Many complain of over-general- kind,whensuchpainorsufferingis ized fear, confusion and, in many cases, inflicted by, or at the instigation of, or shame or guilt. Assessment of torture with consent or acquiescence of, a pub- victims includes comprehensive psycho- lic official or other person acting in an social assessment, post-traumatic stress official capacity. It does not include disorder evaluation, and anxiety and pain or suffering arising only from, depression assessment, in addition to inherent in or incidental to lawful medical and dental examination, if sanctions.’’2 needed. Torture is usually used as a tool in investigation or as a means of harsh punishment to crush political enemies. TREATMENT OF VICTIMS The torture experience aims at destroy- OF TORTURE ing the human being physically, mentally and socially. Victims of torture Traditional treatment approaches usually suffer from complicated physical with torture survivors utilize one form and mental conditions, including med- or another of psychotherapy to deal ical, psychological, neurological, social with post-traumatic disorder and other and vocational problems.3 This comor- psychological consequences of torture. bidity requires a comprehensive treat- A treatment plan may include medical ment approach including medical, psy- services, psychiatric services and case chiatric, neurological, and dental management services. Therapeutic ap- examination and treatment.4–6 proaches with victims of torture include Torture victims at the ACCESS cognitive behavior therapy,10 hypno- From the ACCESS Center for Psychoso- Center for Psychosocial Rehabilitation therapy, eye movement desensitization 11 cial Rehabilitation of Torture Survivors, of Torture Survivors (hereafter referred and reprocessing (EMDR), to deal Dearborn, Michigan. to as the Center) suffer from severe with posttraumatic disorder. Testimo-

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Table 1. Depression and anxiety levels pre- and post-treatment

Pre-treatment Post-treatment Significance Mean SD Mean SD T-Test P Anxiety 32.30 5.863 27.40 6.685 3.375 ,.001* Depression 46.2 6.615 38.3 10.174 3.983 ,.000* PTSD 42.9 7.863 33.8 8.548 4.819 ,.000*

* P,.001. nials, which may be considered as a form capacities and needs. This may include elevating their self-esteem and social of exposure, were also used to help assertiveness training, anger manage- skills. survivors deal with the pain of their ment and problem-solving skills. The torture experience.12 Wraparound of program includes educational skills, VALUATION OF THE case management services and supports, language skills, vocational training re- E TREATMENT PROGRAM which is borrowed from children ser- ferrals and learning how to deal with vices, was also suggested for working public and governmental agencies, This study aimed at evaluating the with torture survivors.13 banks, school systems and the legal effectiveness of the psychosocial rehabilita- On the other hand, the psychosocial system. The therapeutic team provides tion approach in helping clients with their training and coaching to help develop rehabilitation approach aims at helping mental health problems. The study com- the torture survivor restore his/her these social skills. pared the scores obtained by a sample of 38 health, mental health and to develop The Center established the Freedom torture survivors before and after receiving his/her social skills in order to achieve Cultural Club that provides a forum for services on tests of anxiety, depression and successful integration into the commu- socialization, psycho-education and ac- post-traumatic stress disorder. Table 1 nity as a productive member. Psycho- tivities. The Freedom Cultural Club shows the results of the study. social rehabilitation starts with a com- (Cafe´) offers activities and games, in As shown in Table 1, significant prehensive assessment and develops addition to yoga classes, massage ther- decreases in anxiety, depression and person-centered treatment planning apy, relaxation training, stress manage- post-traumatic stress disorder after re- protocols to direct services. In this ment, conflict resolution and domestic ceiving treatment at the Center. These respect, the person served identifies violence prevention and resolution. In consistent changes show that helping problems and needs that will become addition, the club promotes cultural torture victims is very effective in re- the focus of treatment, sets goals of the arts, poetry and talent discovery and lieving their pain and suffering. Further treatment and selects appropriate inter- development activities to help clients studies are needed to help identify the ventions. restore their self-esteem, identity and effectiveness of the different components Psychosocial rehabilitation starts pride. The Center also provides special of the treatment and intervention. with helping stabilize the survivor’s English language classes (ESL) and condition and healing his/her wounds. tutoring that considers the torture REFERENCES At this stage, services may include victims’ mental health conditions and 1. Amnesty International. 2006. Available at: medical treatment, physiotherapy14 tries to meet their special needs, deficits http://web.amnesty.org/report2006/index-eng. and dental care, according to client’s or characteristics. Last accessed: 04/07/2006. 2. United Nations. UN Convention Against needs. Neuropsychological examination The Center’s observations reveal Torture and Other Cruel, Inhuman, or Degrad- and rehabilitation may be utilized to that torture leads to learning difficulties ing Treatment or Punishment. New York: help overcome the effects of closed and memory deficits in many victims. Office of Public Information; 1984. head injuries that may result from ESL classes are adapted to such learning 3. Ramsay R, Gorst-Unsworth C, Turner S. Psychiatric morbidity in survivors of organized torture.15–17 Psychotherapy addresses and memory problems. Additionally, stateviolenceincludingtortureAretrospective post-traumatic stress disorder, depres- the Center also runs a Women’s Art and Series, Brit J Psychiatry. 1993;162:55–59. sion, anxiety symptoms, or any other Crafts Group, composed of female 4. Allodi FA. Assessment and treatment of symptoms. clients and families of torture survivors torture victims: A critical review. J Nerv and The main component of psychoso- who gather on a weekly basis to learn Ment Dis. 1991;179:4–11. 5. Gonsalves CJ. Psychological stages of the cial rehabilitation is the intensive, short- and to practice sewing, art and other refugee process A model for therapeutic term social skills’ training that is crafts. These group sessions have proved interventions. Professional Psychol Res and tailored to the survivor’s characteristics, to be very therapeutic to these women, Practice. 1992;23:382–389.

S3-86 Ethnicity & Disease, Volume 17, Summer 2007 MENTAL HEALTH - Farrag et al

6. McIvor RJ. Assessment and treatment ap- 10. Basoglu M, Aker T. Cognitive-behavioral 14. Amris K, Prip K. Physiotherapy for torture proaches for survivors of torture, Brit J treatment of torture survivors A case study. victims (I). Chronic pain in torture victims: Psychiatry. 1995;166:705–711. Torture. 1996;6:61–65. possible mechanisms for the pain. Torture. 7. American Psychiatric Association. Diagnostic 11. Shapiro F. Eye movement desensitization: 2000;10:73–76. and Statistical Manual of Mental Disorders (4th a new treatment for post-traumatic stress 15. Jacobs U, Iacopino V. Torture and its ed.). Washington, DC: APA; 1994. disorder. J Behav Ther Exp Psychiatry. consequences: a challenge to clinical neuro- 8. Farrag MF. Needs and problems of Arab 1989;20:211–217. psychology. Professional Psychol Res and Prac- American mental health clients. Paper pre- 12. Cienfegos A, Monelli C. The testimony of tice. 2001;32:458–464. sented at the First National Conference on political repression as a therapeutic instrument. 16. O’Rourke N. Vigorous shaking of political Health Issues in the Arab American Commu- Amer J Orthopsychiatry. 1983;53:43–51. prisoners as a means of interrogation: physical, nity: Challenges, Opportunities, and Strate- 13. Kira I, Clifford D, Farrag M, Al-Haydar A. affective, and neuropsychological sequelae. gies. Southfield, Michigan; 1999. Cumulative trauma disorder in Iraqi refugees Politics & Life Sci. 1999;18:31–36. 9. Farrag MF. Needs assessment and psychosocial in Michigan: preliminary data. Paper pre- 17. Weinstein CS, Fucetola R, Mollica R. Neu- rehabilitation of victims of torture. Paper sented in the Second Annual Symposium on ropsychological issues in the assessment of presented at the Second Symposium on Refu- Refugees and Victims of Torture. Dearborn, refugees and victims of mass violence. Neu- gees and Victims of Torture. Dearborn; 2004. Michigan; 2002. ropsychol Rev. 2001;11:131–141.

Ethnicity & Disease, Volume 17, Summer 2007 S3-87 REDUCING THE CANCER BURDEN IN ARABS AND ARAB AMERICANS

SECTION IX. PRE-CONFERENCE WORKSHOP:REDUCING THE CANCER BURDEN IN ARABS AND ARAB AMERICANS

Edited by Amr Soliman, MD

Ethn Dis. 2007;17[Suppl 3]:S3-88–S3-91 INTRODUCTION Community Center for Economic and Social Services (ACCESS) organization. Key Words: Cancer, Arab American, Breast Cancer, Pancreatic Cancer, Liver Cancer Because of the variations in genetics ACCESS is the leading organization of different ethnic groups and the providing health, social, economic and differences in the exposure of diverse educational services to southeastern populations to environmental carcino- Michigan’s Arab population. This geo- gens, the annual incidence, the relative graphic area is home to the largest frequency and the subtypes of various concentration of people of Arab descent From the School of Public Health, University of Michigan, Dearborn, Michigan cancers, differ markedly from one in the United States—a population 2 (AS) and the Collaborative Group of Re- country, or population subgroup, to estimated to be more than 480,000. search on Cancer in Arabs and Arab another. Moreover, the availability of ACCESS recently opened a new Com- Americans. Members of the group are: particular treatments, as well as patients’ munity Health and Research Center, Palmer Beasley, University of Texas School tolerance to treatment, varies from one housing an extensive array of health of Public Health; Robert Chamberlain, University of Texas MD Anderson Cancer country or population group to another. services, public health programs, and Center; Toby Citrin, University of Michigan Thus, an improved ability to control health research, which could facilitate School of Public Health; Richard E. Galla- cancer among populations groups, such cancer research, education, and man- gher, Wayne State University School of as Arabs and Arab Americans, and to agement. Medicine; Iman Hakim, University of Ar- more efficiently use available resources izona Mel and Enid Zuckerman College of The Collaborative Group of Re- Public Health; Stanley Hamilton, University will only be achieved by performing search on Cancer in Arabs and Arab of Texas MD Anderson Cancer Center; research in these populations. Yet, the Americans held a workshop in Dear- Adnan Hammad, The Arab Community lack of resources—both human and born, Michigan during May 8 and May Center for Economic & Social Services financial—has hindered the optimal 10, 2006. The specific aims of the (ACCESS); Joe Harford, National Cancer design and analysis of translational and Institute, Bethesda; Stephen Hewitt, Na- workshop included the following: clinical studies for these groups. Over- tional Cancer Institute, Bethesda; Elizabeth 1) to bring together clinical oncolo- Holly, University of California at San coming these deficiencies represents Francisco School of Medicine; Li-Yu a challenge to those dedicated to cancer gists and cancer researchers from Hwang, University of Texas School of Public control throughout the world. Arab countries and the Arab Amer- Health; Kadry Ismail, Gharbia Cancer Soci- The paucity of cancer research in ican community in Michigan to ety, Tanta, Egypt; Liz Lehman, University of Arab populations is a loss not only to present and discuss their current Michigan School of Public Health; An-Chi practices and ongoing or proposed Lo, University of Michigan School of Public cancer patients in these countries, but to Health; Sofia Merajver, University of Michi- all patients with cancer around the research related to specific cancers; gan School of Medicine; Philip Philip, world. The variety of environments, 2) to discuss the research experience Wayne State University; Virginia Hill Rice, lifestyles and ethnic differences provides and results of existing collabora- Wayne State University College of Nursing; a spectrum of opportunities, which, if tions between the cancer centers Wael Sakr, Wayne State University; Kendra and universities in Arab coun- Schwartz, Wayne State University; Diane studied adequately, would lead to Simeone, University of Michigan School of a much more rapid increase in our tries and US universities and re- Medicine; Amr Soliman, University of understanding of the causes of cancer search institutions, as a model for a Michigan School of Public Health; Mary- and our ability to control cancer.1 broader Arab American coalition; Fran Sowers, University of Michigan School For more than 15 years, the Uni- 3) to develop possible joint research of Public Health; Ken Warner, University of Michigan School of Public Health; Mark L. versity of Michigan School of Public study proposals between Arab Wilson, University of Michigan School of Health (UMSPH) has engaged in countries, the Arab American com- Public Health. a long-term partnership with the Arab munity, and research institutions in

