Title: ‘’Becoming American” from the California Newsreel Documentary
Series Unnatural Causes: Is Inequality Making Us Sick?1 – A Discussion
Guide for Health Professional Students
Prepared by: Olivia Carter-Pokras PhD, Alexander Fischer, Elizabeth Lee-Rey
MD, Ana E. Núñez, MD; Candace Robertson, MPH
Acknowledgements: The authors gratefully acknowledge funding from the
National Heart Lung and Blood Institute’s Cultural Competence and Health
Disparities Academic Award grant program, as well as comments by dental,
medical, and nursing students at the University of Maryland Baltimore, and public
health students at the University of Maryland College Park.
(For the discussion facilitator)
Session Goals(s):
This small group discussion is intended to acquaint health professional students
with examples of specific health disparities that affect communities in the United
States, bring to their attention the role that social determinants of health play in
these disparities, and foster discussion regarding solutions and action that can
be taken to eliminate these health disparities.
Learning Objectives:
1. Describe the nature, extent, and type of health disparities in the United
States.
2. Describe and assess health disparities experienced by immigrants and
their children.
3. Evaluate social determinants of health and other underlying factors related
to disparities for immigrants and their children.
Session Summary:
This is a 28 minute film segment entitled “Becoming American” from the
California Newsreel documentary series Unnatural Causes: Is inequality making
us sick?, followed by a 30 minute small group discussion to explore examples of
health disparities and pathways by which social conditions affect physiology.
The video explores why recent Mexican immigrants, though poorer, tend to be
healthier than the average American. But the longer they're here, the worse their
relative health becomes even as their socio-economic status improves. This is
known as the "Hispanic/Latino Health Paradox." Is there something about life in
America that is harming their health? Conversely, what is protective about new
immigrant communities that we can learn from? The small group case
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UNNATURAL CAUSES: Is Inequality Making Us Sick? Produced by California
Newsreel with Vital Pictures. Presented by the National Minority Consortia.
www.unnaturalcauses.org; www.newsreel.org
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discussion will be facilitated by medical, health professional, and/or epidemiology
faculty or graduate students. Faculty may wish to use this documentary segment
to supplement curriculum materials on immigrant health, and/or as a case study
for eliciting pertinent social and environmental risk factors in history taking.
Facilitators will have familiarized themselves with material in the video and
readings as well as the provided Unnatural Causes Discussion Toolkit.
Facilitators may also have completed “A Physician’s Practical Guide to Culturally
Competent Care” and/or “Culturally Competent Nursing Care: A Cornerstone of
Caring,” training programs designed for providers to increase cultural
competence through case studies about awareness of racial and ethnic
disparities in health, and through curricula about accommodating increasingly
diverse patient populations and improving the quality of health care services
given to diverse populations (available at: http://www.thinkculturalhealth.org).
Students will be provided the background readings at least one week in advance
of discussion.
Readings:
1. Taningco MTV. Revisiting the Latino Health Paradox. Tomas Rivera Policy
Institute Policy Brief. August 2007. Available at:
http://trpi.org/PDFs/Latino%20Paradox%20Aug%202007%20PDF.pdf
2. Palloni A, Arias E. Paradox lost: explaining the Hispanic adult mortality
advantage. Demography 2004;41(3):385-415.
3. Gushulak BD, MacPherson DW. The basic principles of migration health:
population mobility and gaps in disease prevalence. Emerging Themes in
Epidemiology 2006;3:3 doi:10.1186/1742-7622-3-3.
4. Viruell-Fuentes EA. Beyond acculturation: Immigration, discrimination,
and health research among Mexicans in the United States. Social Science
& Medicine. 2007; 65, 1524-1535.
5. Carter-Pokras O, Zambrana RE, Yankelvich G, Estrada M, CastilloSalgado C, Ortega AN. Health status of Mexican-origin persons: Do proxy
measures of acculturation advance our understanding of health
disparities? Journal of Immigrant and Minority Health 2008 (In Press).
Discussion Questions:
1. The video focuses on the “Latino Paradox,” stating that
despite higher rates of poverty and lack of insurance, and
lower use of health services, Latino immigrants to the United
States tend to have lower mortality and morbidity rates than
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non-Hispanic whites. What explanations does the video offer
for this paradox?
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A recent review of the literature on the health of MexicanAmericans (Carter-Pokras et al, 2008), found that U.S.-born
Mexican-Americans have a disproportionate burden of mortality
and morbidity compared to Mexico-born immigrants. The longer
the length of time in the U.S., the more likely Mexico-born
immigrants engage in behaviors that are not health promoting.
Recent research shows that the “Latino paradox” is more limited
than originally proposed. Franzini (2001) found that the health
advantage was limited to those 0-14 years of age (e.g., low infant
mortality rates) and to those over 45 years of age. A
comprehensive analyses of the Latino mortality advantage (Palloni
& Arias, 2004) found that the Latino paradox was only observed for
foreign-born Mexican-origin persons and foreign-born other Latinos
(with the exception of Puerto Ricans and Cubans).
