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”