Race Ethnicity and Health

Hyperdiversity: Identity, Culture and Health GLBH 148. Class 6

Social Determinants of Health Health behaviors of

individuals influence mortality and

morbidity, these do not occur in a

vacuum

Culture

Money

Education

Structure

Geography

Race/Ethnicity

HEALTH DISPARITIES

• The differences that exist for non-racial reasons are called “inequalities” while the differences that implicate race are called “disparities.”

Dispariti es in Health Status: Evidence

Black infant mortality rates are nearly twice that of Whites, and this gap is larger now than it was in 1950.

For much of the past 50 years, the mortality rate for middle-aged Black adults was more than double that of Whites, and there has been no appreciable change in the overall racial disparity in mortality from 1960-2000. Recently, this gap has begun to narrow.

Blacks rate their health as worse than Whites, and they are at greater risk for a number of specific disease conditions, most notably diabetes, hypertension, asthma, AIDS, and certain cancers.

Disparities in Health Care: Evidence

• Differences in access and quality of care exist between racial and ethnic groups in the United States and are particularly dramatic for Black Americans when compared to White Americans.

• Blacks are more often institutionalized, over-prescribed anti-psychotic medications, and under-prescribed anti-depressants when compared to Whites.

• Differences also exist in a wide range of diseases and conditions, including care for cardiovascular disease, but also cancer, stroke, liver transplantation, asthma, diabetes, and many other conditions.

What do we know about inequalities and disparities?

Well documented differences in health status by race, ethnicity, and social class

NIH funded studies documented disparities in medical treatment and in diagnosis and treatment for mental disorders over past two decades

Changes have occurred in health status and health care over time, mostly improvement

Persistent disparities in medical and mental health care continue to exist, and they are not entirely attributable to access or insurance status.

What do we know about inequalities and disparities?

Explaining Disparities in Health Status: Race

• In addition to the indirect effect of race on health, through its historical and contemporary effect on SES, race can also directly impact health through differential exposure to psychosocial stressors.

• Williams/Dressler/Sherman James: Experience of discrimination and racism directly raises stress levels and directly increases risk for a variety of health conditions, especially cardiac disease and high blood pressure.

• Gravlee and Dressler: Subjective indicators of status (such as skin color) can have an independent effect on one’s health

Explaining Disparities in Health Status: Race

Williams and Collins (1995) Three ways that racism effects health 1. Racism blocks mobility so that SES indicators are not equivalent across race. 2. Residential segregation creates concentrated poverty and poorer living conditions that limit access to and the quality of health-related desirable services such as public education, health care, housing, recreational facilities and grocery stores. 3. The experience of racial discrimination and other forms of racism may induce psychological distress that may adversely affect physical and mental health status, as well as the likelihood of engaging in violence and addiction.

Mechanisms underlying SES and Racial Differences in Health

• Medical Care: Inadequate use of medical care, especially preventative medical care, by the poor and members of racial minority populations is generally viewed as an important determinant of their health status. There are racial and socioeconomic status differences in the quantity and quality of medical care.

• Health Behaviors: Health practices such as better nutrition and eating habits, diminished alcohol, and drug abuse, and more exercise can dramatically improve health. Differences in health behaviors fail to account for disparities, though.

• Working Conditions • Environmental Exposure • Macroeconomic Trends (Recessions, etc.) • Personality (John Henryism, vigilant coping,

#racialbattlefatigue) • Early Life Conditions • Power

Explaining Disparities in Health Status: Health Care

A key portion of the unexplained difference in health status is due to differences in the quality of health care received by different groups.

This portion of the observed difference in health status violates our core notions of equity and fairness in a way that diffuse differences in SES and individual behavior does not.

We may not know how to change the SES or health behaviors of disadvantaged groups in the U.S., but we can improve the health care system and treat all groups equally.

Biased test for kidney transplant

• https://www.youtube.com/watch?v=wnn8I1B1FtY

David R Williams: The health impacts of racism

• https://www.rnz.co.nz/audio/player?audio_id=2018761696

• 2.15 – 9.11

Takeaways The causes of observed differences between racial/ethnic groups in health and health status are multilevel and multi- factorial

Some operate at the interpersonal level while others operate at the system level

Differences exist for ostensibly racial and non-racial reasons.

The differences that exist for non-racial reasons are called “inequalities” while the differences that implicate race are called “disparities.”