S3-88 Ethnicity & Disease, Volume 17, Summer 2007 REDUCING THE CANCER BURDEN - Soliman

Michigan and the United States; tobacco affect on liver cancer; HBV a. Improving existing cancer reg- and vaccine introduction and success in istries; 4) to discuss possible comparative Egypt (1993); and issues related to the b. Encouraging the development migration studies between Arabic fact that Egypt is the epicenter for the of infrastructure for additional populations in different Arab coun- HCV epidemic. The group also dis- registries. tries and Arab Americans in Michi- cussed the gaps in knowledge with 7. Training and educating healthcare gan. respect to liver carcinogenesis pathways workers, as well as the general and independent or interactive risk The 35 workshop participants rep- population, with respect to HCV/ factors. resented clinicians, scientists, and edu- HCC risk factors and the impor- Other discussion topics included cators from the following national and tance of utilizing registries. host-genetic susceptibility, mathemati- international agencies: the National cal modeling as a tool for predicting Cancer Institute; the University of long-term trends in HCV transmission Michigan Cancer Center; the University and chronic liver disease, family clus- of Michigan College of Medicine; the BREAST CANCER GROUP tering of HCV cases. The clustering University of Michigan School of Public may suggest the HCV experience in Health; the Wayne State University and This group reviewed the available Egypt is quite different from other Karmanos Cancer Institute; the Univer- data on age-specific breast cancer in- regions and spatial clustering on sity of Texas MD Anderson Cancer cidence rates in different Arab countries a broader scale. Center and School of Public Health; the with cancer registries and the need for The group recommended that fu- World Health Organization (Eastern more information from Arab countries ture research should address the follow- Mediterranean regional office); the without such data. The group also re- ing six areas: University of Arizona; the University viewed the conventional risk factors and recent data on the molecular genetics of of California-San Francisco County 1. Investigating HCV epidemiology, inflammatory breast cancer in Egypt. The Health Department; the Arab Commu- with special emphasis on determi- data were generated by the University of nity Center for Economic and Social nation of HCV incidence in Michigan and included information on Services, Dearborn, Michigan; and Egypt. In addition, the definition estrogen receptor (ER), progesterone re- cancer researchers from Egypt, Tunisia, and characterization of HCV ceptor (PR), human epidermal growth Algeria, Morocco, and Kuwait. transmission patterns in Egypt factor receptor 2 (HER2), and RhoC The workshop included presenta- and exploring the possibility of guanosine triphosphatase. The group also tions of current research on clinical implementing HCV vaccine trials reviewed the possible environmental ex- issues related to four cancer topics: liver in Egypt are also important. posures suspected in the epidemiology of cancer, breast cancer, pancreas cancer, 2. Studying a prospective cohort breast cancer and the importance of liver and tobacco smoking in Arab and Arab study in Egypt to characterize disease, increased endogenous, exogenous Americans. Presentations were followed HCV natural history and addi- estrogens, and genetic polymorphism in by group discussions. By the end of the tional risk factors/distributions of modulating breast cancer pathogenesis in sessions, summary and conclusions were risk factors for HCV as well as Arab women. Discussions also included: outlined and developed into recommen- HCC. the latest knowledge of clinical trials for dations. Within this article, we present 3. Quantifying the presence of afla- breast cancer treatment and advanced a summary of discussions and recom- toxin in food stores to determine stage breast cancer diagnosis among Arab mendations from each breakout group. its role in HCC etiology in Egypt. and Arab American women; advocacy 4. Determining the magnitude of groups; and palliative care for Arab HBV/HCV presence in the Arab patients with breast cancer. IVER ANCER ROUP American community to deter- L C G The recommendations of the group mine if they have greater risk for included: The working group on liver cancer liver disease. discussed the latest knowledge of liver 5. Performing time-space analyses for 1. Developing public and profession- cancer risk factors. The group reviewed: HCC and its risk factors in Egypt al cancer education programs in the International Agency for Research to see if patterns emerge with Arab communities for improving on Cancer (IARC) class 1 carcinogens respect to time and location. early detection of breast cancer by for hepatocellular carcinoma (HCC); 6. Encouraging further work on pop- utilizing local resources. hepatitis B virus (HBV); hepatitis C ulation-based registries in Arab 2. Determining the incidence of IBC virus (HCV); aflatoxin; alcohol, and countries through: from population-based and hospi-

Ethnicity & Disease, Volume 17, Summer 2007 S3-89 REDUCING THE CANCER BURDEN - Soliman

tal-based registries. Future research 3. Conduct research on culturally pancreas cancer, whereas long-term should also address the clinical and appropriate tobacco prevention/ history of these diseases did not put molecular characterization of IBC control/cessation in Arab countries, study participants at increased risk in in North Africa. including the translation into Ara- the San Francisco, California Bay Ar- 3. Developing novel clinical trials in bic. ea.14 Family history of pancreatic cancer different countries using common was not associated with increased risk in protocols and surrogate end points this study. of efficacy. Compared to pancreatic cancer in 4. Recognizing palliative care as an PANCREATIC the United States, diabetes and pancre- important part of breast cancer CANCER GROUP atitis were also related to higher risk of management, especially when due pancreatic cancer in Egypt, particularly to late diagnosis. The purposes of this group was to short-term history of these diseases. provide an outline of the group’s Family history of pancreatic cancer was current research knowledge of pancre- low in both American and Egyptian atic cancer, discuss opportunities to populations. There was no association TOBACCO SMOKING GROUP extend joint collaborative research, and between pancreatic cancer and allergy or discuss sources of funding with an BMI in Egypt as would be expected, This group reviewed the current ultimate goal of maximizing the un- given the hygiene hypothesis that states literature of smoking cigarettes and derstanding of pancreatic cancer in Arab that early exposure to allergens and narghile (water pipe) among Arabs and Americans and Americans. microbes is good if you live through Arab Americans. Estimates from WHO The discussion included description infancy and early childhood. (2005) showed 45% males and 5% of previous research findings in Egypt, The working group on pancreatic females from the Middle East smoke.3 including the early onset of pancreatic cancer recommended the following: The group also discussed ways to cancer in the northeast Nile Delta encourage collaborative activities with region of Egypt,4 higher serum cadmi- 1. Investigating the availability of the Arab American Centers for Eco- um level in pancreatic cancer cases than study populations and pancreatic nomic Development in the United in the control participants in Egypt,5 cancer tissues for possible future States to control tobacco smoking clustering of pancreatic cancer in the studies on the following popula- among Arab American communities, northeast Nile delta region,6 and differ- tions: especially the youth populations. ences in molecular pathologic profile a. Arab Americans in Michigan, The group recommended the fol- between pancreatic cancer tumors from including University of Michi- lowing: Egypt and the United States.7–10 gan, Michigan Wayne State Elizabeth Holly, PhD, MPH, pre- 1. That the United States and all other University, and Henry Ford sented her research findings from the countries ratify the Framework Hospital; San Francisco Bay Area, including Convention on Tobacco Control b. Arab Americans, Egyptian mi- studies on the history of allergies, (see Section V for more information grants to Los Angeles, Califor- severity of allergic syndromes, duration on FCTC). The United States and nia; and of allergen exposure, and later onset of all other countries must share their c. Cancer registry sites in Middle allergies in association with reduced risk research and strategies on tobacco Eastern countries. of pancreatic cancer.11 Other risk fac- industries. tors included higher BMI associated 2. Focusing on the importance of 2. Encourage research and education with increased risk of pancreatic cancer future research on potential link- on narghile smoking as follows: in men, but not in women.12 Other age between samples and large data a. Acknowledge water pipe smok- data included the high vegetable con- bases, such as SEER and hospital ing as a form of tobacco; sumption, particularly beans, onions records, using names and SSN, b. Utilize the available literature and garlic and the association with driver license, and other poten- to make policy recommenda- a reduced risk of pancreatic cancer, tial patient identification mech- tions; whereas high intake of red meat and anisms. c. Design and implement further eggs was associated with an increased 3. Investigating the possibilities of education and research studies risk of pancreatic cancer in the San conducting migration studies and that address the perceived pro- Francisco, California Bay Area.13 An- cohort studies of Arab Americans. tective factor of water filtra- other study found that diabetes was 4. Encouraging studies on early de- tion. associated with very high risks for tection, improving access to treat-

