More primary care, more cultural sensitivity needed to reduce disparities

The 17-year-old girl from Mexico is ill with AIDS. She works to provide for her mother and brothers as well as finish high school and deal with her illness. And she struggles to find help.

As the program director of community health program Project Vida, meaning “Life” in Spanish, Olivia Sanchez sees a lot of misery while trying to help patients of all ages with HIV-AIDS and a host of other illnesses.

While mentoring the young woman, Sanchez campaigns to reduce health disparities among the Latino minority in Chicago.

She said many barriers involving language, poverty, immigration and cultural customs hinder equal opportunities, especially when it comes to health care in the U.S..

In order to bridge the gap between ethnic diversity and the care of patients, doctors and hospitals have begun experimenting with cultural competency education for their staffs.

Cultural competency is “a self-awareness of the biases that you may have and an openness to learning more about the perspectives of others, and having the skills to elicit the appropriate, necessary information from the [patient],” said Carla Green, director of Chicago Metro Area Health Education Center.

The center, which is a federally funded institution, works to educate the health community about cultural competency.

Many of its programs, such as SEARCH, place medical students and residents in community health centers to better enable them to engage with patients who have different beliefs and traditions. This helps the students learn how to work with patient in a way that respects those beliefs but is still in the best interest of the patient’s health.

“In terms of medical care, we think of it in terms of provider/patient relationship, really giving [medical students] the skills to go through a process of self-awareness to realize that some of your actions, some of the words you’re using may be facilitating or hindering the care for the patient,” Green said.

Cultural clashes: minorities and health care by the numbers

With illnesses such as HIV/AIDS and diabetes on the rise among minority groups, patients as well as doctors must learn to overcome cultural barriers.

A sense of shame and of social stigma deters many members of the African-American community from undergoing testing and beginning early treatment of HIV, according to the Centers for Disease Control and Prevention. A lack of information also increases the spreading of the disease and HIV/AIDS has become one of the leading causes of death among blacks.

Some 54 percent of patients newly diagnosed with HIV/AIDS in 2005 were African-American, followed by 29 percent of whites and 15 percent of Latinos, according to the Illinois Department of Public Health.

Considering the fact that African-Americans only represent about 12 percent of the population of Illinois and Hispanics account for 15 percent, the number of minorities with HIV/AIDS is very high.

Difficulties with communication between patients and medical caregivers is exacerbated by the fact that immigrants often do not speak English. Almost 20 percent of the population over five years of age in Illinois does not speak English as a first language and about 9 percent is not fluent in English, according to the U.S. Census Bureau,.

As a result, Green said it is even more important for medical schools to focus on creating as diverse a class as possible. Part of his work is to counteract the effects of an ethnically homogeneous medical community.

“What we have done is look into the literature that is out there,” Green said. “There are current shortages and projected shortages in the health professions" overall and a lack of minorities in the health professions.

The 2008-09 class at Northwestern University's Feinberg School of Medicine has 192 students, with two African-American, 10 Hispanics and one Native American. Twelve of the students have chosen not to disclose their ethnic background.

Language translation services, however, are offered at most major Chicago area hospitals and health centers, including Northwestern Memorial, University of Illinois at Chicago Medical Center and Sinai Health Systems.

When alternative healing meets Western medicine

Cultural competency does not only embrace ethnic barriers such as language and legal status, but it must also deal with the cultural background of patients who seek treatment in the U.S.

The Rev. Terri Buffalo is an elder minister at the Buffalo Star American-Indian spiritual center in Chicago. She said her alternative forms of healing differ from Western medicine in that they address the patient as a whole.

“In our belief, we see that people have illness or disease on many levels, especially on the emotional, physical and spiritual level,” she said. “We don’t treat anything singularly.”

Though many people come to the center as a last resort after all other treatment has failed, she said her community cooperates with mainstream medicine and hospitals have often been accommodating.

“It is important that the [hospital] staff is understanding of what we are doing as a group when we get together to support someone who isn’t well,” she said. “We also pray for the caretakers in the hospital who often go through a lot of trauma.”

Many physicians have been helpful, Buffalo said. But cultural barriers are still present in everyday life. “I’ve done funeral ceremonies where the funeral director had never seen a traditional ceremony,” she said. “There was a lot of staring.”

Other forms of cultural medicine, such as 2000-year-old Chinese practices, struggle for a place within the culture of Western medicine as well.

Elizabeth Heinz, who has a degree in Oriental Medicine and works at “Well Spring: Acupuncture and Chinese Herbology” in Evanston, said Chinese medicine also gives a holistic approach toward curing the patient.

“A patient comes in and the diagnosis lasts about an hour,” she said. “You talk about the problem and also about everything else, like how do you sleep and do you get headaches. We get a good picture about what’s going on because everything hangs together.”

Heinz said the most effective treatments derive from a combined use of Chinese medicine and Western medicine. She said that in China the two healing methods can be found in the same facility and the patients are directed to one or the other according to their needs.

This is where cultural competency can tap into the best of both worlds. But, though acupuncture and herbal remedies appear to be increasingly accepted by physicians and patients as valid treatments, Heinz said some cultural differences are still difficult to overcome.

She said she once met a Vietnamese woman who warded off the first symptoms of illnesses in her children by rubbing the back of their necks with a spoon.

The procedure is painless and is a Vietnamese method used to free the body of negative energy. But when the children talked about the treatment at school, the teachers at school were quite suspicious, Heinz said.

The development of cultural competency

The path toward cultural competency is moving ahead with many medical and nursing schools investing in programs to raise student awareness.

The Chicago Metro Area Health Education Center offers financial aid for medical students to encourage them to work in medically underserved areas, where the patient-to-physician ratio is particularly high. Other programs include offering grants to medical schools to educate students about cultural competency. Cultural competency training becomes particularly important in these situations.

Cultural competency can work in the other direction as well. One of our programs is geared towards recent immigrants for whom English is not their primary language, Green said. “This program helps them understand the U.S. health care system and understanding their rights within that system: rights to an interpreter, questions they should have prepared and knowing the different roles" of hospital staff.

Dr. Bechara Choucair is the medical and executive director of Heartland International Health Center, which offers s services to immigrants and refugees in the Uptown area. He said his facility provides mandatory classes for staff members to learn how to work with immigrants and refugees to ensure the best possible health care.

The goal of the program is to make the patients feel comfortable and respected, according to Choucair, who recently opened another health center in Rogers Park.

Choucair said the centers also have a doula program, where women who were once midwives in their hometowns in Africa are allowed to assist during prenatal and labor programs.

Choucair, who speaks English, Spanish, French and Arabic, said he tries to choose staff members from a variety of cultural backgrounds.

Most doctors as well as patients realize the importance of implementing cultural competency programs.

“I do think the climate has definitely changed over the past 10 to 20 years in that regard,” Green said. “Professional schools are embracing a more holistic aspect of physician training, helping professionals to have better communication skills and bedside manner.”

Buffalo said people appear to be more open toward different cultural realities.

“I think most people want to understand the world in new and deep ways,” she said. “That tends to build on itself.”
Regarding correct approaches toward healing and medicine, she said the important part is achieving the best result respecting different cultures and beliefs.

“We try not to get into an ‘either/or’ situation,” she said. “There are many ways to get to the top of the mountain.”