>Perhaps one of the reasons for the disparities in American Health Care is that this is a nation of all nationalities and ethnic backgrounds. When people come to America the first thing they should do is learn English. Failure to do so has created huge communication walls that often are looked at by outsiders as failures in the American health care system, when all they are is failures of our immigration system in that people were not told or taught that they needed to learn to speak English and, thus, have held onto their old languages.
English speaking skills should become one of the requirements to get into the country on a visa, not just to become a citizen. Our immigration people have failed badly in this important area, at the detriment of those fleeing, or coming, to America.
One of the biggest areas of concern for this today is the Latino populations that have swarmed into California, Arizona, and Texas from Mexico and below, mostly illegally. Greater understanding of the entire problem is not the goal of the article below, but how our system seems to let down those in need the most, the ones who cannot communicate. Don White
Healing the Health Care Wounds
by Manny Frishberg, ColorsNW 4/20/2009
Last week, the ColorsNW article Not All Health Care is Created Equal examined the overwhelming ethnic disparities in the American health care systems. This week, we will explore some of the ways the health care community is combating these disparities to bring balance to the U.S. health system.
At times, those who are working to fix the disparities in the American health care system may feel like they are tilting at windmills. The problem has so many faces and there are no one-size-fits-all answers. While teasing out the reasons for health disparities among ethnic groups is complex, finding the solutions to fix the problems may be an even more intractable issue.
To be sure, the problem of unequal health care in America is daunting. For example, African American children are more likely than White children of comparable economic conditions to have asthma, seek help from the emergency room and receive the latest asthma treatments. And, pharmacies in poorer neighborhoods are less likely to stock the variety and amounts of pain medications needed, which often leads the residents – whatever their race – to live with chronic pain.
Facts such as these highlight the critical need for further research into the reasons and remedies for these disparities. For the moment, at least, the problem seems to be getting the attention it deserves. One aspect of this is finding ways to improve the U.S. health care delivery system, which consists of the combined network of doctor offices, hospitals and clinics that people visit for their health care. How, when and where this care is accessed depends on a range of factors, from insurance coverage to how well the center’s staff communicates with its patients.
Improving Cultural Competency
Too often, health care providers do not understand the cultural, social, psychological, racial and religious influences on a patient’s behaviors. For example, a Muslim patient may refuse to take medicine delivered via gel caps because gelatin is a pork by-product, a food that is against the Muslim religion. Because of the cultural barriers, many health care providers are likely to view this patient as being uncooperative. Indigenous beliefs and remedies may also play a large role in which treatments a patient decides to accept.
“Many health care disparities are due to a lack of cultural awareness on the part of
doctors and nurses,” explains Michael Soon Lee, the author of Cross-Cultural Selling for Dummies and a new American Medical Association book on cultural competence for doctors. “They may not understand how cultures differentiate between disease and illness, folk remedies versus American cures, individual versus group decision-making, how to interview multicultural patients, nonverbal communication cues, end and beginning of life issues and so much more.”
As a result, medical professionals must receive adequate training to understand how to overcome these barriers. There also needs to be a concerted effort to address issues of provider bias. Whether intentional or not, doctors, on the whole, are less likely to discuss healthy behavior changes with patients from lower income groups.
Additionally, health professionals need to learn more about which communities are more susceptible to particular diseases and what the beliefs are surrounding these diseases. Jeff Caballero, executive director of the Association of Asian Pacific Community Health Organizations, cites Hepatitis B as a good example. Because the infection is passed by blood to blood contact, it is classed as a sexually transmitted disease, even though childbirth is the primary method of transmission. While Hep B can be prevented with a vaccine, in the API communities there is a strong taboo against discussing sex openly. Additionally, the treatment requires three doses, a
large barrier for many patients who are unable to return to the doctor. Cabellero explains “clinics that are more proficient in terms of care providers working with those communities may be able to provide just one vaccination. These [health centers also] have higher rates of completion of all three shots.”