S3-90 Ethnicity & Disease, Volume 17, Summer 2007 REDUCING THE CANCER BURDEN - Soliman

ment, and investigating the etiolo- 4. Soliman AS, El-Ghawalby N, Ezzat F, 9. Soliman AS, Smith MA, Cooper SP, et al. gy and signature molecular and et al. Unusually high rate of young-onset Serum organochlorine pesticide levels in pancreatic cancer in the east Nile Delta region patients with colorectal cancer in Egypt. Arch pathologic characteristics of pan- of Egypt. Int J Gastrointest Canc. 2002;32: Environ Health. 1997;52:409–415. creatic cancer. 143–151. 10. Soliman AS, Bondy ML, El-Badawy SA, et al. 5. Developing better strategies for 5. Kriegel AM, Soliman AS, Zhang Q, et al. Contrasting molecular pathology of colorectal cancer prevention and treatment, Serum cadmium levels in pancreatic cancer carcinoma in Egyptian and Western patients. based on our knowledge of differ- patients from the East nile delta region of Br J Cancer. 2001;85:1037–1046. 11. Holly EA, Eberle CA, Bracci PM. Prior history ent risk factors in Arab and Arab Egypt. Environ Health Perspect. 2006;114: 113–119. of allergies and pancreatic cancer in the San American populations. Francisco Bay area. Am J Epidemiol. 2003;158: 6. Soliman AS, Wang X, Stanley JD, et al. 432–441. Geographical clustering of pancreatic cancers 12. Eberle CA, Bracci PM, Holly EA. Anthropo- in the northeast Nile delta region of Egypt. REFERENCES metric factors and pancreatic cancer in a pop- Arch Environ Contam Toxicol. 2006a;51: 1. Soliman AS, Levin B, El-Badawy S, ulation-based case-control study in the San 142–148. et al. Planning cancer prevention strategies Francisco Bay area. Cancer Causes Control. based on epidemiologic characteristics: an 7. Soliman AS, Bondy M, Webb CR, et al. 2005;16:1235–1244. Egyptian example. Public Health Rev. 2001; Differing molecular pathologic features of 13. Chan JM, Wang F, Holly EA. Vegetable and 29:1–11. pancreatic cancers in Egyptian and US fruit intake and pancreatic cancer in a popula- 2. Zogby International. Report on Arab American patients. Intl J Cancer. 2006b. Available at tion-based case-control study in the San Populations in the United States. Washington http://www3.interscience.wiley.com/cgibin/ Francisco bay area. Cancer Epidemiol Bio- DC: Arab American Institute Foundation; fulltext/112593479/HTMLSTART. Accessed markers Prev. 2005;14:2093–2097. 2003. on 5/5/06. 14. Wang F, Gupta S, Holly EA. Diabetes mellitus 3. World Health Organization Tobacco Free 8. Soliman AS, Wang X, DiGiovanni J, et al. and pancreatic cancer in a population-based Initiative. 2005. Available at: http://www. Serum organochlorine levels and history of case-control study in the San Francisco Bay emro.who.int/tfi/countryprofile.htm. Accessed lactation in Egypt. Environmental Research. Area, California. Cancer Epidemiol Biomarkers on: 5/6/06. 2003;92:110–117. Prev. 2006;15:1458–1463.

Ethnicity & Disease, Volume 17, Summer 2007 S3-91 HIV/AIDS IN THE ARAB AMERICAN COMMUNITY: BREAKING THE SILENCE!

SECTION X. POST-CONFERENCE WORKSHOP: HIV/AIDS IN THE ARAB AMERICAN COMMUNITY:BREAKING THE SILENCE!

Edited by: Adnan Hammad, PhD; Miguel Gomez, MA

Ethn Dis. 2007;17[Suppl 3]:S3-92–S3-101 Summary of Post-Conference In addition, marriage at an early age, Workshop Presentations large and close-knit families, and Key Words: HIV/AIDS, Arab Americans other values can make it seem to Arab Americans that the disease cannot make A. OVERVIEW inroads in their community. Yet, HIV/ AIDS is known to exist in the The Arab American population in the Arab world—up to 700,000 cases in greater Detroit, Michigan, area is the North Africa and the Middle East, largest Arab community in North Amer- according to the World Health Organi- ica and the second largest outside the zation (WHO). Because the disease Middle East. Arab Americans have a com- is rarely spoken of privately, and until mon cultural and linguistic heritage and now never publicly, infection rates are mayhaveethnicallylinkedriskfactors unclear closer to home—in Detroit, in and disease patterns. Levels of health Michigan, across the United States. awareness and efforts to improve health The goal of the workshop was to largely vary by socioeconomic and educa- shed light on HIV/AIDS in the Arab tional factors. This population faces American community. It fostered dis- a number of cultural, social, and educa- cussion among domestic and international challenges in adapting to the norms tional healthcare experts, and among and practices of American society. Arab people from here and abroad, A post-conference meeting was held about HIV/AIDS and ways that Arab on the issue of HIV/AIDS on May 13, Americans can respond to it. It also 2006. The meeting, called the HIV/AIDS highlighted current ACCESS efforts to in the Arab American Community: Break- address HIV/AIDS. ing the Silence!, continued work begun at In addition to attending the various the June 2005 HIV/AIDS Health Forum: presentations detailed later in this Perspectives and Attitudes of the Arab, article, participants joined discussion Chaldean, and Muslim-American Com- groups to brainstorm ways the Arab munities. This year’s meeting was held American community can fight HIV/ with the support of The Leadership AIDS. Suggestions included: working Campaign on AIDS (TLCA) from the with religious and community leaders US Department of Health and Human as spokespeople to address the disease; Services (HHS). Taken together, the joining with Arab role models, such as sessions mark the first time the largest celebrities, to conduct HIV/AIDS Arab community in the United States public service announcements; educat- has publicly discussed HIV/AIDS. ing mothers to help raise awareness in The disease has been highly taboo. their families; finding new and addi- Among other factors, the Muslim re- tional venues for testing and outreach; From the ACCESS Community Health & ligion of the Arab community and the disseminating messages to the media Research Center (AH), Dearborn, Michigan; and The Leadership Campaign on AIDS, Office Catholic religion of the Chaldean that address denial and its negative of HIV/AIDS Policy, Department of Health & community teach against some of the impact on the community; incorpo- Human Services (MG), Washington, DC. behaviors that can result in HIV/AIDS. rating HIV/AIDS education with oth-

S3-92 Ethnicity & Disease, Volume 17, Summer 2007 HIV/AIDS IN ARAB AMERICANS - Hammad and Gomez er health issues; and speaking about Disease Control, Michigan Department NithyaMani,MPA,theAsiaNear HIV/AIDS in schools. of Community Health (MDCH). East development advisor, Office of HIV/ Reported in this section are high- Sabri Belgacem, MPA, MD, director AIDS, USAID/Bureau for Global Health. lights from presentations by: of health systems and services develop- Raida Rabah, MD, medical director, Loretta Davis-Satterla, MSA, direc- ment in WHO’s regional office for the HIV Intervention Clinic, Brandywine tor, Division of Health, Wellness and Eastern Mediterranean. Valley Infectious Diseases, Coatesville, PA.

Ethnicity & Disease, Volume 17, Summer 2007 S3-93 B. SUMMARY REPORT:ARAB AMERICANS AND HIV/AIDS IN MICHIGAN

Loretta Davis-Satterla, MSA

Ethn Dis. 2007;17[Suppl 3]:S3-94–S3-95 INTRODUCTION the national trend of level of infection, decreased death rates, and increased Key Words: Michigan, HIV/AIDS, Arab Americans The Michigan Department of Com- prevalence. munity Health (MDCH) estimates that The Detroit metropolitan area, there are 16,200 people living with which includes the city of Detroit and HIV/AIDS in Michigan. This is extrap- the counties of Oakland, Macomb, olated from the total of 12,182 cases Monroe, St. Clair, Lapeer, and Wayne, that were reported as of April 1, 2006. carries much of the burden of HIV Approximately 25%–30% are unaware disease in Michigan. Both the highest of their HIV infection. These individ- number of HIV infections and highest uals are either undiagnosed or have been concentration of infection are found in tested for HIV but have not received the Detroit metropolitan area. Two- their results. Michigan is ranked 17 thirds of those living with HIV or AIDS among the US states for the total reside in the Detroit area, which has number of HIV/AIDS cases. only 45% of Michigan’s total popula- New diagnoses in Michigan have tion. MDCH estimates that 11,200 been statistically level since 1998, with residents are living with HIV/AIDS approximately 900 new cases diagnosed and around 600 cases are newly di- annually. Risk behaviors for new HIV agnosed annually. diagnoses in 2004 were categorized as: men who have sex with men (MSM)a - 57%; heterosexualsb-25%; injecting METHODS drug users (IDU)-12%; no identified riskc-10%; MSM/IDU-4%; and Understanding the scope of the other,d-1%. disease in the Arab American commu- New treatments for HIV disease nity is challenging. Because people of have meant dramatic decreases in Arab descent are not a federally recog- AIDS-related deaths since 1995. This nized racial/ethnic group, HIV/AIDS fact combined with level rates of new surveillance data specific to the popula- diagnoses means that the overall num- tion have not been readily available. At ber of people living with HIV continues the request of ACCESS, MDCH began to rise. This trend in Michigan mirrors to explore ways to review the scope of the disease in the Arab American community. One of the first steps was to conduct a special analysis of existing a Men who have sex with men (MSM) is surveillance data. inclusive of all men who have sex with men. These men may or may not also have sex A second important step in un- with women. derstanding the situation was to add b Heterosexual risk includes individuals a question about Arab ethnicity on the whose heterosexual partners are known to HIV/AIDS Case Report form. The be HIV-infected or at high risk for HIV (an injecting drug user, an HIV-positive blood State of Michigan has collected this recipient, or, for women, a man who is data since 2001. Michigan is one of the behaviorally bisexual). few jurisdictions to collect this data in c No identified risk includes cases for which the United States. However, important there has been no risk consistent with the to note is that this data has a number of categories of MSM, IDU, high-risk hetero- significant limitations, and the numbers From the Division of Health, Wellness sexual, or blood recipient. & Disease Control, Michigan Department of d Other risk includes transmission from of HIV-positive people of Arab descent Community Health, Lansing, Michigan. blood products and perinatal exposure. are likely under-reported. As stated

