Reply to the Latino Paradox

I wanted to comment on the wonderful post by an unidentified person... the post on Feb 22, with the video and news article. I finally got around to reading those! Anyhow, I found the short film clip really interesting. The fact that the most socially marginalized of the population is the healthiest--even healthier than the wealthiest segment of the population--is rather astounding. If you think about it, however, I suppose it's not too surprising: as Dr. Grover mentioned, the Latino community has an extremely strong support network, a religious regard for the body, and (the first generation immigrants) have an extremely high work ethic. These people undergo physically strenuous labor for many hours of the week--probably more laborious than any of the likely sedentary jobs that we will have--and also haven't completely adopted the Big Macs and fries that seem to be so integral to American culture. If there was just a way to help maintain this work ethic, this pride, and this diet...! I suppose I'll mull over this a bit in the couple of weeks that we have until the ASB (and indefinitely after that too...).

Follow-up on Edgardo's post about "The Spirit Catches You"

While I have not read "The Spirit Catches You and You Fall Down" by Anne Fadiman, I thought Edgardo introduced several issues which have been recurring throughout our ASB course.
First, there is the dual nature of the doctor. The medical profession has constructed a subculture with its own esoteric medical jargon which unfortunately seems to exclude patients from grasping the treatments that they are receiving as well as the cause of their symptoms. Many of the problems that I feel come up with cultural competency involve a disconnect between "western medicine" and a patient's native cultural values or beliefs. I do not think that the clash between the two needs to be a zero-sum game with one triumphing over the other. As we read earlier (in Dr. Glover's article? I don't remember exactly), many times compliance might be enhanced if doctors encouraged patients to engage in their herbal or homeopathic remedies in addition to what we consider "medically sound" treatments. If anything a patient might begin to feel better sooner via the placebo effect. Cultural competence is and will only become more important in the coming decade as minorities comprise a larger portion of the population. Medical schools should stress cultural competence and bilingualism as tools for better serving patients, and as Edgardo put it, to reveal the "humanity" of doctors.
Second, there is the role of government in assuring proper care for patients. While I believe the government should ensure access and affordability of health care for all, I believe there are certain lines which the government should be wary of crossing. The case of Teri Schiavo certainly comes to mind, but Lia, one of the characters in the novel seems to also fit this mold. At what point does the government become too controlling of individuals' ability to make personal decisions? Although I certainly agree that cultural health remedies which exacerbate conditions or are dangerous should be frowned upon, individuals have the right to express themselves. The issue of minors and adolescents is particularly tricky. I'm not sure if removing a child from the care of his/her parents simply because the parents aren't agreeing with the child's doctors is in the best interest of the child. No parents (or at least most parents) would not knowingly make decisions that would farm their child. It is at this point that education and cultural competence play such a large role. Are the parents making an informed decision based on all the facts? Do they know the risks of choosing to not accept "western" care? The doctors and legal experts must do their best to inform individuals and caretakers, but in my opinion should not overstep their bounds.

The Spirit Catches You and You Fall Down

The Spirit Catches You and You Fall Down

After our discussion about traditional remedies and the role of religion in patient health, I thought of The Spirit Catches You and You Fall Down, as a too good of an example to let pass. First the book tells the story of Lia, a Hmong infant diagnosed with epilepsy. The collision of Lia's Hmong culture and her doctors Western biomedicine culture leads to Lia being placed under medical foster care after her parents do not comply with the doctor's requests.

At the center of the book, there are many issues. First, is the role of religious traditions and if it applies to a minor. Lia's parents did not want to comply with some of the western medicine because they preferred to try their cultural remedies first, saying they needed to restore her spirit.Plus in the Hmong culture, children with epilepsy are seen as sacred beings. The problem was deciding if religious beliefs applied to a minor, especially if that minor is not old enough to state their position. How do we know that the minor will adhere to the cultural and religious beliefs? This was a problem that the doctors faced. They were interested in the health of Lia but her parents opposed the western biomedicine approach. Currently in California, the law grants the freedom for parents to practice spiritual treatment for a child through prayer as along as it is in accordance with an accredited practitioner and it cannot allow to continue or cause any serious physical harm. If the spiritual treatment cannot be applied successfully with satisfying results and the parents refuse any other medical treatment, the law gives doctors the right to intervene and place the minor under medical foster care. The state acts in the welfare of the child because the minor is the most vulnerable since the child cannot define their religious stance.

