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Cultural Effectiveness, Healing and Latinos

Enrique González-Méndez, MDDirector of Cultural Education

Santa Rosa Family Medicine ResidencyClinical Professor

UCSF Dept. of Family and Community Medicine

Population distribution by race/ethnicity, Sonoma County and California

2009

66.8%

23.6%

4.7%1.6% 1.0% 2.3%

36.7%

12.3%

5.9%

0.6% 2.1%

42.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

White, non-

Latino

Latino Asian/Pacific

Islander

African

American

American

Indian

Multi-race

Sonoma County

California

Source: CA Dept of Finance, Jul 2007

Sonoma County Births 2009:

5,683 Births

White, non-Hispanic

48.3%

Hispanic

42.5%

Asian/Pac Isl

4.9%

African Amer

1.4%

Other

2.9%

Source: CA Dept of Public Health, Birth Statistical Master Files, 2009

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Percent of births to mothers that are foreign-born and Mexico-born, Sonoma County 2000-2007

42.1%

34%33%

25%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2000 2001 2002 2003 2004 2005 2006 2007

Total foreign-born

Mexican born

Source: CA Dept of Public Health, Birth Statistical Master file 2005-2007

Population Distribution* by Race and Ethnicity

Sonoma County, 2007

-40000 -20000 0 20000 40000

0-9

10-1920-29

30-39

40-4950-59

60-69

70-7980+

MALES FEMALES

Non-Hispanic White

(N=332,054)

40,000 20,000 0 20,000 40,000

*State of California, Department of Finance, E-1 Population Estimates for Cities,

Counties and the State with Annual Percent Change — January 1, 2007 and 2008. Sacramento, California, May 2008.

Population Distribution* by Race and Ethnicity

Sonoma County, 2007

-20000 -10000 0 10000 20000

0-9

10-19

20-2930-39

40-4950-59

60-69

70-7980+

MALES FEMALES

Hispanic

(N=107,832)

20,000 10,000 0 10,000 20,000

*State of California, Department of Finance, E-1 Population Estimates for Cities, Counties and the State with

Annual Percent Change — January 1, 2007 and 2008. Sacramento, California, May 2008.

Hispanic population by place of birth and citizenship, Sonoma County 2005-2007

Foreign-born

51.3%

US-born

48.7%

Not a citizen

77.3%

Naturalized

22.7%

Source: American Community Survey, 2005-2007

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Foreign-born population by place of birth, Sonoma County 2005-2007

Latin

America

67.8%

Mexico

89.2%

Asia

16.1%

Other

Latin American Country

10.8%

Europe

10.7%

Other

5.4%

Source: American Community Survey, 2005-2007

Cancer Mortality Rate by Race/Ethnicity, Sonoma County 2006-2008

Source: California Dept of Public Health, Death Statistical Master File, 2006-2008 and CA Dept of Finance, Population Estimates with race and

sex detail, 2000-2050 Jul 2007

82

95.9

107.7

189.2

190.6

0 50 100 150 200 250

Asian/Pac Islander

Hispanic

American Indian

African American

White non-Hispanic

Rate per 100,000

Coronary Heart Disease Mortality Rate by Race/Ethnicity, Sonoma County 2006-2008

Source: California Dept of Public Health, Death Statistical Master File, 2006-2008 and CA Dept of Finance, Population Estimates with

race and sex detail, 2000-2050 Jul 2007

63.7

64.7

125.5

153.2

0 20 40 60 80 100 120 140 160 180

Hispanic

Asian/Pac Islander

White, non-Hispanic

African American

Rate per 100,000

Stroke mortality rate by race/ethnicity, Sonoma County 2006-2008

Source: California Dept of Public Health, Death Statistical Master File, 2006-2008 and CA Dept of Finance, Population Estimates with race

and sex detail, 2000-2050 Jul 2007

37.5

54.2

56.6

0 10 20 30 40 50 60

Hispanic

White, non-Hispanic

Asian/Pac Islander

Rate per 100,000

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Epidemiological Paradox

� Outcomes are better than expected based on the known or standard predictive risk factors

� Low SES does not always translate to worse outcomes

� Mechanisms for these observations remained unclear

Diabetes mortality rate by race/ ethnicity, Sonoma County 2006-2008

Source: California Dept of Public Health, Death Statistical Master File, 2006-2008 and CA Dept of Finance, Population Estimates with race

and sex detail, 2000-2050 Jul 2007

16.6

20.3

0 5 10 15 20 25

White, non-Hispanic

Hispanic

Rate per 100,000

Race/Ethnicity of Physicians and Population, California 2008

Trends in Mexico-US Migration

� Magnitude and Dynamism

� Undocumented Migration

� Erosion of Circulatory Migration

� Increasing Territorial Scope

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Rutas migratorias

Interna

Externa

Principales lugares de origen

Guanajuato, Michoacán, JaliscoY Colima 38%Chih., BC, Son, Coah, N.L., Tamps

21%Sin., Dgo., Nay., Zac., SLP, Ags

22%

Undocumented Migration• Almost six in every ten

illegal immigrants in the US come from Mexico.