S3-94 Ethnicity & Disease, Volume 17, Summer 2007 HIV/AIDS IN ARAB AMERICANS - Hammad and Gomez earlier, the initial analysis of historic DISCUSSION HIV diagnoses, which indicate missed data depended on identification of opportunities for treatment and better names and confirmation of Arab eth- Of the confidentially reported cases health outcomes, as well as missed nicity, which may not have identified all of persons of Arab descent living with prevention opportunities. persons of Arab descent. Data collected HIV/AIDS, 80% (43) are male and MDCH’s Division of Health, Well- via the amended HIV/AIDS Case Re- 20% (11) are female. This is compara- ness, and Disease Control responds to port form may be incomplete because of ble to statewide data, which has 74% the HIV/AIDS epidemic and sexually the newness of the variable and in- male and 26% female cases. Age at transmitted diseases (STD) on multiple terviewer unfamiliarity. Case Report diagnosis for Arab cases is also similar to fronts, using prevention, education, and data also depends on how clients the age distribution for all cases in care programs to effect a decrease in self-identify and how they disclose Michigan, with 6% (3) ages 0–19; 24% HIV/AIDS-STD morbidity and mor- information on race/ethnicity to the (13) ages 20–29; 37% (20) ages 30–39; tality. Michigan’s HIV/AIDS care-re- interviewer. 20% (11) ages 40–49; 11% (6) ages 50 lated programs include the AIDS Drug and older; and one with an unknown Assistance Program, Michigan Dental age at diagnosis. Program, provider education, primary The distribution of cases across risk RESULTS medical care, mental health and sub- behavior is similar for Arab and state- stance abuse services, case management, wide data, but with a smaller proportion As a result of the data review, 58 and supportive services, including trans- of IDU risk among Arab HIV/AIDS portation, emergency financial aid, food individuals with Arab surnames were cases. Among the 11 Arab females, more identified, with 32 confirmed as being banks, client/legal advocacy, and psy- than half were infected heterosexually, chosocial support. Michigan’s HIV/ of Arab descent. Combining that in- and 27% had no identified risk. For AIDS prevention-related programs information with the Case Report data, non-Arab Michigan females, 40% were clude HIV counseling, testing, and 54 confidentially reported cases of infected heterosexually, 22% were IDU, referral to ensure that individuals learn persons of Arabic descent living with and 34% had no identified risk. Of the their serostatus (400 sites statewide); HIV/AIDS in Michigan were derived. 43 Arab male cases, two-thirds were partner counseling and referral pro- One-third have been diagnosed with attributed to MSM (60% MSM and grams at local health departments to HIV, and two-thirds have been di- 5% MSM/IDU), 19% no identified facilitate early notification of HIV agnosed with AIDS. Of these cases, risk, 7% IDU, 5% heterosexual, and exposure to at-risk populations; and the majority (85%) are in Detroit-area 5% blood recipient. For non-Arab evidence-based primary prevention pro- counties: Wayne, including the city of Michigan males, two-thirds were attrib- gramming at 20 community organiza- Detroit (48%); Oakland (22%); Ma- uted to MSM (60% MSM and 6% tions targeting both people of unknown comb (13%); and St. Clair (2%). Other MSM/IDU), 17% no identified risk, status and people living with HIV/ cases are in other Michigan counties, 10% IDU, 5% heterosexual, and 2% AIDS. including 2% in each of Ingham, blood recipient/perinatal. Kalamazoo, Kent, and Ottawa counties. Of the 64 Arab cases in the MDCH The remaining 6% are in other coun- database (including both living and ties. deceased cases), 47 have AIDS diagno- RESOURCES In addition to confidentially re- ses. Of these, 25 were diagnosed with ported cases, six new cases have been AIDS within two months of their initial For more information on HIV/ identified through anonymous testing HIV diagnosis. Of these 25, 20 (31% of AIDS statistics, visit the Bureau of since April 1, 2004. Five of these all cases) were diagnosed with HIV and Epidemiology, Michigan Department were in the Detroit metro area. The AIDS at the same time. These data of Community Health at http:// reported risk behavior for all six was show that about one-third of all di- www.michigan.gov/mdch. Last ac- MSM. agnoses were simultaneous AIDS and cessed: 04/09/07.

Ethnicity & Disease, Volume 17, Summer 2007 S3-95 C. SUMMARY REPORT: HIV/AIDS IN THE ARAB WORLD

Sabri Belgacem, MPA, MD

Ethn Dis. 2007;17[Suppl 3]:S3-96 Most Arab nations have a rela- securing antiretroviral (ARV) treatment tively low prevalence of HIV/AIDS for AIDS patients. Key Words: HIV/AIDS, Arab Americans (,2%), although some countries, such In view of the important role played as Djibouti and Sudan, are known to by media in health promotion, efforts have higher prevalence. However, HIV/ are being made to involve them in the AIDS is on the increase in most various components of the HIV/AIDS countries of the region and remains control programs. The involvement of a source of concern for public the media aims at minimizing stigmati- health program managers and decision- zation of infected people while generat- makers. ing support to patient and providing Patients infected by HIV are young; accurate and appropriate information to the source of contamination is mainly the general public. through heterosexual intercourse. The Civil society organizations and other causes of infection including un- NGOs are also playing a proactive role safe blood, men having sex with men, in health promotion and in lobbying to and intravenous drug users occur with secure access to care for HIV/AIDS less frequency. patients. In some situations, WHO All countries of the region have and funding agencies are making con- developed national HIV/AIDS control tractual arrangements with NGOs to programs with technical and financial implement control program compo- support from WHO, UNAIDS and nents. WHO is also advocating more major donor agencies. The focus of supporttonationalinitiativesand national strategies is on health educa- programs in order to improve epidemi- tion particularly among adolescents and ological knowledge, to strengthen sur- high-risk groups, on strengthening surveillance systems, to improve promo- veillance systems, on improving blood tion, and to secure access to ARV safety and laboratory support, and on treatment when needed.

From the Health Systems and Services Development, WHO-Eastern Mediterra- nean Regional Office, Cairo, Egypt.

S3-96 Ethnicity & Disease, Volume 17, Summer 2007 D. SUMMARY REPORT: HIV/AIDS IN THE MIDDLE EAST AND NORTH AFRICA

Nithya Mani, MPH

Ethn Dis. 2007;17[Suppl 3]:S3-97–S3-99 INTRODUCTION:THE 14%; the Caribbean, 30,000, or 10%; GLOBAL IMPACT and in Oceania, 8,200, or about 9%. All Key Words: HIV/AIDS, Middle East, North Africa together, there were 4.9 million new The ‘‘simple’’ number of HIV/ HIV/AIDS diagnoses around the world AIDS cases in the Arab world may not in 2005, or about 12% of all cases. seem alarming. Comparisons, however, While the Arab world accounted for are cause for great concern. In North a small percentage of the world’s new Africa and the Middle East in 2005, cases, its rate of new infections exceeded there were 510,000 adults and children the world average. living with the disease. To the south, HIV/AIDS-related death rates for where HIV/AIDS is rampant, there are the region are even more alarming. In 25.8 million people living with the 2005, about 58,000 children and adults disease in sub-Saharan Africa. This died from the disease, or nearly 12% of disproportion may obscure the fact that all people with a diagnosis. Even in sub- the Arab-world figures are closer to par Saharan Africa, ‘‘only’’ about 9% of with other regions. In Western Europe people died (2.4 million). In Western there are 720,000 people living with Europe, 12,000 people died, less than HIV/AIDS; in East Asia and the Pacific, 2% of all cases; East Asia and the 870,000; North America, 1.2 million; Pacific, 41,000, less than 5%; North Eastern Europe and Central Asia, America, 18,000, less than 2%; 1.6 million; Latin America, 1.8 million; Eastern Europe and Central Asia, South and Southeast Asia, 7.4 million; 62,000, less than 3%; Latin America, the Caribbean, 300,000; and in Ocea- 66,000, less than 3%; South and nia, 74,000. Combined, there are Southeast Asia, 480,000, about 6%; 40.3 million people around the world the Caribbean, 24,000, about 8%; living with HIV/AIDS. and Oceania, 3,600, about 5%. Thus, Arab nations currently have the highest HIV/AIDS-related death rates in the IMPACT IN NORTH AFRICA, world. MIDDLE EAST Other telling facts are found in The disease is also continuing to a year-to-year comparison of the Arab spread in North Africa and the Middle world. In 2003 there were 500,000 East much as it is across the world. In adults and children living with HIV/ 2005, 67,000 new diagnoses were AIDS in North Africa and the Middle reported in this region; in other terms, East. In two years, this grew to 510,000. about 13% of all the region’s HIV/ In 2003 there were 230,000 women AIDS cases were diagnosed just last living with the disease. But enough died year. By comparison, there were in the intervening two years to counter 3.2 million new diagnoses in sub-Sa- the growing HIV/AIDS contraction haran Africa, or 12% of all cases. In rate, leaving 220,000 women with Western Europe there were 22,000 new the disease in 2005. In 2003, 62,000 diagnoses, or 3–4% of all cases; in East new diagnoses among children and Asia and the Pacific, 140,000, about adults were reported; by 2005, 67,000 16%; in North America, 43,000, less new cases were reported. As mentioned than 3%; in Eastern Europe and Central earlier, 58,000 deaths from the disease were recorded in 2005, an increase From the Office of Development in Asia, 270,000, or about 15%; in Latin Asia, Near East; U.S Agency for Internation- America, 200,000, about 11%; South from the 55,000 deaths reported al Development. and Southeast Asia, 990,000, or about just two years earlier. The adult preva-

Ethnicity & Disease, Volume 17, Summer 2007 S3-97 HIV/AIDS IN ARAB AMERICANS - Mani lence rate remained static at around FINDING SOLUTIONS FOR HIV/AIDS; and bolster quality control 0.2%. PREVENTION,TREATMENT, of public laboratories. USAID also HIV surveillance remains weak in AND CONTROL OF HIV/ helped prepare and release a set of the Arab world, especially in the Middle AIDS booklets about proper home-based care East. More comprehensive information for people living with HIV/AIDS. is available in some countries, notably The United States Agency for In- The agency also supports human Algeria, Libya, Morocco, Somalia, and ternational Development (USAID) capacity development: training hospital Sudan. Except for Sudan, national HIV funds activities in Egypt, Jordan, and staff to manage HIV/AIDS patients and prevalence levels are low in all Arab North Africa Region. USAID also has developing clinical curricula for doctors countries. Those countries with the missions in the West Bank and Gaza, and nurses. It backs a local NGO that is most reliable information also show Morocco, Lebanon, Yemen, and Iraq, managing Egypt’s first outreach center trends of increasing HIV infections, although without designated HIV fund- for IDUs by helping to train outreach especially in younger age groups. This ing. Through its Asia Near East Bureau, workers and peer educators. It hopes to leads to speculation that trends may the agency provides assistance to gov- increase access to anonymous HIV/ exist ‘‘under the radar’’ in much of the ernments, nongovernmental organiza- AIDS counseling and testing, support- rest of the region, not just in Algeria, tions (NGOs), and individuals in most ing the first counseling and testing Libya, Morocco, and Somalia. countries in the region. center at the central laboratory of the The main mode of HIV transmis- USAID’s experience in Egypt is Ministry of Health and Population; sion in the Arab world is unprotected emblematic of both the HIV/AIDS develop policies and guidelines for all sexual contact. Injecting drug use is problem in the Arab world and of the counseling and testing centers and becoming an increasingly important agency’s work in the region. The adult materials and curricula for training factor and is the predominant mode of HIV-prevalence rate in Egypt is lower counselors; and establish a national infection in at least two countries, Iran than 1%. The difference between re- monitoring and evaluation plan for and Libya. Most of the disease is ported cases and estimates may indicate counseling and testing. concentrated geographically and among weaknesses in the surveillance system In Jordan, HIV prevalence is also most at-risk populations, including sex and barriers to HIV testing. Again, data low, less than 1%, with the majority of workers and their clients, IDU, and are scarce on MSM, largely because of cases found in populations engaged in MSM. Infections from contaminated the stigma attached, and on migration high-risk behavior. Sexual relations are blood products, blood transfusions, or and IDU. There are also a large number thought to be the primary mode of lack of infection control measures in of Egyptians living abroad, making data transmission, accounting for 53.5% of healthcare settings remain a problem in collection for them problematic. all infections. USAID’s challenges in the region. USAID’s budget for the country Jordan are similar to the sociocultural There are many barriers to fighting included $3.5 million in fiscal year and religious factors found in other HIV/AIDS in the Arab world. Already 2004 for infectious diseases, HIV/ Arab nations. For example, the concept mentioned, there is a paucity of good, AIDS, and tuberculosis, and $3.1 mil- of anonymous testing is foreign, and not detailed information across the region lion in 2005. Among other things, an acceptable means of surveillance; on patterns of HIV transmission, espe- funds support: an HIV/AIDS hotline condoms are promoted only as a family cially the roles of sex work and of sex that receives more than 1,000 calls per planning method; high-risk behaviors between men. Better information likely month; the establishment of new epide- are not acknowledged officially and the would reveal that HIV is passed through miological surveillance units in Egypt’s social consequences for some are severe; other risky behaviors or in other con- governorates; and development of a sen- there is no systematic access to vulner- texts. Also mentioned, there are strong tinel behavior surveillance site for HIV/ able subpopulations and NGOs are sociocultural taboos against sex between AIDS and sexually transmitted infec- unwilling to work with them; data men, making discussion and informa- tions. Funds are also helping to: about the disease and its control are tion gathering difficult. Little is known renovate HIV/AIDS inpatient wards in inadequate for decision making; and about HIV transmission in prisons, Cairo, Alexandria, and Minia Fever where HIV/AIDS knowledge gaps exist, but some data suggests elevated risk Hospitals; expand the HIV control there is little community dialogue or in this setting. HIV prevention pro- program to 14 demonstration hospitals; involvement to fill them in. grams and services remain sparse and extend an information campaign and USAID provided Jordan $1.7 mil- sporadic; substantive efforts are needed provide education on infection control lion in 2001–2004. The allocation for throughout the Middle East and North and safe injection practices; enhance 2005 was $0.8 million, and for 2006– Africa. care and support for people living with 2009 is anticipated at $0.8 million or