Those most severely affected by the virus are recent immigrants from China, Vietnam, Korea, the Philippines and the Marshall Islands who are, according to Cabellero, “either a limited-English proficient individual or someone from a culture who is just not really familiar enough or sophisticated enough to navigate the health care system here in the country.” “Even if they say, ‘I treat all my patients the same,’ that’s not necessarily a good thing because all your patients are not the same,” says Diane Giese, director of communication and development for the Puget Sound Health Alliance, one organization around the nation funded by the Robert Wood Johnson Foundation (RWJF) to look at the different pieces of the health disparity puzzle.
“But, there are so many facets to this and so many angles, where do you start?” she asks. “The RWJ funding is allowing us to work on a program to answer that question, too.”
A Multi-Faceted Attack
While some progress has been made – such as federal mandates that hospitals must
provide culturally and linguistically appropriate care – actually getting to the point where the disparities in health care are at last eliminated requires attacking the problem on several fronts at the same time. Delivering culturally-appropriate treatments, developing individual disease prevention and health promotion messages, as well as providing care in a language the patient understands is crucial. Reforms also need to be made to social policies, health care worker education and how research is conducted so that more ethnic groups, people of both sexes and different age groups are represented in the final data.
One important aspect of the issue is increasing workforce diversity, which is well
documented in the hundreds of studies on health disparities published in the medical literature every year. “The cadre of people who provides health care needs to become more diverse, so that doctors and nurses looks more like the increasingly multicultural populations they are treating,” Giese says.
Giese says one part of what her group is looking into who is getting good care and where they are finding it. “We do these performance reports comparing the quality of care provided in doctor offices and hospitals. There’s all sorts of national data and observations, but we’re saying, ‘Okay, how’s it working in the Puget Sound area?’ What’s happening locally?” she explains. “How does it work for people in South Seattle, for people in Highpoint, in Sultan in Snohomish County, in eastern Pierce County? How do we build the foundation of actually changing things in the local area?”
The ways to achieve this goal are far from obvious. While projections estimate more than half the country’s population will be people of color by the middle of this century, attendance at medical schools and nursing programs has hardly changed during the past 30 years. Latinos are now more than 13 percent of the population, yet they account for less than one in 25 doctors currently practicing medicine. And, in the 2003-04 school year, they made up just 7 percent of first-year medical students and less than 6 percent of graduates. The numbers are similarly dreadful for African-Americans and even worse for Native-American med students.
One contributing factor to this situation is the legal climate during the past eight years as the appointment of judges to the federal bench who are skeptical of affirmative action policies has increased. Between 1995 and 2001, there were dramatic decreases in medical school enrollment by students of color in states where court challenges or initiatives like Washington’s I-200 have succeeded. In Mississippi alone, the number declined by more than two-thirds.
Learning from the experience of medical facilities that have been able to show some real improvements in those areas, such as Childrens Hospital in Seattle, has been a real help, she says. “Children’s Hospital has been in this cultural competency and literacy program. We are trying to really understand what it is they did to change the culture of care in terms of, well everything, from how the staff interacts with patients to what support tools they use.
We can turn around and work with other providers in the community, whether or not they’re in the heart of a diverse population.” How people receive information about health and medicine is another crucial aspect. There is a somewhat naïve belief that with the explosion of information on the Internet, that part of the problem might take care of itself. Instead, communities of color and poor people in general have found themselves on the wrong side of the digital divide. The National Cancer Institute’s Digital Divide Project is one of several programs looking at ways to help underserved populations find and use health information so they can make
Other issues beyond the scope of the health care system are also waiting to be addressed. Those include the fact that people of color, especially new immigrant groups, are concentrated in hazardous jobs have high rates of workplace injuries, such as meat packing and construction, or jobs that require long hours of heavy lifting, such as waiting tables and home health care.
Low-income communities also often have the dirtiest environments because they lack the political clout to avoid having polluting projects, such as garbage incinerators, located nearby. A large proportion of people subjected to these disparities are ethnic minorities. Some studies have suggested that cancer risks associated with toxins in the air were highest in more segregated metropolitan areas. The key to improving the health care of the various ethnic populations is any effort that maintains and improves the health of the nation as a whole. That means finding and implementing effective strategies to reduce and eliminate the health disparities that continue to plague us today. Until the problems of poverty and racism are finally put to rest, the fight against health disparities is not likely to be won.