Puerto Ricans Epidemiologic Profile A Systemic Perspective (Disdier Om) Final

SYSTEMS BIOLOGY:
THE SCIENCE OF THE 21ST CENTURY

Puerto Rican’s Epidemiologic
Profile: A Systemic Perspective

Orville M. Disdier
Project Manager, Statistics
Instituto de Estadísticas de Puerto Rico

General Objectives
• To describe the social, economic,
morbidity, and mortality profile of Puerto
Ricans
• To put on view other related factors
– Sociology
– Education
• To discuss the information presented
through the open systems theory
• Present some recommendations

2
Puerto Rican’s Epidemiologic Profile – A Systemic Perspective ©Prof. Orville M. Disdier

Methodology
• Literature revision.
• National and International organizations.
– PAHO, WHO, CDC, Others
• Special studies.
• Analysis of several databases.
– Behavioral Risk Factor Surveillance System
(BRFSS).
– Local health insurance companies
– Department of Health databases
– Department of Education
• Internet publications.

3

About the Systems Theory
• Ludwing von Bertalanffy (1968)

4

Social and Economic Indicators

5

Puerto Rico population, income and education, 2000

Work force
participation rate:
40.7%

High Percentage
Population:
school under the
graduates: poverty
3,808,610
59.9% level: 48.2%

Annual house
income (median):
$14,511

Pérez CM, Pérez R, Mattei H, Disdier OM, Rodríguez LA. Perfil sociodemográfico y análisis de morbilidad asociada a causas selectas en la población asegurada de Puerto Rico, 2000 – 2003. 2005.

6

7

Economic resources, Puerto Rico 2008-2009

Presupuesto del Gobierno de Puerto Rico. (2008-2009). Available at: http://www.presupuesto.gobierno.pr/Tomo_I/resumenpresupuesto/recursosConsolidados.pdf.

8

9

Other Faqs
• For each 100 males 109 females
• Life expectancy: 77.5 years
– Males: 73
– Females: 81
• In 2005 for each 100 marriage there was 67
divorces.
• 30% are single-mom households with small children
• 25% of the population has some kind of physical or
mental impairment.
• Teenage births (15 – 19 years old): 18%
• Each morning,13% of Puerto Rico workers
spend >1 hour in the traffic jam.
Rivas. (2008). Situación presente de la educación de personas jóvenes y adultas en Puerto Rico. Centro de Cooperación Regional para la Educación de Adultos en América Latina y el Caribe. Disponible en:
http://www.crefal.edu.mx/novedades/informes_nacionales_confintea.htm.
Lobato y Curi. (2005). El tapón de la mañana. Tendenciaspr.com. Disponible en: http://www.tendenciaspr.com/Publicaciones/transporte/tapon.html#anchor_191.

10

Population pyramid and age indicator,
Puerto Rico 1990 and 2000
1990 2000

1980 1990 2000
Aging index* 25 36 47
Age median (years) 24.6 28.5 32.1
*Number of people ≥ 65 years old per 100 people under 15 years old.


11

Social and economic implications
of population aging
• Population aging represents, in one sense,
a success story for mankind
– But it also poses profound challenges to
public institutions that must adapt to a
changing age structure.
• Increase in the older retired population,
decrease in population of working ages,
– Creates social and political pressures on
social support systems.
Gavrilov L.A., Heuveline P. (2003). Aging of Population. In: Paul Demeny and Geoffrey McNicoll (Eds.). The Encyclopedia of Population. New York, Macmillan Reference USA. Available at:
http://www.galegroup.com/servlet/ItemDetailServlet?region=9&imprint=000&titleCode=M333&type=4&id=174029

12

Violent deaths by category and
age, Puerto Rico 2005

Departamento de Salud (2005). Muertes Violentas por Grupos de Edad, Sexo, Municipio de Residencia y Año. Secretaría Auxiliar de Planificación y Desarrollo, División de Análisis
Estadístico, San Juan, Puerto Rico. Available at: http://www.salud.gov.pr/Datos/InfoSalud/Statistics/GeneralDeath/Pages/MuertesViolentasporGruposdeEdadMunicipiodeResidencia.aspx .

