Cultural Aspects of Health
Disparities in the United
States
Wenda Trevathan
Professor of Anthropology
New Mexico State University
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
National Institutes of Health
statement about health
disparities
“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, 2004
Health Disparities:
Definition
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, 2004
Example areas of health
disparities 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, 2004
Example: Infant Mortality in
in the US (2000)
African Americans
14.0%
Whites
5.7%
All
6.9%
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Infant mortality in New Mexico
and Texas (1999-2001)
12
Rate per 100,000
10
8
6
New Mexico
Texas
4
2
0
Non-Hisp Hispanic
Af Am
Native Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health
disparities 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, 2004
Overall Cancer Deaths
(1998)
Rate per 100,000
300
250
200
150
Death Rate
100
50
0
Non Hisp
Hisp
Af Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Selected Cancer Mortality Rates
(US, 1998)
Rate per 100,000
70
60
50
Hispanic
White
Af Am
40
30
20
10
0
Lung
Breast
Cervical
Colorectal
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Colorectal Cancer
Screening
(U.S. Adults over 50, 1998)
Population
Hispanic or
Latino
African
American
White
Fecal Occult Sigmoidoscopy
Blood Test (%)
(%)
23
27
30
32
36
39
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Colorectal Cancer Screening
(Adults over 50,1998)
Population
Less than High
School
High School
Some College
Poor
Near Poor
Mid/High Income
Fecal Occult
Blood Test (%)
Sigmoidoscopy
(%)
26
29
34
41
23
31
35
44
28
31
39
43
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Breast and Cervical
Cancer Deaths
(Women; 1998)
40
Rate per 100,000
35
30
25
20
Breast
Cervical
15
10
5
0
Hispanic
Non
Hispanic
Af Am
White
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Death Rates for Malignant
Neoplasm of Breast
40
Rate per 100,000
35
30
25
Non Hisp
20
Hisp
15
Af Am
10
Nat Am
5
0
1950 1960 1970 1980 1990 1995 2000 2001
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Female Death Rates:
Trachea, Bronchus, Lung
(1950-2001)
45
Rate per 100,000
40
35
30
Non Hisp
Hisp
Af Am
Nat Am
25
20
15
10
5
0
1950 1960 1970 1980 1990 1995 2000 2001
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Male Death Rates:
Trachea, Bronchus, Lung
(1950-2001)
140
Rate per 100,000
120
100
Non Hisp
Hisp
Af Am
Nat Am
80
60
40
20
0
1950 1960 1970 1980 1990 1995 2000 2001
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Lung Cancer Deaths
(1998)
70
Rate per 100,000
60
50
40
30
20
10
0
Hispanic
Non Hispanic
Af Am
White
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Annual age-adjusted mortality
rates for colorectal cancer deaths
(
1996–2003)
30
Rate per 100,000
25
20
Overall
Non Hisp
Hisp
Af Am
Nat Am
15
10
5
0
New
Mexico
National
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Annual age-adjusted mortality
rates for prostate cancer deaths
(Men; 1996–2000)
80
Rate per 100,000
70
60
50
Overall
Non Hisp
Hisp
Af Am
Nat Am
40
30
20
10
0
New
Mexico
National
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health
disparities 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, 2004
Populations at Risk for
Cardiovascular 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, 2004
Example areas of health
disparities 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, 2004
Example Diabetes Rates in
Selected US Populations
(Females), 1998
•
•
•
•
•
•
•
•
•
•
•
•
US “white” (non-Hispanic)
US Hispanic
US “black”
Indian Health Service (all)
Navajo
Phoenix
Tucson
Native Americans (all)
Arizona Pima (ages 30-64)
Arizona Pima (all ages)
Mexican Pima
Great Britain
%
7.8
10.6
10.8
8.0
8.8
11.6
12.8
12.2
50.0
38.2
6.4
2.0
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health
disparities 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, 2004
HIV Death Rates
(Males; 2001)
40
Rate per 100,000
35
30
25
20
Death Rate
15
10
5
0
Non Hisp
Hisp
Af Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Example areas of health
disparities 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, 2004
Maternal deaths due to
complications of pregnancy
(2001)
Rate per 100,000
25
20
15
Death Rate
10
5
0
Non Hisp
Hisp
Af Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Why do these disparities
exist?
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•
•
•
•
•
•
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, 2004
Cervical Cancer Deaths
Rate per 100,000
(Women; 1998)
8
7
6
5
4
3
2
1
0
Cervical Cancer
Less than
High
School
High
School
Some
College
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Colorectal Cancer Screening
(Adults over 50, per 100,000; 1998)
Characteristic
Less than HS
Fecal Occult Sigmoidoscopy
Blood Test
26
29
High School
34
35
Some College
41
44
Poor
Near poor
23
31
28
31
Mid/High income
39
43
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Percent Obese
Ages 20-74; 1999-2000
(BMI >29)
60
Rate per 100,000
50
40
30
Males
Females
20
10
0
Non-Hisp
Hispanic
Af Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
Ancestral 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, 2004
Adult cigarette smoking
(U.S. 1999-2001)
35
Rate per 100,000
30
25
20
Males
Females
15
10
5
0
Non-Hisp
Hispanic
Af Am
Native Am
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004
More Common Explanations
for 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, 2004
Thoughts from Classical
Medical Anthropology
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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, 2004
Culture: A Powerful
Explanatory 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, 2004
Explanatory Models of
Hypertension among African
American Women
high 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, 2004
Example behaviors that may be
encountered when working with
adherents of the hot-cold theory
Diseases 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, 2004
Recommendations to health
care 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, 2004
Views of Alternative
Treatments
• 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, 2004
Recommendations
• 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, 2004
The 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, 2004
Thoughts from Medical
Anthropology
“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, 2004
More Thoughts from Medical
Anthropology
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, 2004
More Thoughts from Medical
Anthropology
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, 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, 2004
More Thoughts from Medical
Anthropology
“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”
Wenda Trevathan, Professor of Anthropology,New Mexico State University, 2004