Multicultural MedicineMulticultural Medicine

Ronald D. Garcia, Ph.D.Ronald D. Garcia, Ph.D.

Assistant Dean for Minority AffairsAssistant Dean for Minority Affairs

Director, Center of ExcellenceDirector, Center of Excellence

Associate Director, PCAPAssociate Director, PCAP

Candles, shark jaws, Buddhas, dried flowers, magic powders, and incinse highlight the merchandise at a botánica, or herbal stall, in Mexico City.

Botánicas are a common sight throughout Latin America, with most of the herbs, potions, and charms intended to help the users improve their health, financial standing, or love life.

Until I was eighty-four I ran three miles a day. In the winter I would run in the snow with only my underwear on.” John Parrish, medicine man, Monument Valley, AZ. 104 years old.

Working in their jet, members of an Orbis mission restore the gift of sight, as part of a three-day stop in Varna, Bulgaria. Orbis doctors and nurses have carried out more than ninety missions in fifty-five countries since the first flight in 1982, with the administrative staff raising the multimillion-dolla`r operating budget

from various international agencies and private sponsors. According to Project Orbis statistics, about two-thirds of the forty-six million cases of blindness worldwide could be surgically treated or prevented.

GoalsGoals

• Examine the role of culture in clinical Examine the role of culture in clinical interactionsinteractions

• Learn about culturally appropriate Learn about culturally appropriate patient care strategiespatient care strategies

• Examine our own culturally-bound blind Examine our own culturally-bound blind spotsspots

Key ThemesKey Themes

• Generalizations promote stereotypesGeneralizations promote stereotypes

• Race and ethnicity are markersRace and ethnicity are markers

• Community-referenced careCommunity-referenced care

• Intra-cultural variationIntra-cultural variation

• Culture impacts health behaviors and Culture impacts health behaviors and attitudesattitudes

• Patient-centered carePatient-centered care

National ContextNational Context

• Population diversityPopulation diversity

• Migration and ImmigrationMigration and Immigration

• Health Professions diversityHealth Professions diversity

• Health Care DisparitiesHealth Care Disparities

U.S. Race/Ethnicity U.S. Race/Ethnicity

Ca. Race/EthnicityCa. Race/Ethnicity

California’s PopulationCalifornia’s Population1995–20201995–2020

51%47% 43% 40% 37% 35%

8%8%

8%8%

8% 8%

1%1%

1%1%

1% 1%

12%14%

16%17%

19% 20%

30% 32% 34% 35% 36%28%

1995 2000 2005 2010 2015 2020

White African American American Indian Asian & Pacific Islander Hispanic

41%37% 33% 30% 26% 24%

9%9%

9%9%

9%9%

13%15%

16%18%

20% 21%

39% 41% 43% 44% 46%

1%1%1%

1%1%

1%

37%

1995 2000 2005 2010 2015 2020

White African American American Indian Asian & Pacific Islander Hispanic

California’s Population 1995–2020 California’s Population 1995–2020 Persons Aged 0-19Persons Aged 0-19

Health Care DisparitiesHealth Care DisparitiesUnequal Treatment, Institute Unequal Treatment, Institute

of Medicine, 2002of Medicine, 2002

• Cardiovascular proceduresCardiovascular procedures

• Cancer careCancer care

• HIV careHIV care

• DiabetesDiabetes

• Renal disease and kidney transplantsRenal disease and kidney transplants

DisparitiesDisparities

• Black infant death rate is 14.2/1,000 compared Black infant death rate is 14.2/1,000 compared to Whites at 6/1,000 (1996).to Whites at 6/1,000 (1996).

• Vietnamese women cervical cancer rate is 47.3 Vietnamese women cervical cancer rate is 47.3 compared to Whites at 8.7/100,000.compared to Whites at 8.7/100,000.

• IHS reports higher death rates: ETOH IHS reports higher death rates: ETOH (321%),TB (220%),Diabetes(139%) compared (321%),TB (220%),Diabetes(139%) compared to U.S. populationto U.S. population

• Latino incidence of TB is (24/100,000 compared Latino incidence of TB is (24/100,000 compared to 17 for Ca.to 17 for Ca.