One theory is that the Latino immigrants that come to the U.S. have
better health on average than those that stay behind, resulting in a
skewed representation of Latino health in the U.S.
The theory that the video focuses on most is the cultural hypothesis
in which very strong, cohesive family ties hold Latino families
together even under hardship.
2. The video looks at stronger family and community ties as the
most likely reason behind good health in recent immigrants to
the United States as compared to long-time U.S. residents.
What are your thoughts about this explanation? Are there
other explanations?
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The cultural or social buffering effect is the most accepted
argument for explaining lower infant mortality rates among
Latinos, however, these factors are mainly brought into play
in the first month of life and do not affect the post-neonatal
period (Palloni & Morenoff, 2001).
A comprehensive study of the Latino paradox (Palloni &
Arias, 2004) concluded that the social or cultural buffering
effect did not explain the mortality advantage of foreign-born
Mexicans or foreign-born other Latino adults.
Another researched explanation is the “salmon bias” or the
“return migration hypothesis”, saying that immigrants will
often return to their country of origin due to illness or
unemployment, causing them to remain in the population
count but not appear in the death count, thus lowering
mortality rates of Latinos in the U.S.
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Palloni and Arias (2004) showed that the return migration
effect does explain the mortality advantage among Mexicoborn individuals at older ages.
3. What is it about stronger family and community ties that keep
us healthy? Why might social isolation accelerate the rate of
aging?
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One-quarter of Americans say that they have no one with
whom they discuss important matters.
The video says that social isolation kills. A study conducted
in California in the 1970s found that people who are really
isolated have a higher risk of almost every cause of death,
including cardiovascular disease, infectious diseases,
diabetes, strokes, and cancer.
Being socially isolated is a chronically stressful situation that
weighs heavily on the body.
4. The video states that the longer people stay in their country of
origin before immigrating, the less likely they are to have
psychological disorders such as depression and anxiety in the
U.S. What about the U.S. could cause such outcomes?
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Studies found that after 13 years in the U.S., immigrants were more
likely to have psychological disorders.
When you are a new immigrant, the relationship between wealth
and health is relatively loose, but as you become more American,
the relationship becomes tighter and tighter. Protective factors
begin to wear down. After multiple generations, we can anticipate
that they look like the American population.
In the U.S., the focus tends to be on the individual and not on the
strong family units that immigrant families tend to display. Such
psychological disorders may be exacerbated by the stress of
having to constantly fend for oneself, not having that family support,
and being socially isolated.
5. How does hopefulness for the future play into health
outcomes for Latino immigrants and their children?
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Community support in Kennett Square gives youth reason to
be hopeful as they look ahead. If they can climb the
economic ladder, they stand a better chance of a healthy
future.
Yet, over 20% of Latino households are poor. It is seen that
the longer immigrant families are in the U.S., the more they
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struggle with discrimination, low-paying jobs, bad schools,
and bad housing.
There is a loss in hopefulness if the environment in which
you are living is giving you cues that you are not wanted and
have very little prospect for a good future. These feelings of
devaluation are internalized as they start to build up and
weigh on the body.
One-quarter of Latino children drop out of high school. One
in seven Latina girls attempt suicide.
6. What does the video mean when it says the “Mythology of the
American Dream”? What factors prevent poor immigrants
from working their way out of poverty?
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The belief exists that in America, with enough hard work and
determination, anyone can rise to the top, yet three-quarters
of Americans who started out at the bottom of the income
ladder in the late 1980s were still there a decade later.
The video documents workers who work 8 to 10 hours a day,
7 days a week. That leaves little to no time for taking care of
themselves and their families or for further education such
as English language classes. These families usually need
as many incomes as they can generate, so children are
often working jobs, and educational benefit can suffer as a
result.
Although knowledge of English is considered to be essential
to full participation in U.S. society, immigrants desiring to
learn English are faced with lengthy waits to enroll in English
as a Second Language (ESL) classes (Tucker, 2006)-57.4% of ESL providers have waiting lists, some have
abandoned waiting lists altogether, and others have
discontinued classes due to lack of funding.
Half of Americans have no paid sick days from employers.
Often these workers will not go to see a doctor until
symptoms are very bad, because any time taken off from
work is money not earned.
7. The video says that the good health of Latino immigrants
comes with an expiration date. Why is it that negative social
and health outcomes start to appear in the Latino community
after only 5 years of residence in the U.S., and are especially
noticeable just one generation after immigration to the U.S.?
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The social and cultural shield that comes with immigrant
families gradually starts to fade away as they become more
American causing the family interdependence to start
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dissolving, and as a result, negative health outcomes are
seen.