Hyperdiversity: Identity, Culture and Health Background

• Health care institutions have been attending to race, ethnicity and culture for many decades

• Resurgent interest in culture and medicine as a strategy to reduce health disparities

• Past 20 years have brought burgeoning “disparities” and “culture counts” movements into the heart of medical practice and training

Problem • Not clear whether this resurgent interest in culture and medicine effectively targets the mechanisms that

produce disparities

• Culture often rendered at group level, risks reductionism and stereotyping

• Increasing immigration and demographic change further challenges the fusion of identity and culture as the boundaries between groups blur and the cultural complexity of individuals within groups is revealed

• Thus, it is important to investigate how race, culture and ethnicity are understood and utilized by clinicians today and how they are influenced by these massive demographic changes

Motivating Questions • How do clinicians and their institutions provide care for diverse patient populations?

• How do clinicians view the importance of race, ethnicity and culture?

• What are the tensions and complications that arise when clinicians take race, ethnicity and culture into account in their daily work?

• What does this tell us about contemporary race and ethnic relations?

• Are current approaches to cross cultural health care effective, or might they do more harm than good?

Theoretical Approach

Clinical spaces are sites for the generation of inequality

Interpersonal Processes

• Quality of doctor-patient relationships are shaped by trust and effective communication

• Universal processes of social categorization enable clinicians to sort patients into groups that are relevant to improving the efficiency of their work using existing social categories (race/ethnicity, gender, immigration status) or emergent social categories (difficult vs. model patient)

Theoretical Approach Institutional Processes

• Availability of medical interpreters, cultural brokers, or patient navigators varies from clinic to clinic and conditions access to care for linguistic minorities

• Institutions vary in the degree to which they explicitly seek to monitor and reduce health disparities

Interpersonal and institutional processes interact and are deeply affected by the larger social environment, particularly by rapid demographic change

Theoretical Approach: Universalism vs. Particularism

Spectrum of Approaches to Cross-Cultural Health Care

Less Culture More Culture

Group Culture Matters

Tools: Culturally Specific Services

Racial/ethnic matching

“No one knows this population like we do”

Group Culture Matters

Tools: Cultural Competence Training

Medical Interpreting

Cultural Brokers

“let me show you this manual we use”

Individual Culture Matters

Group Culture Does Not

Tools: Clinical Ethnography

“Just ask them what their beliefs are”

Culture Does Not Matter

Tools: Universal Approach to Care

Biomedical Model

“Just be a good clinician”

Theoretical Approach: Universalism vs. Particularism

Spectrum of Approaches to Cross-Cultural Health Care

Less Culture More Culture

Group Culture Matters

Tools: Culturally Specific Services

Racial/ethnic matching

Group Culture Matters

Tools: Cultural Competence Training

Medical Interpreting

Cultural Brokers

Individual Culture Matters

Group Culture Does Not

Tools: Clinical Ethnography

Culture Does Not Matter

Tools: Universal Approach to Care

Biomedical Model

Currently Favored Policy Approach

Cultural Humility

• https://www.youtube.com/watch?v=wDIGXUzULug&t=1s

Specific Research Questions

1. How do clinicians who work in highly diverse settings conceptualize and use culture in their daily work?

2. How well-suited are popular group-specific approaches to culture to periods of rapid demographic change and increasingly complex patterns of diversity?

The Research

• “How Does Culture Make a Difference in American Health Care,” project funded by the Russell Sage Foundation

(PI: Mary-Jo DelVecchio Good)

• More than 250 interviews with clinicians, staff, management and patients in 5 hospitals with 9 psychiatric clinical sub-sites in the greater Boston area.

• Ethnographic observation in multiple clinics.

• In-depth interviews conducted by team of NIMH pre and post-doc fellows from 2006-2008.

Psychiatrists, Psychologists and other MD’s (M.D. Psychiatrists/PhD. Psychologists/Other MD’s) 72

Other Mental Health Professionals (Social Workers/Mental Health Counselors with MA Degree) 27

Other Health Care Staff (Nurses/Mental Health Workers/Occupational Therapists/Dieticians) 27

Patient Support Staff (Interpreters/Chaplains/Advocates/Mental Health Associates) 47

Administrative Support Staff (Security/House Keeping/Dietary/Clerical) 11

Management Support Staff (Non Medical Administrative and Clerical Managers) 6

Basic and Clinical Researchers 2

Patient Interviews N= 55

Formal Interviews with Clinicians and Support Staff: N=192 Patients N=55

Boston and Environs • Boston is historically interesting in the “culture counts” movement, as the first

culturally tailored community clinics in the US were established in Boston to treat Italians and African Americans in the early 1960s.

• Boston’s Mayor Menino charges the city’s health care institutions to redress the disparities in health status and in health care following the publication of Unequal Treatment in 2001.

• Psychiatry and mental health services in the greater Boston area have responded in diverse ways depending on place, communities of practice, and geographies of population change. Disparities and culturally specific services are deeply tied into the dramatic changes in Boston’s demographic profile.