Cancer Deaths per 100,000 by Cancer Deaths per 100,000 by Race, 1999Race, 1999

CA U.S.

White 186 199

Black 233 254

Source: National Center for Health Statistics, 1999

Rate of Nonelderly Uninsured Rate of Nonelderly Uninsured by Race/Ethnicity, 2001by Race/Ethnicity, 2001

CA. U.S.

White 12% 12%

Black 17% 20%

Hispanic 34% 35%

Source: K aiser Family Foundation Health Facts Online, 2001

Number of Diabetes Deaths per Number of Diabetes Deaths per 100,000 by Race, 1999100,000 by Race, 1999

CA. U.S.

White 21 23

Black 47 50

Other 21 24

Source: National Center for Health Statistics, 1999

%

Whether they are male orfemale

Whether or not they arephysically disabled

Their sexual orientation—thatis, if they are gay or lesbian

What their race or ethnicbackground is

How well educated they are

How well they speak English

How much money they have

Whether or not they haveinsurance

Very Often Somewhat Often Rarely Never

Perception of Disparities in the Health Care SystemPerception of Disparities in the Health Care SystemGenerally speaking, how often do you think our health care system treats people unfairly based on…Generally speaking, how often do you think our health care system treats people unfairly based on…

2%

3%

4%

6%

8%

9%

14%

31%

13%

20%

19%

23%

31%

34%

33%

57%

57%

59%

55%

48%

44%

42%

24%

27%

19%

16%

14%

12%

11%

10%

3%41%

Whether they are male orfemale

Whether or not they arephysically disabled

Their sexual orientation—thatis, if they are gay or lesbian

What their race or ethnicbackground is

How well educated they are

How well they speak English

How much money they have

Whether or not they haveinsurance

Very Often Somewhat Often Rarely Never

Physicians on Disparities in the Health Care SystemPhysicians on Disparities in the Health Care SystemGenerally speaking, how often do you think our health care system treats people unfairly based on…Generally speaking, how often do you think our health care system treats people unfairly based on…

14%

21%

23%

25%

37%

43%

47%

72%

15%

24%

18%

33%

34%

42%

40%

69%

19%

34%

32%

52%

50%

61%

50%

74%

44%

49%

49%

77%

72%

72%

77%

88%

Whether they are male orfemale

Whether or not they arephysically disabled

Their sexual orientation—thatis, if they are gay or lesbian

What their race or ethnicbackground is

How well educated they are

How well they speak English

How much money they have

Whether or not they haveinsurance

White PhysiciansAsian PhysiciansLatino PhysiciansBlack Physicians

Perspectives of Physicians of Different Racial and Ethnic BackgroundsPerspectives of Physicians of Different Racial and Ethnic BackgroundsGenerally speaking, how often do you think our health care system treats people unfairly based on…Generally speaking, how often do you think our health care system treats people unfairly based on…

Percent saying Percent saying “Very/Somewhat Often”“Very/Somewhat Often”

CultureCulture

• Culture refers to integrated patterns of Culture refers to integrated patterns of human behavior that include the human behavior that include the language, thoughts, communications, language, thoughts, communications, actions, customs, beliefs, values and actions, customs, beliefs, values and institutions of racial, ethnic, religious, or institutions of racial, ethnic, religious, or social groups.social groups.

Cultural CompetenceCultural Competence

• Refers to the knowledge, skills, attitudes Refers to the knowledge, skills, attitudes necessary to function effectively within necessary to function effectively within the context of the cultural beliefs, the context of the cultural beliefs, behaviors, and needs presented by behaviors, and needs presented by consumers and their communities.consumers and their communities.

Complementing modern cancer treatments with traditional herbs in China, Dr. Sun Yan prescribes Radix Astragali roots along with the shorter Radix Angelicae Sinensis roots to combat the side effects of chemotherapy. He and his colleagues at the Chinese Academy of Medical Sciences Cancer Institute and Hospital in

Beijing also say that the herbs can strengthen a cancer patient’s immune system.