S3-98 Ethnicity & Disease, Volume 17, Summer 2007 HIV/AIDS IN ARAB AMERICANS - Mani more. Related activities include support Activities under the International USAID is also allied with the Global to the Ministry of Health to purchase HIV/AIDS Alliance include capacity Fund to Fight AIDS, Tuberculosis and laboratory equipment to test viral loads building for organizations to promote Malaria, a program that has been active in individuals living with HIV; support HIV/AIDS prevention among MSM in in the Arab world. Recent grants have to the Jordanian National AIDS Pro- Algeria, Lebanon, Morocco, and Tuni- gone to Algeria, Jordan, Mauritania, gram Counseling and Testing Hotline sia. In the first three of those countries, Morocco, Sudan and Yemen. Center, for a day clinic to provide other work promoted rapid assessment Looking ahead, USAID plans to antiretroviral drugs and condoms; and of MSM, followed by a regional work- focus on information and its dissemina- training for health educators. shop in July 2004 to review and validate tion. It will continue to improve surveil- Other work includes strengthening the data collected. A report on the lance systems in the region to glean better collaborations with local organizations; assessment was distributed in French, data for decision-making, and will behavior-change communication, but is also available in English. Also in conduct surveillance in high-risk groups namely peer-education workshops to Algeria, Lebanon, Morocco, and Tuni- and link them to prevention activities. raise HIV/AIDS awareness among sia, Participatory Community Assess- The agency will review past programs to young adults; coordinating World ments training was supported by determine lessons learned and gaps, help AIDS Day activities with the Ministry USAID in late 2005. develop national policies and strategic of Health and NGOs; helping the For the Behavioral Surveillance ini- plans, encourage proper social-behavioral ministry develop protocols and relevant tiative, USAID, in conjunction with studies of vulnerable populations, ‘‘learn materials to begin surveillance; provid- UNAIDS and WHO provided regional how to reach hidden groups in quiet ing technical assistance for a limited training on integrated HIV surveillance ways’’ (in USAID’s own words), make behavioral surveillance survey within systems in 2005. For 2006, planned better use of NGOs and regional a single at-risk population; and support- activities include translation of behav- expertise, and develop a framework for ing the National AIDS Program and its ioral surveillance survey manuals, re- addressing regional issues such as migra- partner NGOs to ensure that monitor- lated supplements, and generic proto- tion and the drug trade. ing and evaluation systems remain in cols into Arabic; providing technical place and are valid. assistance to one or two countries to USAID’s Asia Near East Bureau build local capacity; developing national RESOURCES activities include projects such as the surveillance systems; promoting rapid Health Policy Initiative: People Living assessments of the current situation and For more information: with HIV/AIDS, International HIV/ response to HIV/AIDS; providing tech- International Programs Center, AIDS Alliance: Men Who Have Sex nicalassistancetodevelopnational Population Division, U.S. Census Bu- with Men, and Family Health Interna- HIV/AIDS and STI surveillance plans; reau, HIV/AIDS Surveillance Data tional: Behavioral Surveillance. holding consensus meetings with all Base, June 2000 The Health Policy Initiative included relevant stakeholders to gain approval USAID/Jordan Website: http:// a five-day seminar in Tunisia, in Febru- for the developed surveillance plans; www.usaidjordan.org ary 2006, Training for Leadership and expanding services; and improving USAID HIV/AIDS Website for Networking in the Middle East and North monitoring and evaluation of HIV/ Jordan: http://ww.usaid.gov/our work/ Africa. Participants, some of them wom- AIDS programs to improve understand- global health/aids/Countries/ane/jordan. en, came from nine countries in the ing of successful interventions, their html Middle East and North Africa, repre- cost, and how they can be replicated USAID/Global Initiatives: http:// senting NGOs recognized organizations. and sustained. www.usaid.gov/our_work/global_health/aids

Ethnicity & Disease, Volume 17, Summer 2007 S3-99 E. SUMMARY REPORT:TREATING HIV/AIDS

Raida Rabah, MD

Ethn Dis. 2007;17[Suppl 3]:S3-100–S3-101 MEDICAL PERSPECTIVES Africa. Risk factors of HIV include men having sex with men (MSM), illicit drug Key Words: HIV/AIDS treatment The HIV epidemic, as it enters its 25th use, unprotected heterosexual sex, blood year of global devastation, has demon- or blood product transfusion, being strated that no one is safe regardless of his/ born to HIV-infected mothers, and her age, gender, sex, ethnicity or color. By working in healthcare settings. the time this epidemic runs its course, if it The HIV lifecycle is complicated and ever does, it will be looked upon as an requires infection of certain human cells annihilating scourge that dwarfs every- and incorporation of the virus’s RNA thing from the past. In fact, occasional (genetic code) into the human cell’s comparisons to the black plague of the DNA. The DNA transforms these cells 14th century are nothing but wishful into viral factories from which new thinking. By the time it takes you to read viruses are released into the blood stream this paragraph, almost 14 seconds, AIDS where new cells become infected. The will turn a child into an orphan. To date, most important target is the T4-lympho- HIV has orphaned more than 13.2 cyte, or CD4-helper cells, which provide million children worldwide. With the earliest warning to the immune 14,000 persons acquiring HIV each day, system when invaded by microbes. With it is estimated that 40 million adults and time, the CD4 lymphocyte cell count children are currently living with HIV decreases as the reservoirs are depleted and, despite our efforts, almost 3.5 mil- and the immune system is weakened lion succumb to this virus each year. The leading to AIDS and its complications. worst hit areas are sub-Saharan Africa and Although we have not won the war southeast Asia. against HIV yet, we did win some On June 5, 1981, five cases of battles along the way. One very impor- unusual pneumonia called PCP (pneu- tant advancement is the significant mocystis carinii) in gay men at the decrease in mother-to-child HIV trans- University of California at Los Angeles mission (from 30% to 0.3%) by treating (UCLA) were reported in Morbidity and those mothers and their newborns with Mortality Weekly Report from the Centers antiretrovirals. for Disease Control and Prevention HIV-infected individuals remain (CDC). Shortly thereafter, reports of asymptomatic for many years (usually similarly immunocompromised men and nine years) until significant immune women, as well as blood transfusion deficiency leads to complications. How- recipients from other cities and coun- ever, about 5% of HIV-infected indi- tries, followed. In 1982, the term AIDS viduals will never progress to AIDS due was given to this condition but the HIV to inherited resistance to HIV and those virus was not isolated until 1983. In are labeled over the years as non- 1985, the US Food and Drug Adminis- progressors, while a small percentage tration (FDA) approved the first com- of patients will progress very rapidly and mercially available HIV antibody test. within two years of infection develop AZT (Zidovudin) the first drug to be full blown AIDS and opportunistic FDA-approved for the treatment of HIV complications. Several causes for death did not become available until 1987. have been reported but those are Currently, the world is affected by changing as patients with HIV are living longer with healthier immune systems, From the HIV Intervention Clinic, two types of HIV: HIV1, which is the Brandywine Valley Infectious Diseases, most common worldwide; and HIV2, in fact the significant reduction in HIV- Coatesville, PA. which is found mostly in sub-saharan related mortality, which was reported to

S3-100 Ethnicity & Disease, Volume 17, Summer 2007 HIV/AIDS IN ARAB AMERICANS - Rabah be around 90% in the late 1980’s, to need remains great. It is estimated that guidelines by the DHHS (Department less than the 5% in developed countries only 8% of the 4 million infected of Health and Human Services) and the in recent years, represents another battle people in Africa are actually receiving IDSA (Infectious Disease Society of the human race has won in the war ARV. America). against HIV. Advances in treating the HIV virus In terms of prevention, obviously The CDC has developed several were achieved by better understanding reducing risky exposures via sex and clinical criteria, such as viral and fungal this virus’s replication cycle and the way drug use remain the cornerstone since infections as well as malignancies, and it affects the human cells. Drugs that attempts to develop protective vaccines laboratory (CD4 count of 200 cell/cm3 target different stages and steps in viral have been disappointing. However, or less) criteria to define AIDS. Com- replications have been developed and a therapeutic vaccine which may help plete physical and laboratory evaluation are best used in combinations to prevent in treating HIV-infected patients seems will help stage the patient and detect the emergence of resistance. Combina- more possible based on several clinical any complications. Appropriate vaccines tions of three drugs or more, which is trials to date. and antibiotics can protect AIDS pa- now considered to be the standard of Workshop attendees learned about tients from certain infections and care, are called highly active antiretro- the impact that HIV/AIDS has in the should be used when indicated. There virals (HAART) and commonly known Arab-American community and heard are several issues that complicate the as the HIV cocktail. In the United the perspective of national and interna- care for HIV-infected individuals, men- States, only 36% of the 480,000 HIV- tional speakers in their quest to fight the tal health, drug and alcohol, homeless- infected individuals who are eligible to disease and diminish its impact on ness, partner and family notification, receive HAART are actually receiving families and communities. ACCESS availability and affordability of medical them. also released a report outlining the care and finally treatment adherence. About 27 drugs have been ap- discussions and outcomes of the June proved by the FDA to date; several 2005 HIV/AIDS Health Forum. This more drugs are in different stages of report was available to workshop atten- HIV TREATMENT clinical trials. Initiating treatment with dees. We will continue this dialogue these regimens depends on clinical and locally, nationally, internationally espe- Although use of antiretrovirals laboratory criteria with the help of the cially due to our affiliation with WHO- (ARV) has increased worldwide, the frequently updated HIV treatment EMRO.