Another issue, was the lack of a cultural barterer between the American doctors and the Hmong parents. The doctors, even though they had the best intentions were not educated to the customs of the Hmong culture. Anne Fadiman, the author, writes "Neil and Peggy were dimly aware of some of these remedies( or example when Lia had marks on her chest from coin rubbing), but they never asked them about them and they certainly never recommended them." The need of a cultural barterer was very much needed to build comprehension between the two cultures. In the book, Fadiman interviews Arthur Kleinman who suggests a return to a whole doctor. Doctors should not only concentrate on the science of their art but also on the humanity. It is essential for doctors to know more about their patients because it is the only way to offer optimal care.

Another response to "On Racial Profiling" - Anand

Like Tara, I too, am going to give my take on the article "On Racial Profiling" by Sally Satel. This is a really thought-provoking article, especially for those considering a career in the health professions. It caused me to reevaluate my own perspective on the role of race in medicine.

While I am in no way an advocate of racial profiling in the strictest sense (I am ardently against it), I believe that including race in any patient's history/physical as part of making an educated diagnosis is critical. Based on the article I think it's rather clear that race isn't being used as the only factor in diagnoses. Doctors still take into account the symptoms presented by patients (proximate causes) and couple these symptoms with overarching correlates - like race, gender, ethnicity. Nobody (or very few at that) is saying that because of a person's race he/she has certain conditions. The science available to say that is speculative at best. Empirical evidence, however, does show that certain conditions do cluster and occur more frequently among certain populations - i.e. sickle cell anemia in African Americans, Tay-Sachs in Ashkenazi Jews - and thus one could make an educated argument establishing a strong correlation between conditions (many of which have a genetic component) and a person's race.

As Tara points out, to adopt a race-blind or gender-blind approach would be ill-conceived. Doctors are looking for all available puzzle pieces, and if race happens to narrow down the number of possible diagnoses and thus means the patient is subject to fewer unnecessary tests then I believe that race-consciousness is beneficial in medicine. Dr. Satel and others like her are not saying that a person's race should affect the quality of care that doctors afford to their patients; rather she is contending that race may play a role in the effectiveness of certain treatments.

"Racial profiling" in the context of medicine does not imply the creation of two-classes of patients - one receiving better care than the care - it simply points towards more specialized medicine. To understand this better, consider: If a doctor sees an African American patient with heart problems and is choosing between prescribing BiDil and Enalapril, wouldn't the doctor be remiss to take into account the preponderance of studies that shows the relative efficacy of BiDil vs. Enalapril (which by the way might lead to serious complications)? I know I would certainly hope my doctor would. Likewise, when it comes to dosing, isn't it wiser for a doctor to begin with a lower dose of anesthetics for an Asian American patient undergoing surgery due to the increased risk of apnea than to be negligetn and ignorant and simply treat the patient like everyone one? While discrimination and prejudice are significant problems throughout society today, we should not blindly shut the door on racial-consciousness especially when it might save a person's life.

By Tara Gu, Fervent "House" Fanatic

I'm going to blog about the Sally Satel article, "I am a Racially Profiling Doctor," because it was a much more interesting article to read than the one we were actually assigned (although, like Amy said, some of the folk remedies in Welch were eclectic enough to raise a few eyebrows and arouse my interest).

Satel begins with a bold statement: "In practicing medicine, I am not colorblind. I always take note of my patient's race. So do many of my colleagues. We do it because certain disease and treatment responses cluster by ethnicity."