• 3000 km border guarantees continuation of flow: has moved from California to Arizona and New Mexico.

• Estimates suggest 73% of agricultural workers in California are undocumented Mexicans.

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Remittances

• Mexico became the world’s top country in labor remittances in early 2000s ahead of mega-countries such as India.

• Remittances have surpassed FDI + aid combined.

• After oil, remittances have become the main source of foreign exchange for Mexico.

Health Implications of Migration

� “Migration of Latin American citizens to the United States involves the movement of not only people across borders, but also the movement of information, ideas, customs, traditions and visions.”

Health Implications of Migration

� Increased interface of cultures◦ Need for health care providers, systems and public health to include cultural and epidemiological context of individual patients and communities in order to effectively improve health, prevent and treat disease

◦ Broad context of culture as well as cultural aspects more specific to health

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Personalismo

� For the Mexican patient it is important to have their own doctor (médico de cabecera), in whom they can trust their health and their family’s health and who will know you well enough to give you the best advise for their well being.

Respeto

� Respect� A fundamental value in the Mexican culture

� “Sin respeto, no hay nada” – Without respect there is nothing

� If you don’t respect me, I cannot have any trust in you

� Respect of the family, especially the parents and the elderly, is fundamental in the function of the Mexican family

� The sign of respect is to shake hands of every individual in the room during a medical visit.

� Acknowledging the children will open a good relationship with the family and your patient

� Always use formal Spanish, except with children, but especially with women and the elderly

Fatalismo

� A very prevalent sentiment among Mexican

� “Me voy a morir cuando me llegue la hora” – I’m going to die when it’s my time, not before nor after

� It is written somewhere when people are going die

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Personalismo

� For the Mexican patient it is important to have their own doctor (médico de cabecera), in whom they can trust their health and their family’s health and who will know you well enough to give you the best advise for their well being.

Universidad Nacional Autónoma de México (UNAM)

School of Medicine Mural “La vida, la muerte, el mestizaje y los cuatro elementos”

“Indigenous traditional medicine is…a system of concepts, beliefs,

practices , and material and symbolic resources dedicated to addressing different ailments.”

Mesoamerican Traditional Medicine in the Context of Migration to the United States, 2008

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� In Latin America, especially in Mexico, the use of healers (curanderos) is very popular and affordable.

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� Popular healers are also called Sobadores, that cure disease with massages, including mental illness.

� Some believe it is important for a mother to visit a sobador soon after the delivery to prevent a disease called “caida de la matriz.”

� The use of a faja (girdle) is believed to help prevent the caida de matriz by giving support to abdominal muscles.

Popular Beliefs

� It is important for a mother to visit a sobador soon after the delivery to prevent a disease called “caida de la matriz.”

� The use of a faja (girdle) can help prevent the caida de matriz by giving support to abdominal muscles.

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Popular Beliefs

� Newborns should also be treated by a sobador in order to prevent “la caida de la mollera” and “el empacho.”

Empacho

� Is characterized by a variety of symptoms, mainly gastrointestinal. For example, poor appetite, dyspepsia, nausea, as well as sadness and low energy.

� In older children, empacho can be caused by eating certain foods like the dough of tortillas that hasn’t been cooked.

Empacho

� There is the popular idea that food can attach itself to the stomach wall and cause the symptoms of empacho.

� Swallowing gum can also cause the symptoms.

Lead Poisoning Cases Associated with Traditional Healer

� Between 2004 and 2008

� 8 children ages 1-3 years

� Elevated lead levels (13-41)

� All treated by a traditional healer (curandera and sobadora)

� All treated for gastrointestinal complaints consistent with empacho

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Remedies

� rubbing the stomach or back

� popping of the skin,

� purgative teas

� Lead (azarcón or greta) powders are still occasionally given.