13

14

Domestic violence
• Several reasons Entre enero y diciembre
– Social de 2001 la Policía de
Puerto Rico informó 17,700
– Cultural
intervenciones por
– Economic violencia doméstica.
• Limited essential
En el 86% la víctima fue
resources una mujer.
– Housing
– Employment
– Education
Oficina de la Procuradora de la Mujer. (2008). La violencia doméstica nos toca a todos.

15

Morbidity and Mortality

16

Principal causes of death,
Puerto Rico, 2004
4.2
Alzheimer

5.3
Hypertension

8.8
Diabetes

16.6
Cancer

17.3
Heart disease

Porcentaje (%)
Estado Libre Asociado de Puerto Rico. Informe Anual de Estadísticas Vitales, 2004. Secretaría Auxiliar de Planificación, Evaluación, Estadísticas, y Sistemas de Información. División de
Estadísticas

17

Prevalence estimates of the first 15 health
conditions/diseases Puerto Rico, 2003
Hypertension #1
14.76

Asthm a 12.23

Diabetes
#3
7.73

Arthritis 7.27

Sinusitis (chronic) 7.12

Allergic rhinitis 5.39

Lipoproteins problem s 5.28

Migraine 4.29

#9
Circulatory problem s 3.67

Myopia and astigm atism 3.29

Intervertebral discs problem s 2.98

#12
Depressive episode 2.88

Acute rinofaringitis 2.79

Gastritis 2.50

Back disability 2.43

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
Prevalence (%)
18

Asthma prevalence at the time of the survey in
Puerto Rico, BRFSS (2000-2002)

“…a decreasing tendency in the asthma prevalence as income reported increases.
A statistically significant difference was observed during year 2000 between
income groups of less than $15,000 and $50,000 or more.”
Bartolomei-Diaz, 2007

Bartolomei-Diaz, J. (2006-2007). Epidemiological Profile of Asthma in Puerto Rico . Puerto Rico Asthma Project. Puerto Rico Department of Health. Available at:
http://www.salud.gov.pr/OficEpidemiologia/Documents/AsthmaEpiProfile.pdf.

19

Overweight and obesity in the Puerto Rican
adult population – BRFSS*, 1996–2007

45 40.70
40.60 39.00 39.00
39.60
39.30
38.00
Prevalence (%)

39.40
40 37.20
37.20 38.30
36.80

35
30
26.60
25
24.30 24.70
20 23.70
22.90
21.70 22.20 22.00
21.30
19.30
19.00
15 16.80 Normal (BMI < 24.9)
10
Overweight Obese Overweight (25 < BMI < 29.9)

5
Obese (BMI > 30)

0

Year
* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 años). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1996-2007. Atlanta, GA: United
States, Department of Health and Human Services.

20

Prevalence of diabetes in adults,
Puerto Rico – BRFSS*, 1996–2007
14 12.5 12.5
Prevalence (%)

11.9
12 10.7
11.0
10.8 10.5 10.5
9.8
9.6
9.6
10
8.5

8

6

4
1.9
2
Diabetes Pre-Diabetes 1.5 1.3
1.1
0

Year
* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 años). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1996-2007. Atlanta, GA: United States, Department of
Health and Human Services.

21

Overweight and obesity in the Puerto Rican
adult population with Diabetes BRFSS*, 2004

35.7
Obe se

43.9
Ove rwe ight

20.4
Normal

0 5 10 15 20 25 30 35 40 45 50

Percent (% )
Normal (BMI < 24.9)
Overweight (25 < BMI < 29.9)
Obese (BMI > 30)

* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 años). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1996-2003. Atlanta, GA: United
States, Department of Health and Human Services.