Knowledge - information Knowledge - information relevant to cultural beliefs and relevant to cultural beliefs and

practicespractices• Race, ethnicity, heritage, cultural biasesRace, ethnicity, heritage, cultural biases

• Historical factors that impact healthHistorical factors that impact health

• Stressors: war, migration, refugee,role loss, Stressors: war, migration, refugee,role loss, acculturationacculturation

• Cultural differences:death,sexuality,child Cultural differences:death,sexuality,child rearing,religion,elderly,pregnancy, birthrearing,religion,elderly,pregnancy, birth

• Family life cycles: gender, age, decisionsFamily life cycles: gender, age, decisions

• Indigenous healers and healing practicesIndigenous healers and healing practices

Home is where the heart is for Mississippi nurse Maureen Raubert, who puts about 100 miles a day on her compact car visiting patients. “I love it,” says Raubert, here with Boyd McCallum and his wife, Gladys. I treat patients in their own environment, and they get very attached to me.” Raubert is one of nearly 200 nurses

who work for South Mississippi Home Health, a private agency credited with pioneering organized home-health services in the late 1960s. The days of house calls may seem like the stuff of nostalgia, but health care providers now say that home visits by trained professionals could play an important role in cutting health care

costs in the years to come.

Skills - verbal and nonverbal Skills - verbal and nonverbal approaches to patient approaches to patient

interactionsinteractions• Recognize culture-bound health problemsRecognize culture-bound health problems

• Respond to verbal and nonverbal cuesRespond to verbal and nonverbal cues

• Effective use of interpretersEffective use of interpreters

• Effective use of community resourcesEffective use of community resources

• Conduct culturally appropriate Hx & PEConduct culturally appropriate Hx & PE

• Negotiate & Convey treatment plansNegotiate & Convey treatment plans

• Access culturally relevant informationAccess culturally relevant information

Combining two Eastern healing arts in a California setting, Dr. Rong Zhou uses moxibustion and acupuncture at Emperor’s College in Santa Monica. By using the acupuncture needle to conduct heat into the body, Zhou doesn’t have to apply the burning moxa stick directly to the skin. The treatment is used for patients who are low in energy or suffer from noninflammatory pain. With 10,000 patients annually, Emperor’s College is the leading treatment center among Eastern

medicine schools in the West.

Attitudes - perceptions of Attitudes - perceptions of others based on race, ethnicity, others based on race, ethnicity,

and cultureand culture• Self awareness and examinationSelf awareness and examination

• Role of religious and spiritual beliefsRole of religious and spiritual beliefs

• Differences in health belief systemsDifferences in health belief systems

• Role of cultural identityRole of cultural identity

• Role of alternative forms of healingRole of alternative forms of healing

• Survival merits of immigrants and Survival merits of immigrants and refugeesrefugees

DiagnosisDiagnosisTreatmentTreatment

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A sangoma and her trainee study a series of objects to diagnose a patient’s illness in the southern African nation of Swaziland. She will use the spear in her right hand to point to the objects, which were thrown onto the mat from a small bag, and may prescribe any number of treatments, ranging from a special bath to the slaughter of a goat. The patient hopes that the objects—a mah-jongg tile, dice, a snail shell, polished stones, seashells, bones, beads, and a domino—face

upward after they’re thrown; objects facing downward are bad omens and may mean death. The horse’s mane in front of the sangoma-in-training is a key weapon in the arsenal of a traditional healer in southern Africa; to ward off evil; the sangoma will dip the mane in liquid and twirl it.

Shrouded in controversy as well as in her protective suit, San Francisco orthopedic surgeon Lorraine Day models the operating room garb that she claims protects her from exposure to the AIDS virus. Twenty-seven U.S. health workers were accidentally infected with the virus in the 1980s, but most medical experts say that

suits like Day’s, which is designed to keep her from breathing aerosolized blood particles, don’t solve the problem—and may contribute to the misconceptions about how AIDS is spread. “It’s very difficult to get infected,” says Dr. Laurens White, a past president of the California Medical Association, “even in the

operating room. And there’s no proof that inhaling infected blood will give you AIDS.”