Ethnicity & Disease, Volume 17, Summer 2007 S3-101 SECTION XI. APPENDICES FOURTH BIENNIAL NATIONAL CONFERENCE ON HEALTH ISSUES IN THE ARAB AMERICAN COMMUNITY

CONFERENCE COMMITTEES David A. Ippel / CAO, Oakwood University & the Karmanos Cancer Health Care System Center Steering Committee Hassan Jaber / Associate Executive May Darwish-Yassine, PhD / Co-Chair, Adnan Hammad, PhD / Conference Director, ACCESS Scientific Committee / Sr. Research Chair / Director, ACCESS Commu- Nazih Jawad / Pharmacist, Director, Scientist, Michigan Public Health nity Health & Research Center ACCESS Pharmacy Institute Marwan Abouljoud, MD / Surgical Tom Johnson, ASCW / CEO, Apex David Bassett, PhD / Professor, Wayne Director, Transplant Program, Behavioral Health, PLLC State University Henry Ford Health System Mark Kelley, MD / Executive Vice Eitedal Basyouni, PhD / Counselor, Ismael Ahmed / Executive Director, President and CEO, Henry Ford ACCESS Mental Health ACCESS Health System Rodney Clark, PhD / Associate Pro- Abdallah Boumediene / Operations Rose Khalife, RN / President, National fessor, Wayne State University Manager, ACCESS Community American Arab Nursing Association David Clifford, PhD / Director, In- Health & Research Center Anahid Kulwicki, DNS, RN / Public stitute for the Study of Children, Robert Burack, MD, MPH / Professor, Health Director, Wayne County Families and Communities, Eastern Internal Medicine, Medical Director, Health Department Michigan University Barbara Ann Karmanos Cancer In- Scot Mollison / District Sales Manager, Basim Dubaybo, MD / Chief of Staff, stitute Glaxo Wellcome Inc. John D. Dingell VAMC Cathy Mozham / Director, Community Jean Chabut / Chief, Center for Health Mohammed Farrag, PhD / Clinical Affairs, Blue Cross Blue Shield of Promotion, Michigan Department Director, ACCESS Mental Health Michigan of Community Health Adnan Hammad, PhD / Director, David Pieper, PhD / CME Consultant, Toby Citrin, JD / Director, Office of ACCESS Community Health and Assistant Dean, Wayne State Uni- Community-Based Public Health, Research Center versity School of Medicine U-M School of Public Health Walid Harb, MD / Medical Education, Edson Pontes, MD / Director, Interna- David Clifford, PhD / Director, In- Oakwood Health System tional Center of DMC, Wayne State stitute for the Study of Children, Linda Jaber, PharmD / Associate Pro- University School of Medicine Families, and Communities, Eastern fessor, Wayne State University Toni Price / Regional Manager, Amer- Michigan University Nabil Khoury, MD / Emergency Medicine ican Heart Association Kristine Coryell / Government Rela- Physician, Henry Ford Health System Victoria Rakowski, RN / Executive VP tions & Public Affairs, Pfizer Parke- Ibrahim Kira, PhD / Psychologist, of Medical Activities, American Davis Inc. ACCESS Mental Health Cancer Society Nina Dodge / Vice President, American Michael Massarani, MD, MS / Pro- Robert G. Riney / Senior VP, COO, Near East Refugee Aid fessor, Wayne State University Henry Ford Health System Hassan Fehmi, MD / Senior Staff Jerome Nriagu, Ph.D, DSc / Professor, Megan Roether, MPH / Vice President Physician, Nephrology & Hyperten- University of Michigan of Field Operation, American Can- sion, East Pointe Dialysis Center David Pieper, PhD / Assistant Dean, cer Society Gerald Fitzgerald / President and CEO, Wayne State University John C. Ruckdeschel, MD / President Oakwood Healthcare System Virginia Rice, PhD, RN, APN, FAAN / and CEO, Barbara Ann Karmanos Professor, Wayne State University Robert Frank, MD / Interim Dean, Cancer Institute Maryjean Schenk, MD, MPH / Chair, Wayne State University School of Mark Safer, MD / President, Midwest Wayne State University Medicine Health Plan Princella Graham / Corporate Director Wael Sakr, MD / Scientific Committee Kendra Schwartz, MD / Associate Pro- Public Policy, St. John Health System Chair, Professor, Wayne State Uni- fessor, Wayne State University Nathan Grey / National VP, Internation- versity School of Medicine Manuel Tancer, MD / Chair, Wayne al Affairs, American Cancer Society State University Mouhanad Hammami, MD / Presi- Scientific Committee Nancy Wrobel, PhD / Psychologist, dent, Michigan Chapter, National Wael Sakr, MD / Chair, Scientific Associate, University of Michigan - Arab American Medical Association Committee / Professor, Wayne State Dearborn

S3-102 Ethnicity & Disease, Volume 17, Summer 2007 APPENDIX

International Scientific Speakers American University of Beirut Med- Layth Ibrahim, MD / Oncology De- Rasmi Abu-Helu PhD / Director of ical Center partment, College of Medicine, Uni- Medical Research, Al-Quds Univer- Hassan Ghanem, MD / Head of versity of Mosul, Iraq sity, Jerusalem Epidemiology Department, Sousse Wasim Maziak, PhD / Director of the M. Nizar Akil, MD / President, Aleppo Medical School, Tunisia Syrian Center for Tobacco Studies, University, Syria Moujahed Hammami, MD, PhD / Damascus, Syria Ahmad Boran, MBBS, PhD / Assistant Professor of Obstetrics & Gynecolo- Sabri Belgacem, MPA, MD / Director, Professor, Faculty of Medicine, Pub- gy, Director, University Hospital, Health Systems and Services Develop- lic Health Department, Jordan Uni- Aleppo, Syria ment, World Health Organization versity of Science and Technology Laila Hessissen, MD / Professor, Pedi- Mohammed Shaheen, PhD / Director, Nagi El-Saghir, MD, FACP / Clinical atric Hemato-Oncology, Children Primary Care Center, Ramallah, Associate Professor of Medicine, Hospital of Rabat, Morocco Palestine

Ethnicity & Disease, Volume 17, Summer 2007 S3-103 FOURTH BIENNIAL NATIONAL CONFERENCE ON HEALTH ISSUES IN THE ARAB AMERICAN COMMUNITY

Conference Supporters Supporters American Lung Association American Cancer Society, Great Lakes American Near East for Refugee ACCESS would like to acknowledge Division Aid and thank the following sponsors, American Heart Association American Public Health Association partners, and supporters for their APEX Behavioral Health American Red Cross generous sponsorship, financial con- AstraZeneca Pharmaceuticals LP Arab American Coalition tribution, and participation to this Blue Cross Blue Shield of Michigan Arab American Nursing Association significant conference: Eastern Michigan University Arab American Pharmacist Association Glaxo SmithKline Detroit Wayne County Mental Health Sponsors International Center of DMC Agency Life for Relief and Development ACCESS Community Health and Re- Epilepsy Foundation Midwest Health Plan search Center Greater Detroit Health Council Mt. Clemens General Hospital Wayne State University School of Michigan Council for Maternal & National Arab American Medical Asso- Medicine Child ciation - Michigan Chapter NorMedex Center, LLC Michigan Department of Community Partners OmniCare Health American Cancer Society International Pfizer Inc. Michigan Institute of Public Health US Department of Health & Human Wayne State University College of Michigan State Medical Society Services, Office of HIV/AIDS Poli- Nursing National Arab American Medical Asso- cy-Leadership Campaign on AIDS WSU Dept of Psychiatry & Behavioral ciation Oakwood Health Care System Neurosciences Primary Care Health Association Henry Ford Health System Voices of Detroit Initiative Karmanos Cancer Institute Honorary participants World Medical Relief University of Michigan School of Public Alzheimer’s Association ZIAD Health Care for the Underserved Health American Diabetes Association Inc.

S3-104 Ethnicity & Disease, Volume 17, Summer 2007 ETHNICITY &DISEASE MANUSCRIPT SUBMITTAL INFORMATION rev. 1/06