22

Prevalence of diabetes mellitus
by age and sex, 2000-2003
40.3

35.9

32.1
31.1
30.0
27.6
Prevalence (%)

24.4
22.2

Female
Male
14.3
12.4

8.3
8.0 6.2
4.9
2.4
3.1

<18 18-24 25-34 35-44 45-54 55-64 65-74 >74

Age (in years)

23

Prevalence of the metabolic syndrome and
its components according, San Juan 2005
Prevalence (%)

49.0 48.7
45.6
38.2
31.2 30.8

MS Abdominal Ele vate d Low HDL-C Ele vated Hype rtension
O besity Glucose Triglyceride s

Prevalence of the metabolic syndrome and its individual components in the adult population of the San Juan metropolitan Area. C. Pérez, PhD*, A. Ortiz, PhD*, M. Estrella, MPH*, N. Pérez, MS*, Y.
Valle, MPH*, M. Guzmán, MD†, L. Haddock, MD†, E. Suárez, PhD*, Graduate School of Public Health* and School of Medicine†, University of Puerto Rico.

24

Population aging and chronic diseases
• Sanitary policies
must focus on efforts
to increase the
expectancy of
incapacity-free
years.
– Instead of just the
simple life
expectancy .
Organización Mundial de la Salud. (2007). Panorama de la Salud en la Región. Salud en las Américas 2007.

25

Incidence for vaccine-preventable diseases
Puerto Rico, 1990 - 2003

AÑO DE INCIDENCIA
ENFERMEDAD
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Tétano 4 1 1 2 2 0 2 1 1 2 0 0 3 0
Tosferina 26 57 14 11 3 3 3 2 1 9 2 0 0 1
Paperas 8 13 3 3 2 3 2 7 1 0 0 1` 2 0
Meningitis XH FLU 35 15 8 3 3 3 2 0 2 2 4 1 2 4
Hepatitis B 610 580 393 422 415 689 1,073 843 278 303 313 258 219 143
Hepatitis B Perinatal N/A N/A 35 75 108 98 126 117 96 89 95 51 63 17
Sarampión Común 1,817 160 577 356 46* 3 3 0 0 1 3 1 2 0
Sarampión Alemán 0 0 1 0 0 0 0 0 0 2 0 3 0 0
Difteria 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Polio 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Rabia Humana 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Varicela** 1,332 5,233 8,524 8,240 9,193 5,678 5,942 8,854 4,348 5,019 5,200 2,186 1,141 *

* Incluidos los falsos positivos por método de Clark
**Obligatorio a partir del 1997
Fuente: Departamento de Salud, Programa de Epidemiología, 1990-2003.

26

AIDS distribution by year of
diagnosis, Puerto Rico, 1981-2009
3000
2,669
2,526
2500 2,348
2,306
2,133
2,053
2000
1,851
Number of cases

1,735
1,598
1,447
1500
1,283 1,279
1,177 1,177
1039 1050
1000 898 917
813
750
672
455
500 441
268
184
5
0
85

86

87

88
89

90

91
92

93

94

95
96

97

98

99
00

01

02
03

04

05

06
07

08

09
5
98
19

19

19

19
19

19

19
19

19

19

19
19

19

19

19
20

20

20
20

20

20

20
20

20

20
<1

Year of diagnosis

N = 33,074 Casos reportados hasta el 01/30/2009.

27

Pediatric cases by year of diagnosis,
Puerto Rico, 1981 – 2008*
60

48
45
42 41
37
37
40
Number of cases

32
25
21
17
20
15
13 12
65
4
3 2
2 1
1 10
1 0 0
0
83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

00

01

02

03

04

05

06

07

08
19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

20

20

20

20

20

20

20

20

20
Year of diagnosis

Fuente: Programa Vigilancia de SIDA, División de Epidemiología, Departamento de Salud de Puerto Rico
N =411
*Casos pediátricos reportados hasta el 1/30/2009.
28

Distribución Porcentual de Casos VIH (no-
SIDA) por Modo de Exposición, Puerto Rico
Sexo H/H y UDI 3%

No Ident.
12%

Uso Drogas
Inyectables (UDI)
36.1
Sexo Hom bre/Hom bre
38% 14%

Contacto
Heterosexual
33%

N = 7,346 Casos reportados adults/adolesc. hasta el 1/30/2008

29

Mental Health

Vincent van Gogh, who himself suffered from depression and committed suicide, painted this picture in 1890 of a man that can symbolize the desperation and hopelessness felt in depression.