Explanatory ModelExplanatory Model

• 1. What do you think caused your problem? 1. What do you think caused your problem? (etiology)(etiology)

• 2. Why do you think it started when it did? (onset)2. Why do you think it started when it did? (onset)• 3. What do you think your sickness does to you? 3. What do you think your sickness does to you?

(pathophysiology)(pathophysiology)• 4. How severe is your sickness? (course of illness: 4. How severe is your sickness? (course of illness:

acute,chronic, impairment)acute,chronic, impairment)• 5. What kind of treatment do you expect? 5. What kind of treatment do you expect?

(treatment expectation)(treatment expectation)

Top left: “I never hurt anyone. I was honest and helped charities.” Mollie Silberman, Dallas, TX. 104 years old.

Top right: “I’m too far gone to give advice, kiddo. I drink a lot of water.” Clarence Reed, Bedford, VA. 101 years old.

“I smoke my pipe every day, and until recently I drank sugar cane liquor every day.” Maria Madalena Venanca Da Silva, Belmiro Braga, Brazil. 103 years old.

Using soldier ants to stitch a cut is a tradition in central Africa, where it is still observed but slowly disappearing with the proliferation of hospitals and clinics on the continent. Holding the edges of a cut together, a healer places the ants, of the genus Dorylus, on the wound. Instinctively, the ants bite down and lock their jaws, sealing the cut. The healer then cuts off the thoraxes and tails of the ants, leaving the jaws in place for several days until the flesh is healed.

LEARN-Berlin and FowkesLEARN-Berlin and Fowkes

• LListen to patient’s perceptionisten to patient’s perception

• EExplain your perceptions of problemxplain your perceptions of problem

• AAcknowledge differences & similaritiescknowledge differences & similarities

• RRecommend treatmentecommend treatment

• NNegotiate treatmentegotiate treatment

ETHNIC-Robert LikeETHNIC-Robert Like

• EExplainxplain

• TTreatmentsreatments

• HHealersealers

• NNegotiateegotiate

• IInterventionntervention

• CCollaborateollaborate

ConclusionsConclusions

• Every clinical encounter is cross-culturalEvery clinical encounter is cross-cultural• There is no “one way” to treat groupsThere is no “one way” to treat groups• ““Cookbook” strategies promote stereotypesCookbook” strategies promote stereotypes• Intergenerational differences existIntergenerational differences exist• Respect patient’s explanatory model of illnessRespect patient’s explanatory model of illness• Patient-centered approach is most helpfulPatient-centered approach is most helpful

An Inuit child in the Soviet far north gets a checkup from Dr. Larissa Abrutina, who travels by helicopter from reindeer camp to reindeer camp, carrying simple medical equipment and a small cache of drugs and medicines. In the summer months, she takes a mobile X-ray machine on her rounds.

Behold the lowly leech, once again the doctor’s friend. Bloodsuckers like these, raised by Dr. Roy T. Sawyer and his Biopharm Ltd. In the Welsh village of Hendy, are back in vogue in many American hospitals, where they’re used to drain excess blood after micro-surgical procedures such as the reattachment of severed fingers and ears. In the 1500s, the term “leech” was used to describe all healers; even into the 1800s, the tiny creatures played a major role in medical care as doctors placed dozens at a time on an ill patient, believing that the hungry leeches would suck out only the patient’s “bad blood.” With its rediscovery in the early 1980s by medical

science, the medicinal leech, known more formally as Hirudo medicinalis, has also attracted the attention of bioengineers. The saliva contains an anticoagulant, a local anesthetic, and an antiobiotic, and bioengineers hope to re-create the saliva for use in the treatment of various maladies, including arthritis, glaucoma, embolisms—

even heart attacks and strokes.

Developing new eating habits is a key part of the Pritikin program, so Susan Massaron uses her daily cooking classes to teach participants how to make tasty meals

with only ten percent fat—as opposed to the forty or fifty percent fat that graces most American dinner tables. Here, she shares her recipes for spicy raspberry chicken, fish in lime sauce, brown-and-wild-rice vegetable salad with dill dressing, and banana cake.