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Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Cultural Aspects of Health Cultural Aspects of Health Disparities in the United Disparities in the United
StatesStatesWenda TrevathanWenda Trevathan
Professor of AnthropologyProfessor of Anthropology
New Mexico State UniversityNew Mexico State University
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
National Institutes of Health National Institutes of Health statement about health statement about health
disparitiesdisparities“Despite notable improvements in the overall
health of the Nation in the last two decades, there continue to be striking disparities in the burden of illness and death experienced by African Americans, Hispanics, and Native Americans. Overcoming such persistent and perplexing health disparities and promoting health for all Americans, particularly those who have suffered most, ranks as one of our Nation’s foremost challenges.”
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Health Disparities: Health Disparities: DefinitionDefinition
Differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health Example areas of health disparities in the United Statesdisparities in the United States
• Infant mortality
• Cancer screening and management
• Cardiovascular disease
• Diabetes
• HIV infection/AIDS
• Maternal Mortality
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example: Infant Mortality in Example: Infant Mortality in in the US in the US (2000)(2000)
African Americans
14.0%
Whites 5.7%
All 6.9%
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Infant mortality in New Mexico Infant mortality in New Mexico and Texas and Texas (1999-2001)(1999-2001)
0
2
4
6
8
10
12
Rate per 100,000
Non-Hisp Hispanic Af Am Native Am
New Mexico
Texas
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health Example areas of health disparities in the United Statesdisparities in the United States
• Infant mortality
• Cancer screening and management
• Cardiovascular disease
• Diabetes
• HIV infection/AIDS
• Maternal Mortality
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Overall Cancer Deaths Overall Cancer Deaths (1998)(1998)
0
50
100
150
200
250
300
Rate per 100,000
Non Hisp Hisp Af Am
Death Rate
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Selected Cancer Mortality Rates Selected Cancer Mortality Rates (US, 1998)(US, 1998)
0
10
20
30
40
50
60
70
Rate per 100,000
Lung Breast Cervical Colorectal
Hispanic
White
Af Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Colorectal Cancer Colorectal Cancer Screening Screening
(U.S. Adults over 50, 1998)(U.S. Adults over 50, 1998)
PopulationFecal Occult
Blood Test (%)Sigmoidoscopy
(%)
Hispanic or Latino
23 27
African American
30 32
White 36 39
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Colorectal Cancer ScreeningColorectal Cancer Screening (Adults over 50,1998)(Adults over 50,1998)
PopulationFecal Occult
Blood Test (%)Sigmoidoscopy
(%)
Less than High School
26 29
High School 34 35
Some College 41 44
Poor 23 28
Near Poor 31 31
Mid/High Income 39 43
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Breast and Cervical Breast and Cervical Cancer Deaths Cancer Deaths (Women; 1998)(Women; 1998)
0
5
10
15
20
25
30
35
40
Rate per 100,000
Hispanic NonHispanic
Af Am White
Breast
Cervical
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Death Rates for Malignant Death Rates for Malignant Neoplasm of BreastNeoplasm of Breast
0
5
10
15
20
25
30
35
40
Rate per 100,000
1950 1960 1970 1980 1990 1995 2000 2001
Non Hisp
Hisp
Af Am
Nat Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Female Death Rates: Female Death Rates: Trachea, Bronchus, LungTrachea, Bronchus, Lung
(1950-2001)(1950-2001)
0
5
10
15
20
25
30
35
40
45
Rate per 100,000
1950 1960 1970 1980 1990 1995 2000 2001
Non Hisp
Hisp
Af Am
Nat Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Male Death Rates:Male Death Rates: Trachea, Bronchus, Lung Trachea, Bronchus, Lung
( (1950-2001)1950-2001)
0
20
40
60
80
100
120
140
Rate per 100,000
1950 1960 1970 1980 1990 1995 2000 2001
Non Hisp
Hisp
Af Am
Nat Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Lung Cancer Deaths Lung Cancer Deaths (1998)(1998)
0
10
20
30
40
50
60
70
Rate per 100,000
Hispanic Non Hispanic Af Am White
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Annual age-adjusted mortality Annual age-adjusted mortality rates for colorectal cancer deathsrates for colorectal cancer deaths
((1996–2003)1996–2003)
0
5
10
15
20
25
30
Rate per 100,000
NewMexico
National
Overall
Non Hisp
Hisp
Af Am
Nat Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Annual age-adjusted mortality Annual age-adjusted mortality rates for prostate cancer deathsrates for prostate cancer deaths
(Men; 1996–2000)(Men; 1996–2000)
0
10
20
30
40
50
60
70
80
Rate per 100,000
NewMexico
National
Overall
Non Hisp
Hisp
Af Am
Nat Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health Example areas of health disparities in the United Statesdisparities in the United States
• Infant mortality
• Cancer screening and management
• Cardiovascular disease
• Diabetes
• HIV infection/AIDS
• Maternal Mortality
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Populations at Risk for Populations at Risk for Cardiovascular DiseaseCardiovascular Disease
African American– Higher rates of hypertension– Development of hypertension at an
earlier age– Less likely to seek and undergo treatment
35% of African American men ages 20-74 had hypertension compared with 25% of all men in US sample.