Introduction tion. The first review is generally com- Letters to the Editor pleted within 2 months from original Ethnicity & Disease prints letters to the Ethnicity & Disease (Ethn Dis) is an submittal. Once reviewers’ comments editor regarding issues important to international, peer-reviewed journal that are collected, the author will receive all health care in ethnic minority popula- provides information on causal relation- feedback and will be asked to make tions or letters related to manuscripts ships in the etiology of common ill- revisions as recommended by the re- published in the journal. Guidelines for nesses through the study of ethnic viewers and resubmit within 3 weeks (or content can be found herein. patterns of disease. It is distributed to earlier, as determined by the editorial readers in more than 15 countries and calendar). The revised manuscript is Book and Media Reviews reaches healthcare professionals inter- then returned to the reviewers to ensure Individuals may submit reviews on ested in improving health outcomes for compliance with suggested changes (a books and other media related to the ethnic minority populations. Ethn Dis process that generally takes 2–3 weeks); subject matter of Ethn Dis. Guidelines publishes original reports, reviews, edito- subsequent revisions may be necessary. for content can be found in Guidelines rials, special articles, reviews and com- Upon acceptance, the author is invited for Book and Other Media Reviews. mentaries, book and other media re- to submit the final version of the views, and letters on such topics as manuscript, adhering strictly to the Updates on Health Agencies, ethnic differentials in disease rates, the guidelines listed herein. Health Legislative News, Grants impact of migration on health status, and Funding Information, social and ethnic factors related to Clinical Trials Individuals obtaining information on healthcare access, and metabolic epide- Types of Submittals the areas of focus for these sections of miology. The journal also provides Accepted Ethn Dis are invited to call the editorial information in special sections dedicat- office to discuss relevance of material for ed to legislative and regulatory issues, Original works de- Original Reports: an upcoming issue. grants and funding resources, clinical scribing results of clinical trials, investi- trials, and agency updates. Authors gations, community-based research, or wishing to submit a manuscript for epidemiologic study. Manuscripts are Manuscript Criteria and consideration should follow the guide- evaluated and accepted through the Preparation lines herein. peer-review process. Guidelines for Orig- inal Reports are provided herein. Researchers and authors who would like to submit an article for publica- Editorial Process Commentaries/Reviews: Original works tion in Ethn Dis must abide by the providing comment of existing policies, following guidelines when preparing Each manuscript submitted to Ethn Dis procedures, or observation of clinical and presenting their article for consid- enters the journal’s peer-review process, approaches. This category also includes eration by the journal’s scientific and which is governed by an editorial board. reviews of scientific literature. Manu- editorial review board. Authors should Authors can expect to receive a letter scripts are evaluated and accepted carefully refer to each section before acknowledging receipt of manuscript through the peer-review process. Guide- final preparation and submittal of within 2 weeks of submittal. Once lines for Commentaries/Reviews are the a manuscript. received in the Ethn Dis editorial office, same as those for Original Reports. an article is submitted to a minimum of Content Requirements of 2 reviewers who rate each article on Guest Editorials (invited only) Manuscript merit of content; scientific validity and Letter of invitations are issued to When preparing a manuscript for integrity of data; appropriateness to individuals with expertise related to an submittal to Ethn Dis, an author should Ethn Dis subject matter; and general issue’s scientific focus. Editorials are develop text in the following sequence presentation and readability of informa- accepted by the editor-in-chief. and as described below: title page,

Ethnicity & Disease, Volume 17, Summer 2007 MANUSCRIPT SUBMITTAL INFORMATION introduction, methods, results, dis- bution to the manuscript. The Author Methods cussion, acknowledgments, references, Responsibility, Contributions and Finan- Describe your selection of the observa- figure legends, tables. Ethn Dis does cial Disclosure Form must be submitted tional or experimental subjects (patients adhere to strict word limits. Submis- with each manuscript. or laboratory animals, including con- sions do not exceed 5,000 words, trols) clearly. Identify the age, sex, and including references. Each table/figure Group Authorship. In some cases, au- other important characteristics of the counts as 500 words of the total count. thorship of multi-center trials is attri- subjects. buted to a group. All members of the Title page group who are named as authors Identify the methods, apparatus (give The title page should carry in this order: should fully meet the criteria set for- the manufacturer’s name, city, and state 1) a short running head of no more ward on the Author Responsibility and in parentheses), and procedures in suf- than 40 characters (count letters Contributions Form. Group members ficient detail to allow other workers to and spaces); who do not meet these criteria should reproduce the results. Give references to 2) the title of the article, which should be listed, with their permission, in established methods, including statisti- be concise but informative; the Acknowledgments. cal methods; provide references and 3) the name of each author with his or brief descriptions for methods that have her highest academic degree (see Abstract and Key Words been published but are not well known; Authorship below); describe new or substantially modified Abstract. The abstract should appear 4) the abstract (see Abstract below); methods, give reasons for using them, on the title page and should be no more 5) key words (see Key Words below); and evaluate their limitations. Precisely than 250 words for structured abstracts. 6) the name of the department and identify all drugs and chemicals used, The abstract should state the purposes the institution to which the work including generic name, dose, and route of the study or investigation, basic pro- should be attributed followed by of administration. cedures (selection of study subjects, ob- the initials of the lead author(s) in servational or analytical methods), main parenthesis; Reports of randomized clinical trials findings (giving specific data and their 7) the department(s) and institu- should present information on all major statistical significance, if possible) and tion(s) of each additional author, study elements including the protocol the principal conclusions. It should em- followed by the initials of related (study population, interventions or ex- phasize new and important aspects of author; posures, outcomes, and the rationale for the study or observations. A structured 8) the name, address, phone, fax and statistical analysis), assignment of inter- abstract will include the following head- email address of the author for cor- ventions (methods of randomization, ings: Objective(s); Design; Setting; Pa- respondence and requests for re- concealment of allocation to treatment tients or Participants; Interventions; prints of the manuscript. If reprints groups), and the method of masking Main Outcome Measures; Results; Con- will not be available, provide a (blinding). clusions. statement that reprints will not be available from the authors; Statistics 9) word count (inclusive of references, Key Words. Below the abstract, au- Describe statistical methods with tables, figure legends) number of thors should provide 3 to 10 key words enough detail to enable a knowledgeable figures, number of tables, number or short phrases that will assist indexers reader with access to the original data to of references; in cross-indexing the article. Key words verify the reported results. When possi- 10) date of submittal (include date of are published with the article. Terms ble, quantify findings and present them revision submittal, if applicable). from the medical subject headings with appropriate indicators of measure- (MeSH) list of Index Medicus should ment error or uncertainty (such as con- Authorship be used. fidence intervals). Avoid relying solely Each author listed should have partici- on statistical hypothesis testing, such as pated sufficiently in the work to take Introduction the use of P values, which fails to con- public responsibility for appropriate State the purpose of the article and sum- vey important quantitative information. portions of the content. The lead author marize the rationale for the study or ob- Discuss the eligibility of experimental should take responsibility for the integ- servation. Give only strictly pertinent subjects. Give details about randomiza- rity of the work as a whole, from incep- references and do not include data or tion. Describe the methods for, and suc- tion to published article. Authors are re- conclusions from the work being re- cess of, any blinding of observations. quired to identify each author’s contri- ported. Report complications of treatment. Give

Ethnicity & Disease, Volume 17, Summer 2007 MANUSCRIPT SUBMITTAL INFORMATION numbers of observations. Report losses them as such. Recommendations, if ap- Chapter or article in book. to observation (such as dropouts from a propriate, may be included. clinical trial). References for the design Philips SJ, Whisnant JP. Hypertension of the study and statistical methods Acknowledgments and stroke. In: Laragh JH, Brenner BM, should be to standard works when pos- List all contributors who do not meet eds. Hypertension: Pathophysiology, Di- sible (with pages stated) rather than to the criteria for authorship, such as a per- agnosis, and Mangement. 2nd ed. New papers in which the designs of methods son who provided only technical help York: Raven Press; 1995: 465–478. were originally reported. Specify com- (eg, writing assistance, data input, or puter programs and software used. general support). Authors must have The titles of journals should be abbre- written permission from each person viated according to style used in Index Restrict tables and figures to those needed listed in the Acknowledgment section. Medicus. This list of journals can be ob- to explain the argument of the paper Financial and material support should tained through the National Library of and to assess its support. Use graphs as also be acknowledged. Medicine’s website (http://www.nlm. an alternative to tables with many en- nih.gov/). tries; do not duplicate data in graphs References and tables. Avoid non-technical uses of References should be numbered consec- Figure Legends technical terms in statistics, such as utively in the order in which they are Type or print out legends for figures us- ‘‘random,’’ ‘‘normal,’’ ‘‘significant,’’ first mentioned in the text. Identify ing double-spacing, starting on a sepa- ‘‘correlations,’’ and ‘‘sample.’’ Define references in text, tables, and legends by rate page, with Arabic numerals corre- statistical terms, abbreviations, and most Arabic numerals (in superscript font, sponding to the figures. When symbols, symbols. For requirements on figure/ outside of punctuation marks including arrows, numbers, or letters are used to chart submittals, please see Illustrations/ periods and commas). References cited identify parts of the illustrations, iden- Figures. only in tables or in legends to figures tify and explain each one clearly in the should be numbered in accordance with legend. Results the sequence established by the first Present your results in a logical sequence identification in the text of the partic- Tables in the text, tables, and illustrations. Do ular table or figure. See Tables, found in ‘‘Technical Re- not repeat in the text all the data in the quirements of Manuscripts.’’ tables or illustrations; emphasize or Do not use the Footnote, Endmark, or summarize only important observations. Citation command in software. Technical Requirements of Discussion References should be prepared accord- Manuscript Emphasize the new and important as- ing to style guidelines based on Uniform pects of the study and the conclusions Requirements style and presented in the General that follow from them. Do not repeat N American Medical Association Manual Double-space all parts of the manu- in detail data or other material given in of Style, 9th edition (1997). Two ex- script (except tables, which may need the Introduction or the Results section. amples of the most commonly used ci- to be single-spaced). Include in the Discussion section the N tations follow; please note and precisely Review the sequence and make sure implications for future research. Relate employ text enhancements, capitaliza- the manuscript is presented in this or- the observations to other relevant studies. tion, spacing, and punctuation. der: 1) title page (including abstract and key words), text, acknowledg- Link the conclusions with the goals of ments, references, figure legends. Standard journal article. the study, but avoid unqualified state- Tables and figures should be con- ments and conclusions not completely tained in a separate electronic file. supported by the data. In particular, au- Vega KJ, Pina I, Krevsky B. Heart trans- N Include permission to reproduce pre- thors should avoid making statements plantation is associated with an viously published material or to use on economic benefits and costs unless increased risk for pancreatobiliary dis- illustrations that may identify human their manuscript includes economic ease. Ann Intern Med. 1996;124(11):980– subjects. data and analyses. Avoid claiming pri- 983. N Submit the original manuscript and ority and alluding to work that has not electronic file in required format. been completed. State new hypotheses If more than 6 authors, present the first N Use only standard 10- or 12-point when warranted, but clearly identify 3 authors followed by ‘‘, et al.’’ font size.