• Mexican Community:– Azarcon & Greta:bright powders used for GI upset (empacho)

Lead in Folk Remedies & Cosmetics

Interviews

Women #3 and #4 from Michoacan, Mexico

� Azarcon is illegal but “almost all small Mexican Markes sell it”

� Empacho can also be cured with Azogue (usually a small teaspoon)

� Azogue = Mercury

Barriers to Reducing Lead Exposure and Poisoning

� Lead not perceived as a risk to children in our community

◦ By individuals and community

◦ By some medical providers

� Reluctance to disclose use of traditional healers and remedies with physicians

� Reluctance to offend healer

� Concern regarding immigration status

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Imported Ceramics Lead in Imported Candy*

*& other foods & spices

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Chapulines from Oaxaxa

AJPH, May 2007, v97,#5

Susto

Susto

� Extreme fear

� Susto believed to cause diabetes, hypertension, and other diseases by changing the balance of the body and the mind, especially if sweets are consumed after the fact.

Coraje

� Rage

� Being a strong emotion can make people sick and cause diseases.

� Coraje can also cause biliary colic, because there is a sudden uncontrolled “derrame de la bilis”

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Aire

� Being exposed to an ‘aire’ (air), can cause bell’s palsy, especially in a vulnerable state: post-partum, after surgery, etc.

� El ‘aire’ can come inside the body through the ears.

� During post-partum, many women use cotton in their ears to avoid an ‘aire’

Death

� Mexicans make fun of death

� On November 2nd, Dia de los Muertos (Day of the Dead), they make rhymes about their own death

� Sugar skulls are made and given as a present with the name of the recipient written on the forehead

Percent families (with children < 18yrs) below

federal poverty level, Sonoma County 2009

14.4%

32.5%

9.0%

25.0%

6.1%

20.0%

0%

5%

10%

15%

20%

25%

30%

35%

All families Families headed by single female

Hispanic

Total

White, non-Hispanic

2009 Federal Poverty Levels (FPL)

� Family of 4 FPL = $22,050.

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Sonoma County High School Completion Rates* –

Class of 2008

�All 75%

*Percentage of 9th graders enrolled in 2004 that graduated in 2008

Source: Sonoma County Office of Education, Data Trends:

Making Sense of Sonoma County’s Enrollment and Achievement Numbers, SCOE Bulletin, April 2009.

- White non-Hispanic 81%

- Hispanic 64%

Percent 4th Graders NOT Meeting Reading Competency

Standards, Sonoma County 2008-2009

0%

20%

40%

60%

Hispanic African American White non-Hispanic

Asian

Sonoma CountyCalifornia

Source: CA Dept of Education, 2008/2009

Source: CDC Behavioral Risk Factor Surveillance System.

(*BMI ≥≥≥≥30)

Hispanic

State-specific Prevalence of Obesity* Among U.S. Adults, by Race/Ethnicity,

2006-2008White non-Hispanic Black non-Hispanic

Percent of 5th graders in Santa Rosa City Schools overweight or

obese, Sonoma County 2006-2008

17.0% 21.0% 20.0%

16.0%

33.0%26.0%

0%

10%

20%

30%

40%

50%

60%

White, non- Hispanic Hispanic Total**

**Includes all race/ethnicitiesSource: Santa Rosa City Schools 5th grade assessment, 2006- 2008

ObeseOverweight

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Childhood Obesity

• 1 in 3 children born

in 2000 will be

diabetic

• Rates are higher for

Hispanic and Black

children (53% and 45%

respectively)

This is the first generation of kids in the US that are This is the first generation of kids in the US that are This is the first generation of kids in the US that are This is the first generation of kids in the US that are expected to have shorter life spans than their parents.expected to have shorter life spans than their parents.expected to have shorter life spans than their parents.expected to have shorter life spans than their parents.

www.discoveryhealthCME.com, N Engl J Med Vol. 352(11) March 2005, pp. 1138-1145

Percent of Sonoma County adults who report being obese, 2001-2007.

14.116.7

24.2

28.0

47.2

34.5

29.6

0

10

20

30

40

50

2001 2003 2005 2007

Pe

rce

nt

2020 Vision

Target: 15%

Total

Hispanic

Leading Causes of Death: US

1. Heart disease

2. Cancer

3. Stroke

4. Chronic lower respiratory disease

5. Accidents

6. Diabetes

7. Alzheimer's

8. Influenza and pneumonia

9. Kidney disease

10. Septicemia (severe infection)

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Questions?

“The ability to reach unity in diversity will be the beauty and the test for our civilization”

-Mahatma Gandhi