Diversity Within Categories

Boston’s Latino Population is Highly Diverse

Diversity Within the Black Population in Boston

One-Third of Boston’s Black Population is Foreign Born

Diversity Within the Black Population in Boston

Nearly 40% Identify as having West-Indian or Sub-Saharan African Ancestry

Ethnographic Findings

• Clinicians and staff members, many of whom work in clinical environments with dynamic and highly diverse racial and ethnic patient and staff populations, have difficulty classifying their patients along simple, census-based racial and ethnic lines and instead see finer grained cultural differences such as what language a patient speaks or more individualized patterns of behavior such as a patient’s propensity for violence as more salient in their daily work.

Cultural Environments of Hyperdiversity Definition

A cultural environment of hyperdiversity is a social setting that is highly diverse (in terms of race and ethnicity as well as social class, immigration status and religion), dynamic (unstable or undergoing change), and multidimensional (individuals may choose to identify with broad racial and ethnic categories or narrower categories such as country of origin, neighborhood, or sexual orientation). In these settings, racial and ethnic classification is more difficult and the link between census based racial/ethnic identities and culture is likely to be weak or broken (“shattered”).

Cultural Environments of Hyperdiversity Five Scenarios

• Efforts to provide culturally sensitive care that are based primarily on group-based cultural difference are disrupted in these “cultural environments of hyperdiversity”

• Hannah observed 5 scenarios in his field sites that illustrate this

Cultural Environments of Hyperdiversity Five Scenarios

1. Multiplicity Where the number of different racial-ethnic groups is numerous, making the organizing services based on identity impractical.

2. Ambiguity Where racial or ethnic identity of patients is not easily recognized using physical features alone.

3. Simultaneity Where patients occupy multiple racial/ethnic categories at once.

4. Fluidity Where the self-asserted racial and ethnic identity of patients is flexible or changes over time.

5. Misapplication: Where an individual patient’s cultural orientation is idiosyncratic and does not significantly resemble the cultural characteristics associated with their racial/ethnic group.

Case Example: Somali Refugee Treatment

● Neighborhood Community Health Center North of Boston

● Refugee Health Program conducts initial health screenings of new refugees, conducts home visits and connects them to health care services, including mental health.

● 600 Somali “Bantu” refugees settled in the area.

● Health Center hires Somali staff (outreach workers, interpreters, mental health counselors) to provide culturally sensitive care to Somali refugees.

Findings: Myth vs. Reality Cultural expectations are embedded in refugee treatment programs

● Ethnic / Tribal Identity is coherent and stable

● Aversion to “Western” medicine

● Seeking treatment for trauma experience

Sadia’s Journey

Sadia is a middle-aged Somali refugee mother of seven. She and all of the clinic staff involved in her care were interviewed. In addition, Hannah conducted ethnographic observation of the clinic, attended group therapy meetings, and interviewed a wide variety of clinicians, interpreters, administrators, and managers throughout the clinic.

Her story reveals the cultural complexities involved in refugee health care and the difficulties in using a culturally specific treatment approach with what appears to be a very discrete cultural group.

On Trauma Experience and Seeking Care • Sadia seeks care due to social Isolation and concern for her children

“I'm a woman who went through a lot of issues, you know, after the war I was raped and went through things that I can't even talk about. We left the country, went to the camp, the camp itself had a lot of issues, a lot of problems, and thanks God we came to America.”

“…What made me come to the doctor is the problem that I went through back in Somalia and what I went through in coming here and seeing the kids and what they have become of – – the combination of that with this and not being able to have any family here and the only people that I knew were the interpreters and girls over here so that is what made me to come and to get help.”

On Health Care Experiences

• Sadia has had a positive treatment experience. She gets along well with her therapist (a Somali woman), her psychiatrist (a native Spanish speaker from South America), and the cadre of refugee specialists and interpreters in the program

“It's not something new to me, I used to see doctors and get medications. I'm not one of those people who don't believe doctors and medicine, (I'm) one of the people who believe God and medicine and doctors. The reason that you are seeing a doctor is the doctor being able to help you with what you have, to be able to help you with your issues.”

Distress Caused by Children

• Although a victim of trauma, she is driven to seek care primarily due to the behavior of her children, who she views are not adjusting well to life in the U.S.

“But the kids that I brought here, I took them and showed them away from the war and brought them here and seeing them going through the changes of wearing the hippie, baggies, you know and the 'yo, and yo, and the hip-hop and the yo thing' and you know, it's a lot.”

“…After we came here and seeing the kids going through this change and becoming what they are, it destroyed me a lot and put me in the stage that I was very upset and very worried. And I used to cry a lot and I got contact or I was able to get the help of providers, seeing the doctors, giving me medication. So I got medications and I'm fine now.”