While immigrant Latinos acculturate, there is the problem of
stress levels accumulating. Immigrant children and children
of immigrants start to lose that sense of belonging to the
community, because parents have to work long hours and
are not always around. They start to lose the sense of why
they came, why they are here, and why their parents were
hopeful.
Subsequent generations acquire American habits, diets, and
sensibilities. They may be gaining traction in the American
way of life, but they begin to lose the hopefulness that their
immigrant parents brought with them that might actually be
health protective.
8. How is Kennett Square, Pennsylvania working to form a more
cohesive community? What social and health-related benefits
will community members get out of such a set-up?
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The video gives two examples of initiatives to strengthen the
Kennett Square community. “Bridging the Community”
meetings which are a way for all of the community members
to tell about the resources available and also find out what
opportunities are offered. The “Garage” is a center where
youth can go for tutoring and other educational resources,
and to hang out to build that sense of community belonging.
Both examples are initiatives to strengthen the community
bond. Having such resources, as discussed in the video,
gives a sense of hopefulness that is vital for success, and
that sense of family and community that may be health
protective.
The aspect of the “Garage” that provides a system where
those that help out actually care about the education and
success of the children is crucial for the children to believe in
themselves and their own futures.
9. What is needed to make sure that immigrants to the U.S. stay
healthy? How does this translate to people who are already
living in the U.S.?
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Immigrants need to maintain those aspects of community
that are keeping them healthy, the strong family and
community ties, and the sense of hopefulness for the future.
We need to make sure that immigrants to the U.S. as well as
those already living in the U.S. have access to good
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education and jobs, decent housing, and a strong
community.
As a society we need to be able to build our communities by
providing our residents with a reason to be hopeful for the
future, with access to such resources that can give them the
potential for success.
We must take what we see in new immigrant communities
that are health protective benefits, and then understand and
translate them into public health interventions that can affect
the broader community.
10. As a health professional student, these problems may seem
very ‘big picture’ and overwhelming. After watching this video,
what do you think you can do as a health professional student,
and future health professional to address these issues?
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As part of the accreditation standards for medical schools (LCME,
2003), medical schools are now required to document development of
skills in cultural competence. Cultural competency refers to the ability
to understand the language, culture, and behaviors of other individuals
and groups, and to make appropriate recommendations. It also
includes an awareness of one’s own cultural influences as well as
personal biases and prejudices.
Students can learn how to work with professional medical interpreters.
Online training materials on cultural competency, including how to work
with medical interpreters, can be found here:
http://www.aamc.org/meded/tacct/tacctresourceguide.pdf.
Students can participate in effective clinics and projects that serve
immigrants.
Students can also participate in coalitions to effect social policy
changes (e.g., institute living wage, increase funding for English
language classes).
Other examples of possible activities include (from least to most):
i. AT LEAST:
1. Join student groups that include advocacy (e.g. AMSA)
2. Register to vote, ask questions and hold politicians
accountable.
3. Identify easy-to-search websites and listservs to monitor
(e.g. Kaiser Health watch) and pay attention.
4. Participate in community outreach programs and find out
what is working and what isn’t. Ask patients their opinion.
ii. MORE:
1. Encourage your patients to register to vote and to vote.
2. Get formal training about lobbying and being a resource to
elected officials (e.g. AMSA)
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3. Find mentors and faculty who care about these issues and
see if there are ways you can work with them / learn from
them.
4. Get formal training in a skill called “Motivational
Interviewing”
5. Employ health literacy skills like the “Teach Back”
approach in patient-doctor communication.
iii. MOST:
1. Do a rotation in health policy (at city health departments,
with State legislators, with foundation or organizations who
focus on policy changes)
2. Create a project or student outreach program to make a
difference (early) and later develop culturally appropriate
interventions that you test (as a research project.)
Cited References:
Franzini L, Ribble JC, Keddie AM: Understanding the Hispanic paradox. Ethn Dis
2001;11:496-518.
Liaison Committee on Medical Education. Functions and Structure of a Medical
School: Standards for Accreditation of Medical Education Programs Leading to
the M.D. Degree. Association of American Medical Colleges. September 2003.
Available at http://www.lcme.org/functions2003september.pdf Accessed: March
20, 2008.
Palloni A, Arias E. Paradox lost: explaining the Hispanic adult mortality
advantage. Demography 2004;41(3):385-415.
Palloni A., Morenoff JD: Interpreting the paradoxical in the Hispanic paradox:
demographic and epidemiologic approaches. Ann N Y Acad Sci 2001:140-174.
Tucker JT. The ESL Logjam: Waiting Times for Adult ESL Classes and the
Impact on English Learners. September 2006. Available at:
http://www.naleo.org/downloads/ESLReportLoRes.pdf NALEO Educational
Fund. Accessed: March 22, 2008.
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