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health Example areas of health disparities in the United Statesdisparities in the United States
• Infant mortality
• Cancer screening and management
• Cardiovascular disease
• Diabetes
• HIV infection/aids
• Maternal Mortality
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example Diabetes Rates in Example Diabetes Rates in Selected US Populations Selected US Populations
(Females), 1998(Females), 1998 %
• US “white” (non-Hispanic) 7.8• US Hispanic 10.6• US “black” 10.8• Indian Health Service (all) 8.0• Navajo 8.8• Phoenix 11.6• Tucson 12.8• Native Americans (all) 12.2• Arizona Pima (ages 30-64) 50.0• Arizona Pima (all ages) 38.2 • Mexican Pima 6.4• Great Britain 2.0
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health Example areas of health disparities in the United Statesdisparities in the United States
• Infant mortality
• Cancer screening and management
• Cardiovascular disease
• Diabetes
• HIV infection/AIDS
• Maternal Mortality
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
HIV Death Rates HIV Death Rates (Males; 2001)(Males; 2001)
0
5
10
15
20
25
30
35
40
Rate per 100,000
Non Hisp Hisp Af Am
Death Rate
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health Example areas of health disparities in the United Statesdisparities in the United States
• Infant mortality
• Cancer screening and management
• Cardiovascular disease
• Diabetes
• HIV infection/AIDS
• Maternal mortality
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Maternal deaths due to Maternal deaths due to complications of pregnancy complications of pregnancy
(2001)(2001)
0
5
10
15
20
25
Rate per 100,000
Non Hisp Hisp Af Am
Death Rate
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Why do these disparities exist?Why do these disparities exist?
• Education
• Socioeconomic factors
• Obesity rates
• Diet
• Annual health exams, screenings
• Smoking, alcohol consumption
• Physical activity levels
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Cervical Cancer Deaths Cervical Cancer Deaths (Women; 1998)(Women; 1998)
01
2
3
4
5
6
78
Rate per 100,000
Less thanHigh
School
HighSchool
SomeCollege
Cervical Cancer
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Colorectal Cancer Screening Colorectal Cancer Screening (Adults over 50, per 100,000; 1998)(Adults over 50, per 100,000; 1998)
Characteristic Fecal Occult
Blood Test
Sigmoidoscopy
Less than HS 26 29
High School 34 35
Some College 41 44
Poor 23 28
Near poor 31 31
Mid/High income 39 43
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Percent ObesePercent ObeseAges 20-74; 1999-2000Ages 20-74; 1999-2000
(BMI >29)(BMI >29)
0
10
20
30
40
50
60
Rate per 100,000
Non-Hisp Hispanic Af Am
Males
Females
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Ancestral DietsAncestral Diets
• Great variety of nutrients• Low fat• High protein• Complex carbohydrates• Few nutritional deficiency diseases• High cholesterol• High fiber, calcium, vitamin C• Low sodium
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Adult cigarette smoking Adult cigarette smoking (U.S. 1999-2001)(U.S. 1999-2001)
0
5
10
15
20
25
30
35
Rate per 100,000
Non-Hisp Hispanic Af Am Native Am
Males
Females
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
More Common Explanations More Common Explanations for Disparitiesfor Disparities
• Insurance gap, access to health care• Language and communication problems (e.g.,
cultural variation in how pain is expressed)• Ethnic/racial concordance or discordance
between practitioners and patients, racial and ethnic discrimination
• Hierarchies of choice in health-care seeking• Cultural beliefs and values
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Thoughts from Classical Thoughts from Classical Medical AnthropologyMedical Anthropology
• Cultural relativism
• Emic and etic explanations
• Proximal and distal causes of illness
• Illness compared with disease
• Holism
• Comparative perspective
• Explanatory models
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Culture: A Powerful Culture: A Powerful Explanatory ModelExplanatory Model
• Affects how ethnicity, gender, ages and Socioeconomic Status are perceived
• Complex and ever-changing• Defies labeling, does not correspond