Ethnicity & Disease, Volume 17, Summer 2007 MANUSCRIPT SUBMITTAL INFORMATION

Format of manuscript Illustrations/Figures copyright holder to reproduce the ma- N The text of original reports is usually N Submit 2 complete sets of figures. terial. Permission is required irrespec- divided into sections as described un- N Figures should be professionally tive of authorship or publisher, except der ‘‘Content of Manuscripts.’’ drawn and photographed; freehand or for documents in the public domain. N Submit the typed manuscript on typewritten lettering is unacceptable. N Currently Ethn Dis publishes only white bond paper 8K 6 11 in (216 N Instead of original drawings, x-ray black and white illustrations/figures. 6 279 mm) or ISO A4 (212 6 297 films, and other material, send sharp, mm), with margins of at least 1 in glossy, black and white photographic Abbreviations and Symbols (25 mm). Print on only one side of prints, usually 5 6 7 in (127 6 N Use only standard abbreviations. the paper. 173 mm) but no larger than 8 6 10 N Avoid abbreviations in the title and N Use double-spacing throughout, in- (203 6 254 mm). abstract. cluding the title page, abstract, text, N Illustrations prepared in PowerPoint N The full term for which an abbrevia- acknowledgments, references, and leg- must be submitted as a sharp, glossy, tion stands should precede its first use ends. black and white photographic print. in the text unless it is a standard unit N Number pages consecutively, begin- Electronic files of PowerPoint figures of measurement. ning with the title page. Put the page are not acceptable. number in the lower right-hand cor- N Do NOT send figures embedded in Style Writing style should follow guidelines ner of the page. other word-processing software. If fig- outlined in the American Medical Asso- N Leave right margins unjustified (jag- ure is sent as an electronic file, it must ciation Manual of Style, 9th edition ged edge). be submitted in one of the following (1997). formats: *.tif or *.eps, with file reso- Tables lution of 350 dpi for grayscale. Files N Prepare each table on a its own page of lower resolution will be rejected. Submittal Requirements in an electronic file separate from the Please check with your institution’s main text file. audiovisual or graphics department to N Do not submit tables as photographs. ensure the correct file format and Where to submit N Number tables consecutively in the print. A printout of the electronic file Manuscripts and supporting documents order of their first citation in the text, must accompany the file. as described herein can be submitted: and supply a brief title for each. N Letters, numbers, and symbols should 1) Via USPS mail or courier delivery N Give each column a short or abbre- be clear and even throughout and of service. Include the original and viated heading. sufficient size that, when reduced for electronic file(s) on disk. Disk must N Place explanatory matter in footnotes, publication, each item will still be contain the full manuscript in one not in the heading or body of the ta- legible. file; tables in another file; and other ble. N Titles and detailed explanations be- supporting files. Files should be pre- N Explain in footnotes all nonstandard long in the legends for illustrations, pared in PC-compatible word-pro- abbreviations that are used in each ta- not on the illustrations. cessing software, preferably Word- ble. For footnotes, use the following N Each figure should have a label pasted Perfect or MS Word. Name each file symbols, in this sequence: *, single on its back indicating the number of with the lead author’s last name, fol- dagger, double dagger, section marker, the figure, author’s name, and top of lowed by an abbreviation of a key parallel bars, paragraph marker, **, 2 the figure. word (eg, smith-cvd.doc or for ta- single daggers, 2 double daggers, etc. N Do not write directly on the back of bles, smith-cvd-tables.doc). N Identify statistical measures of varia- figures or scratch or mar them by us- 2) Via Ethnicity & Disease web site. Ac- tions such as standard deviation and ing paper clips. cess http://www.ishib.org/ethndis/ standard error of the mean. N Do not bend figures or mount them and follow submittal instructions. N Do not use internal horizontal or ver- on cardboard. tical lines. N Figures should be numbered consec- What else to submit N Be sure that each table is cited in the utively according to the order in text. which they have been first cited in the Cover letter N If you use data from another pub- text. All manuscripts should be submitted lished or unpublished source, obtain N If a figure has been published, ac- with a cover letter that identifies the in- permission and acknowledge them knowledge the original source and dividual responsible for correspondence fully. submit written permission from the with the editors. Provide an exact postal

Ethnicity & Disease, Volume 17, Summer 2007 MANUSCRIPT SUBMITTAL INFORMATION address, telephone and fax numbers, Manuscript Submittal Checklist mission of a letter constitutes permis- and email address. Authors must submit the completed sion for ISHIB, its licensees, and its as- checklist as the first page following the signees to use it in Ethnicity & Disease’s Upon Acceptance cover letter. print publication, in collections, revisions, and any other form or medium. Responsibility, Contributions, and Financial Disclosure Forms Guidelines: Each listed author must complete and Letters to the Editor Guidelines: submit a Author Responsibility, Contri- Book and Other Media bution, and Financial Disclosure Form, Ethnicity & Disease is pleased to print Review which certifies the role each author has letters to the editor regarding issues im- taken in the preparation of the article. portant to health care in ethnic minority It also includes a financial disclosure populations or letters related to manu- Follow these specifications to prepare statement ensuring that the article is not scripts published in the journal. Please a book or other media review. in conflict with financial interests of the send letters submitted for possible pub- author. lication to: Word count: 750–1000 words Title, author(s). City/State/Country of Copyright Transfer Editor-in-Chief, Ethnicity & Disease Publication. Publisher, year of publica- Manuscripts considered for publication 100 Auburn Avenue, NE; Suite 401 tion. have not been previously published or Atlanta GA 30303 ISBN#, # pp. $$ submitted elsewhere for publication. It is a condition of acceptance that the pa- You may also submit your letter elec- Introduction to book/media, could in- pers become the copyright of the pub- tronically to [email protected] or sub- clude: lisher; authors will be asked to transfer mit online at www.ishib.org. Letters are N Author’s intended purpose for writing copyright of accepted manuscripts to subject to editing. When preparing a the book (publishing media) the publisher, ISHIB. A copyright trans- letter to the editor, please keep the fol- N Targeted readership fer form must be submitted with the fi- lowing in mind: N Other books/media by the same au- N nal version for publication. Letters discussing a recent article must thor, if a connection can be made be received within 4 weeks of the ar- Acknowledgment Permissions ticle’s publication. N Letters presenting opposing opinions Contents, could include: Authors must provide a written state- N ment that permission has been obtained to a recent article may be sent to the Synopsis of topics found in book/me- from each person or organization listed article’s original author to request a re- dia (Starting with Foreword and Pref- in the acknowledgments. buttal/comment. ace) N N Letters must not duplicate other ma- Accuracy of information (Research based? Include information on litera- Other Permissions terials published or submitted for ture references cited) If using figures, tables, or other infor- publication. N N Strengths (Highlight pertinent quota- mation directly from a previously pub- Letters must not exceed 400 words of tions)-Weaknesses (Pertinent infor- lished work, authors must submit a text and 5 references. Please include a mation omitted?) statement of permission from the pub- word count. Figures and tables are not N If appropriate, compare the contents lisher of the information, including the allowed in letters. N of book with a previously published publisher’s required citation of the ma- Include a cover letter with a signed book on the same topic. terial. statement of author responsibility and financial disclosure (if applicable). Reviewer Suggestions Style of presentation, could include: All manuscripts must be accompanied Authors will receive a brief response via N Organization of topics by a list of at least two potential review- e-mail or fax that the letter was received. N Literary skills (Is the writing concise, ers with expertise in the subject matter Decisions regarding publication of let- to the point, clear and understandable of the paper. Please provide reviewer’s ters will be made within 1 month of by the target audience?) email, mail and phone contact infor- receipt. Prepublication proofs are not N Point out humor or humorous epi- mation. available for letters to the editor. Sub- sodes

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Conclusion, could include: 150 pages may only be published as Ethnicity & Disease is an international N Has book’s intended purpose been standalone. journal that exclusively publishes infor- reached? Emphasize important con- 5. Cost. The publication costs for sup- mation on the causal relationships in the clusions reached. plement are $225 per page for an etiology of common illnesses through N Recommended—why or why not? add-on supplement and $250 per the study of ethnic patterns of disease. page for a standalone supplement. This peer-reviewed journal publishes 6. Copyright Transfer. ISHIB retains original reports, reviews, editorials, spe- Guidelines: the copyright for all papers pub- cial articles, commentaries, brief reports, Supplement Publication lished in Ethn Dis, including those book reviews, and letters on such topics published in supplements. Sponsor- as ethnic differentials in disease rates, Ethnicity & Disease will publish sup- ing agencies of a supplement must the impact of migration on health sta- ported supplements, as both a freely agree to secure copyright transfer tus, social and ethnic factors related to bound standalone and as an add-on to forms from all authors of the articles healthcare access, and metabolic epide- regular editions, which relate to issues intended for the supplement. miology. A major priority of the journal surrounding ethnicity and health. Below 7. Process. To propose a supplement, is to provide a forum for exchange be- are guidelines for determining the ap- the sponsor will submit a proposal tween the United States and the devel- propriateness of material as a supple- outlining: topic and manuscript con- oping countries of Europe, Africa, Asia, ment. tents, number of papers, estimated and Latin America. number of pages (including intro- 1. Content. In order to be considered ductions and summaries), anticipat- Ethnicity & Disease (ISSN: 1049-510X) for a supplement, the papers must ed number of graphs/charts, whether is published four times a year by ISHIB. collectively make a contribution to the supplement should be standalone Address: 100 Auburn Avenue; Suite 401 the understanding of ethnicity and or add-on, and the anticipated Atlanta, GA 30303. health. Topics might include ethnic date the materials will be available. The differentials in disease rates or treat- lead investigator/author must agree Ethnicity & Disease is abstracted/in- ment patterns; socioeconomic factors to provide at least an introduction dexed in Index Medicus, MEDLINE, related to healthcare access; or effects to provide background as to the pur- BIOSIS, and Cambridge Scientific Ab- of migration and acculturation on pose of the program/trial. In the case stracts. health. The editor-in-chief, in con- of conference proceedings, the consultation with the associate editors, ference agenda should be included in will determine appropriateness. Subscription rates. The subscription the introduction. Supplements re- 2. Source. Supplements may come rate for ISHIB members is included in porting on study findings should in- from a variety of sources, such as and is not deductible from the annual clude all study sites, private investi- conference proceedings or manu- ISHIB membership dues. The annual gators, study design and protocols. scripts resulting from a clinical trial subscription rates for nonmembers are supported by academic or research $138 within the United States/Canada institutions. In the interest of pre- Once accepted, it is the sponsor’s and $178 outside the United States/ serving the journal’s integrity, Ethn responsibility to make timely payment Canada. The annual subscription rates Dis will not accept industry-gener- and to submit all papers and copyright for institutions $227 within the United ated content. transfer forms to Ethn Dis. States/Canada and $257 outside the 3. Review. All supplement materials United States/Canada. Address all sub- will be subject to Ethn Dis editorial scription communication to: Ethnicity review and will be made compliant General Information & Disease Subscription Office; ISHIB; with Ethn Dis editorial standards 100 Auburn Avenue, NE; Suite 401. and styles. Guidelines for Manuscript Submittal Phone 404-880-0343; 404-880-0347 4. Length. The sponsor can propose to to Ethn Dis are based on The Uniform (f ); [email protected]. publish either as standalone (ie, as a Requirements for Manuscripts Sub- separate, self-contained issue) or as mitted to Biomedical Journals, 5th Correspondence concerning advertising an add-on to a regular issue of the Edition, developed by the International or submittal guidelines should be ad- journal. Material longer than 100 Committee of Medical Journal Editors dressed to Editorial Assistant, Ethnicity pages should be published as a stand- and appearing in JAMA.1997;277:927– & Disease, ISHIB; 100 Auburn Avenue, alone, and supplements longer than 934. NE; Suite 401; Atlanta, GA 30303.

Ethnicity & Disease, Volume 17, Summer 2007