To give an example -- "Kassirer, the former editor of The New England Journal of Medicine, is a renowned diagnostician. He is legendary among trainees for what he can tell about a case from just a few facts. He gave an example from a recent morning report, the daily session in which young doctors describe to senior physicians the most vexing cases admitted to the hospital the previous night. During one report, the resident began: "The patient is a 45-year-old Asian male who came to the emergency room complaining of 'feeling weak and wobbly in my legs' after drinking two bottles of beer." Kassirer stopped her right there. "Here's what I infer from that information," he said. "First, we know that sudden weakness can be caused by a low concentration of potassium in the blood, and we know that Asian males have an unusual propensity for a rare condition in which low potassium causes temporary paralysis. We know that these paralytic attacks are sometimes brought on by alcohol." Of course, the patient could have been suffering from some other muscular or neurological disease, and Kassirer instructed the trainees to consider those as well. But in this case the patient's potassium was low, and the diagnosis was correct -- and confirmed within 24 hours by simply observing the patient. Thanks to racial profiling, the Asian patient was spared an uncomfortable and costly work-up -- not to mention the worry that he might have something like Lou Gehrig's disease."

Now before all those PC activists out there get all ants-in-the-pants to make a tirade about racial equality, let's consider the purpose of a physician. A doctor, like a good detective, tries to solve a mystery based on the clues that they can gather from the symptomps of the illness. However, they consider both the obvious physical signs of disease as well as other potential clues by deduction. To me, Dr. Kassirer's diagnosis sounds a lot like those of Dr. Gregory House, who is named after Sherlock Holmes.

What is the difference between using racial data and other factors of a patient, such as his history or genetics? If racial profiling, in this case, is a form of discrimination, then isn't patient history also a form of discrimination? Can we execute any type of "judgment" or dicernment of the illness without discrimination? When we infer that something is caused by one disease, we are discriminating against all other illnesses that could have caused the same symptoms.

We split medical research into women-only and men-only studies because some treatments respond differently to gender. Current research centers on finding more female-friendly approaches to treating heart attacks. Are we now all sexist doctors as well, because we treat men and women differently?

A friend sent me this story about Lloyd Carter, an environmental activist in Fresno. I think it is good information to share, especially since it is occurring in the area we will be visiting. As a quick summary, Lloyd Carter is a the deputy attorney general is being pressured to resign from his post in the California Save Our Streams Council after commenting on farmworker's social position in a local tv interview.

It is reported that Carter said the children of farmworkers "are the least educated people who turn to lives of crime. They go on welfare. They get into drug trafficking and they join gangs."

Farmworkers and other groups are advocating for Carter to resign from his position in the Attorney General's Office in Sacramento. The farm workers have organized themselves to meet with lawmakers. Attorney General has condemned Carter's remarks but has not acted towards any action.

The full story can be read by clicking on this link:
http://www.fresnobee.com/local/story/1191212.html

Plus. found this really cool site titled "Unnatural Causes". It was series on PBS exploring health inequalities in the United States. This video is about the Latino Paradox. I recommend visiting the site it has a lot of information and videos.

Health Care in Shadows

http://www.nytimes.com/2008/05/10/us/10migrant.html?_r=1&ex=1211256000&en=a8a08ef786055855&ei=5070&emc=eta1

 

           

            As already mentioned repeatedly, farmers have one of the most dangerous occupations. At the same time, most of the migrant farmers are working illegally and more importantly, they do not have access to conventional healthcare since they cannot obtain health insurance nor have enough money to go see a doctor. Furthermore, they are anxious to go see a doctor because of the fear that they will be deported from the United States. The traditional healers, curanderas, provide much hope for these farmers who cannot afford conventional healthcare. No matter how absurd these remedies may seem, as long as they provide the placebo effect at the least, they should be continued to be practiced.

 

            Nonetheless, one must note that some of the traditional methods of healing may be harmful. It is extremely important that we inform these curanderas of the detrimental ways of healing. Additionally, we must convince the local doctors to work together with these traditional healers to effectively maintain good health in these farmers.