easily to other categories• Individuals have multiple cultural
“templates” and they use them in different situations
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Explanatory Models of Explanatory Models of Hypertension among AfricanHypertension among African
American WomenAmerican Womenhigh blood: blood becomes too hot due
to diet, heat, heredity – seek treatments that cool the blood (primarily dietary)
high-pertension – caused by stress – seek treatments that reduce stress
Women who hold these beliefs less likely to comply with clinical recommendations.
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example behaviors that may be Example behaviors that may be encountered when working with encountered when working with adherents of the hot-cold theoryadherents of the hot-cold theoryDiseases and treatments are seen as hot or cold
If penicillin (hot) is prescribed, patient will stop taking it if diarrhea (hot) develops.
• A pregnant woman is in a hot state, so she will not take hot foods or medicines (including iron tablets and most vitamins).
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Recommendations to health Recommendations to health care professionalscare professionals
• Listen to the patient’s perception of the problem.
• Explain your perception of the problem• Acknowledge and discuss the differences and
similarities.• Recommend treatment.• Negotiate agreement about treatment.
Berlin and Fowkes, Western Journal of Medicine
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Views of Alternative Views of Alternative TreatmentsTreatments
• Effective: encourage use.– e.g.: chamomile tea for sleep and relaxation
• No effect, neutral: leave alone– e.g. breaking an egg on a child’s stomach to treat
susto
• Potentially dangerous: encourage disuse– e.g.: lead-based remedies for treating empacho
in Mexican-origin populations.
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
RecommendationsRecommendations
• Referral (e.g., patient referred to a curandera for susto)
• Work with the patient (e.g., help the patient “build up blood” before a surgery)
• Problems could ensue if the patient’s beliefs are dismissed or disregarded (nocebo phenomenon)
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
The Nocebo PhenomenonThe Nocebo Phenomenon
The process by which negative expectations result in negative effects.
Communication about conditions may not only describe them, but foster sickness by creating expectations.
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Thoughts from Medical Thoughts from Medical AnthropologyAnthropology
“Many…have incorrectly attributed regional disparities in health to local sociocultural differences without examining the influence of global political-economic inequality on the distribution of disease.”
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
More Thoughts from Medical More Thoughts from Medical AnthropologyAnthropology
1992 Institute of Medicine report on emerging infectious diseases did not list poverty or inequality among it “causes of emergence.”
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
More Thoughts from Medical More Thoughts from Medical AnthropologyAnthropology
A 1995 study of TB among immigrant populations concluded “The major determinants of risk in the foreign-born populations were the region of the world from which the person emigrated and the number of years in the United States.
(no mention of poverty or inequality)
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
More Thoughts from Medical Anthropology
1994 (15 years into the pandemic): the first published research in a major medical journal that considered the impact of SES on AIDS mortality (in Lancet).
Editorial: “We are not aware of other investigators who have considered the influence of socioeconomic status on mortality in HIV-infected individuals.”
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
More Thoughts from Medical More Thoughts from Medical AnthropologyAnthropology
“We live in a world where infections pass easily across borders – social and geographic – while resources, including cumulative scientific knowledge, are blocked at customs.”
Paul Farmer, “Social Inequalities and Emerging Infectious Diseases”
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