30

“…un cantante de música religiosa es
acusado de agresión sexual y actos
lascivos contra una niña de 11 años”
31

Prevalence estimates of one or more psychiatric
disorders, Puerto Rico versus other countries,
2000 - 2003

4.3
China (Shangai)
8.8
Japón
9.1
China (Beijin)
12.2
Mexico
17.8
Colombia
26.4
Estados Unidos
27. 5
Puerto Rico

Prevalencia (%)

Avilés LA, Cannino G, Rubio-Stipec M. Proyecciones de diagnósticos psiquiátricos: Puerto Rico, año 2000. Puerto Rico Health Sciences Journal 1990; 9(3):235-243.
World Mental Health Organization. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004; 291(21): 2581-2590.

32

Depression and lifestyle
• It has been found that people with major
depression tend to have poorer health
behaviors, specially those which are risk factors
for obesity and diabetes (Talbot F, & Nouwen, 2000; Knol, Twisk, & Beekman, 2006).

– Unhealthy diet
– Smoking
– Sedentary lifestyles

33

Psychiatric disorders and Diabetes
• Some psychiatric disorders, such as
depression, anxiety, and schizophrenia,
have been associated with diabetes (Lean, &
Pajonk, 2003; Anderson, Freedland, & Clouse, 2001; Lustman,
Anderson, & Freedland, 2000; Lustman, 1988).

• Individuals with diabetes have twice the
risk of suffering from depression than
people without diabetes (Anderson, Freedland, &
Clouse, 2001)

34

Diabetes and Depression in Puerto
Rico, 2005 (Disdier & Jiménez, unpublished)

Diseases Prevalence
Diabetes 9.8 %
(96% CI: 9.7% - 10.1%)
Major depression 3.1%
(95% CI: 3.2% - 3.3%)
Diabetes in 14.6%
subjects with POR
(95% CI: 14.2% - 15.0%)
major depression
1.6
Diabetes in 9.7%
subjects without (95% CI: 9.5% - 9.9%)
(95% CI: 1.5 – 1.6)
major depression
Pvalue < 0.001
35

Depression and Unemployment
• Unemployment is a risk factor for
psychological symptoms of depression
requiring medical attention
– Even in those men without previous
psychological vulnerability.
• Adjusted RR = 2.10 (95% CI: 1.21 - 3.63).

Montgomery, S., Cook, D., Bartley, M., & Wadsworth, M. (1999, February). Unemployment pre-dates symptoms of depression and anxiety resulting in medical consultation in young men.
International Journal Of Epidemiology, 28(1), 95-100. Retrieved January 13, 2009, from MEDLINE with Full Text database.

36

Lifestyles

37

Daily Fruits and vegetables consumption
(5 or more servings),
BRFSS, Puerto Rico, 2007

Yes
14%

No
86%

* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 años). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 2007. Atlanta, GA: United States,
Department of Health and Human Services.

38

Food marketing and health
• Each year more money is expended in
unhealthy food advertisement than in
government publicity and efforts aimed to
promote health lifestyles
(US Department of Health and Human Services. Nutrition and Overweight.
Healthy People 2010. January 21, 2004)

US Department of Health and Human Services. Nutrition and Overweight. Healthy People 2010. January 21, 2004.

39

40

Physical activity, Puerto Rico 2001

Unknown Yes
14% 17%

No
69%

Estudio Continuo de Salud. Departamento de Salud de Puerto Rico. Universidad de Puerto Rico, Escuela Graduada de Salud Pública, 2001.

41

Physical activity is associated with
dramatic risk reductions
quot;We know that diet is important,quot; said co-
author Chris Riddoch, Ph.D., of Bath
University, quot;but what this research tells us is
that we mustn't forget about activity.“
quot;It's been really surprising to us how even
small amounts of exercise appear to have
dramatic results,quot; he said in a statement.

Online in the open-access journal PLoS Medicine.
Just 15 Minutes of Physical Activity Lowers Kids@Risk of Obesity and Diabetes. http://www.diabetesincontrol.com/results.php?storyarticle=4665.

42

“Estudio establece que ejercitarse
por sólo tres minutos cada día
protége contra la diabetes”

43

http://www.andertoons.com

44

Education in Deep

45

“A primera vista en el país se podría
identificar un alto nivel de ingresos, y se
podría suponer una agenda educativa…”
“…una segunda mirada nos revela… casi
la mitad de la población vive en la pobreza,
el país tiene un coeficiente de desigualdad
social alto...”
Myrna Rivas Nina, 2008.