On Relationship with Psychiatrist and Medications

• Sadia has a good relationship with her psychiatrist and a positive experience with psychiatric medications

“The most helpful thing was when I was having a lot of problems, not being able to sleep, not remembering where I put the stuff, not myself, I came and talked to her and she gave me medications which I was much better, I was feeling much better. That was the most helpful.”

On Her Therapist

• Sadia’s therapist calms her down and helps her deal with significant marital difficulties

“As you know, we are women and I pour my heart to her and the issues that we talk about are my mother, my son, you know, if God's willing you could see them. And issues with the kids and what they are going through and if you know, eventually they will come around. You know, ‘women stuff’!”

“I don’t see her for a lot of issues, but she talks to me and she calms me down. When I have a lot of issues and I don’t know who to tend to and I can’t handle it, I just walk out of the house and come in here and she calms me down and she talks to me and I go home and I’m calm – even you (addressing the interpreter), a couple of times I’ve come to you and you’ve calmed me down.”

On Ethnic Identity

• Sadia is herself not Bantu, and draws bright distinctions between herself and Bantus (such as her husband and many of the other women seen in the clinic) who she feels superior to

Sadia:

“I am — my tribe is Madhibaan. But my husband's tribe is Somali Bantu, so my children are Somali Bantus.”

“The people who work here are not my children's type, not my husband's people in other words. But they are more on my side.”

On the Importance of Tribe

• Sadia insists that tribe matters little to her, yet it continues to divide her from her husband and the rest of the community

“To me it does not make any difference, Somali is Somali, whether you are different tribe or not. A while ago, we did not know what tribe was. The only way we knew what tribe was after the civil war. But I still believe that no matter where you came from, what part you came from in Somalia, that a Somali is a Somali. And everybody, as long as they are Somali, it does not make any difference to me.”

Conclusion: Shattering Culture • Health care personnel do not encounter one unified block of Bantus as there are blended

families and complex local norms that shatter the assumption of cultural unanimity.

• Contrary to what is often assumed about African refugees, Sadia embraced biomedical treatment, especially medications. She was not seeking treatment primarily because of her “old” traumas; instead she sought help to relieve her stress over her children’s acculturation and her need for connection and community.

• Culturally specific services for refugees and other disadvantaged groups, even ones that appear on the surface to be culturally homogeneous, are challenged by the diversity of individual experience. Policy-makers should be sensitive to this diversity and modify cultural-competence efforts that are targeted too broadly.

Know Your Audience

• Culture and Medicine

• Hyperdiversity

• Immigrants and Refugees are not a monolithic group

• People, Principles and Practices: https://www.youtube.com/watch?v=_Mbu8bvKb_U

• CULTURAL Humility (complete documentary). https://www.youtube.com/watch?v=SaSHLbS1V4w

ARTICLES

PAUL FARMER Department of Anthropology Harvard University

Sending Sickness: Sorcery, Politics, and Changing Concepts of AIDS in Rural Haiti

In this article I trace the emergence of a collective representation of AIDS in a village in rural Haiti. I initiated investigation of local understand- ings of AIDS years before the advent of the illness to the community itself and continued documenting the subsequent elaboration of a fairly de- tailed and widely shared cultural model of the new disorder. Through following serial interviews with the same persons over a period of six years, one can discern the rate at which consensus was achieved, the events which led to it, and the sign8cance of preexisting interpretive frameworks for current understandings of AIDS. This case contributes to the anthropological study of cultural meaning in formation and transfor- mation.

IDS presents new challenges to medical anthropology. Some are theoret- ical and not substantially different from the challenges faced by other eth- A nographers who seek to study, comprehend, and describe new phenom-

ena. Others involve the ethical dilemmas inherent in both the study of a terrible new affliction for which there is only limited therapeutic recourse and the deeply vexed question of how anthropologists might best contribute to the effort to pre- vent transmission of HIV. What follows is a processual ethnography of the advent of AIDS in Do Kay, a small village in Haiti’s central plateau. It is primarily a descriptive exercise, and the theoretical questions posed relate to the description of a new illness. Its chief goal is to call attention to the problems inherent in study- ing cultural meaning while it is taking shape.

The need for a more processual approach to the study of illness representa- tions is most dramatically illustrated when one is witness to the advent of a new disorder or one previously unknown to one’s host community. Some of the steps in this process of growing awareness are easily intuited. Before the anival of the new malady there exists no collective representation of the disorder; then comes a period of exposure, if not to the illness, then to rumor of it. With time and ex- perience, low interinformant agreement may give way to a cultural model shared by the majority of a community.’ What determines whether or not consensus is

6

CHANGING CONCEITS OF AIDS IN RURAL HAITI I

reached? In studies of illness representations, medical anthropologists have usu- ally asked, “To what degree is the model shared?” But when studying a truly novel disorder, a new set of questions pertains. How does cultural consensus emerge? How do illness representations, and the realities they organize and

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