46

“… la lucha político partidista, la
corrupción y la burocracia definen muchos
ámbitos de la política pública y de la
educación.”

Myrna Rivas Nina, 2008.

47

Educational attainment, for persons 25 years old
and over, Puerto Rico 1990, 2000, 2005
60.0
Puerto Rico está en la posición #48 (de 51) en
50.3
50.0 cuanto al total de personas con bachillerato o más
40.0

40.0
Percent (%)

33.6

20.7% 1990
30.0
24.2
2000
22.3
21.0

20.0 2005
15.5
13.6
12.2 11.9
10.7
9.5
10.0 8.8
7.2
5.6
4.7 5.3
3.6

0.0
Less than High Some Associate Bachelor Graduate
High School College, no Degree Degree School
School Graduate degree Degree

Negociado del Censo. Censo 1990, Censo 2000, Encuesta de la Comunidad 2005.

48

Analphabetism, for persons 10 years old and
over, Puerto Rico by year
90.0
79.6
80.0 78.4

70.0 65.5

60.0
Percent (%)

55.0
50.0
40.0 41.4

31.5
30.0
24.7
20.0 16.6
13.1 11.5
10.0 10.7 10.6

0.0

Negociado del Censo. Censo 1890-1990.

49

50

Average NAEP scores for mathematics, Puerto
Rico versus U.S.A. Nation

WWW.ED.GOV

51

Average NAEP scores for mathematics, Puerto
Rico versus U.S.A. Nation

WWW.ED.GOV

52

Education and Life expectancy
1

y = 0.732x + 0.1319 Iceland
0.9

r = 0.74
0.8
R=55%
0.7
Life Expectancy Index

0.6

0.5

0.4

0.3
Africa
0.2

0.1

0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Education Index

Raw data from: United Nations Development Programme. (2008). Human Development Reports 2007-2008. Available at http://hdr.undp.org/en/terms/.

53

Education and Gross Domestic
Product (GDP)
1
United States
0.9

y = 0.807x + 0.0488
0.8
r = 0.78
0.7
R=61%
0.6
GDP

0.5

0.4

0.3
Africa
0.2

0.1

0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Education Index

Raw data from: United Nations Development Programme. (2008). Human Development Reports 2007-2008. Available at http://hdr.undp.org/en/terms/.

54

Captive kids:
$elling obesity at schools
• quot;More and more companies see school-
based marketing as the most compelling,
memorable and cost effective way to build
share of mind and market into the 21st
Century”.
• “Candy and snack food manufacturers,
soft drink bottlers, and fast food
restaurants are among the companies that
market most heavily in schools”
California Project LEAN . (2006). Captive kids: $elling obesity at schools- An action guide to stop the marketing of unhealthy foods and beverages in school. Available from:
http://www.californiaprojectlean.org/Assets/1019/files/CK2007.pdf.
55

Television violence and children
(Parents Television Council, 2006)

56

(Parents Television Council, 2006)

The results were staggering.
In the 443.5 hours of children’s
programming analyzed by the PTC there were:

•3,488 instances of violence – an average of 7.86
violent incidents per hour.

•There is more violence aimed directly at young
children than at adults on television today.
•858 incidents of verbal aggression
•250 incidents of offensive language
•662 incidents of disruptive, disrespectful or
otherwise problematic attitudes and
behaviors
•275 incidents of sexual content

57

Interactions: social problems, economics,
communication, social forces, and social wellness
Interacción entre Problemas Sociales, Metas y Procesos y Fuerzas Inhibidoras
y Facilitadoras del Ambiente Social Sano.
RESULTADOS
PROCESOS
ESTRUCTURA
Metas y Procesos
Problemas Sociales
Fuerzas Inhibidoras y
Facilitadoras de
Ambiente Sano
J P
U O
Empleo
S Optimo L
CRIMEN
T
I
I I
Comunicación T DROGADICCION
C
N M Social Sana
I
I
E
T R ALCOHOLISMO
C
A
E C
A
MODELO ECONOMICO
A
R DESERCION
D AUTOSUSTENTABLE
N ESCOLAR
O
A P
C
U
C MATERNIDAD
A
B
I P
PRECOZ
I
L
O P
CULTURA
T
Familia
I
A
A
N Sana
I VIOLENCIA
L Z
A
C DOMÉSTICA
L T A
I E
CORRUPCIÓN
C
Z DEL GOBIERNO
N
DEMOCRACIA
A O
PARTICIPATIVA
L
S
C CIVISMO
O
A SIDA
E
I G
L
Nivel de
I
Q
O
Soberanía
A U
U
N Optima D
I
A
Comunidad
D Empoderada
B
A y
L
Organizada
D E

US Department of Health and Human Services. Nutrition and Overweight. Healthy People 2010. January 21, 2004.
58

General recommendations
• Promote lifestyles changes, specially at a
community level.
– Improvements in education and socioeconomics
• Innovations in effective prevention
programs.
• Keep the developing of new medical and
technologic advances.
• Conscientious rejection or acceptance of our
new and future culture.

59

Selected references
Avilés LA, Cannino G, Rubio-Stipec M. Proyecciones de diagnósticos
psiquiátricos: Puerto Rico, año 2000. Puerto Rico Health Sciences Journal
1990; 9(3):235-243.
Centers for Disease Control and Prevention. Behavioral Risk Factor
Surveillance System 1996-2007. Atlanta, GA: United States, Department of
Health and Human Services.
Montgomery, S., Cook, D., Bartley, M., & Wadsworth, M. (1999, February).
Unemployment pre-dates symptoms of depression and anxiety resulting in
medical consultation in young men. International Journal Of Epidemiology,
28(1), 95-100. Retrieved January 13, 2009, from MEDLINE with Full Text
database
Pérez CM, Pérez R, Mattei H, Disdier OM, Rodríguez LA. Perfil
sociodemográfico y análisis de morbilidad asociada a causas selectas en la
población asegurada de Puerto Rico, 2000 – 2003, 2005.
Rivas. (2008). Situación presente de la educación de personas jóvenes y
adultas en Puerto Rico. Centro de Cooperación Regional para la Educación
de Adultos en América Latina y el Caribe. Disponible en:
http://www.crefal.edu.mx/novedades/informes_nacionales_confintea.htm.
World Mental Health Organization. Prevalence, severity, and unmet need for
treatment of mental disorders in the World Health Organization World Mental
Health Surveys. JAMA 2004; 291(21): 2581-2590.
60

quot;Para que el hombre fuera hombre, es decir,
digno de realizar los fines de su vida, la
naturaleza le dio conciencia de ella, capacidad
de conocer su origen, sus elementos
favorables y contrarios, su trascendencia y
relaciones, su deber y su derecho, su libertad y
su responsabilidad, capacidad de perfecciones
y de mejorar por si mismo las condiciones de
su ser y por sí mismo elevar el ideal de su
existenciaquot;
Eugenio María de Hostos

61

Información de Contacto
Prof. Orville M. Disdier-Flores
Gerente de Proyectos Estadísticos
Instituto de Estadísticas de Puerto Rico
Calle Quisqueya #57, 2do piso, San Juan, PR 00917
P.O. Box 195484, San Juan, PR 00919-5484
Teléfono: (787) 993-3342
Fax: (787) 993-3346
Email: Orville.Disdier@estadisticas.gobierno.pr
Página de Internet: www.estadisticas.gobierno.pr

http://disdier.blogspot.com

Puerto Ricans Epidemiologic Profile A Systemic Perspective (Disdier Om) Final

Recommended

Recommended

More Related Content

Similar to Puerto Ricans Epidemiologic Profile A Systemic Perspective (Disdier Om) Final

Similar to Puerto Ricans Epidemiologic Profile A Systemic Perspective (Disdier Om) Final (20)

More from Dr. Orville M. Disdier

More from Dr. Orville M. Disdier (20)

Recently uploaded

Recently uploaded (20)

Puerto Ricans Epidemiologic Profile A Systemic Perspective (Disdier Om) Final