05 Apr Cultural Competence in Disease Prevention and Management: A South Asian Perspective
India, a land, remarkably known for its potpourri of “cultures” spanning North, South, East, and West, is my homeland. For all technical purposes I am South Asian Indian, yet share largely different experiences with respect to customs, beliefs, language and food (to name a few), with family and friends in India. I am also one of many, who have contributed to “multiculturalism” here in the US, where racial and ethnic minorities will comprise almost half of the population by the year 2050.
Specifically, the Asian population will increase by 212.9%, the Hispanics by 187.9%, and African Americans by 71.3%, compared to only 32.4% growth in whites (US Census Bureau).
The cultural landscape while breathtakingly diverse and endearing, shoulders a burgeoning endemic of chronic health problems such as diabetes and cardio-vascular disease. Minority groups experience higher prevalence of these diseases when compared to non-Hispanic White Americans.
In California 2011-2012, 10.5 % Hispanics, 8.8% African Americans, 7.5% American Indian/Alaska Native, 6.2% Asian/Pacific Islander, and 4.9% Non-Hispanic Whites had diagnosed diabetes, California Health Information Survey (CHIS).
As a consequence and for the sake of their health, they must visit the doctor more regularly, adhere to their doctor’s advice and medication schedule, follow a healthy diet, exercise and so on; seemingly simple tasks, right? But there are problems; for example, a large number of people, English is their second language and many admit to not speaking it “very well”, this among other factors, ultimately leads to dissatisfaction with the care they are receiving and a severed relationship with their care team. They believe they would have received better care if they weren’t African American, Hispanic, or Asian American. We almost always accompany our older parents, who have a long stay in the US, for doctor and pharmacy visits; anxious they might be misunderstood, in the absence of culturally appropriate services.
Asian Americans feel their doctors don’t understand their background and values and often look down upon them (Health Policy Institute, Georgetown University).
Among Asia-Pacific sub groups in the US, Pacific Islanders, South Asians and Filipinos bear the highest brunt where diabetes is concerned, according to Kaiser Permanente Division of Research and the University of California, San Francisco (UCSF). While I was training as a Heart Health Coach at the South Asian Heart Center, El Camino Hospital, our community’s health numbers shocked me: a four fold higher risk of type 2 diabetes, in spite of being non-obese and primarily vegetarian, than any other ethnicity in the US. The combination of high-risk genes, a higher percentage of body fat around the stomach (visceral fat) also known as central adiposity, and poor lifestyle choices, ultimately leads to insulin disorders and chronic inflammation. Ashish Mathur, Co-founder and Executive director of the Center explains,
“It is no mystery now, that most chronic disease can be prevented by adopting physically active, nutritiously sound, and mindful rest associated lifestyle behaviors. Cultural practices and preferences while sometimes helpful (such as vegetarianism and fasting) can also often hinder in the adoption of these life-saving behaviors. At the South Asian Heart Center, our participants have benefitted from advanced risk evaluation to expose hidden risks and science based approach to lifestyle counseling, followed by intense health coaching. In their incredibly busy and complex lives, our participants have been able to incorporate these seemingly simple, yet hard to implement behaviors and reduced risk for chronic disease. By averting a major health event in their lives, they have learned the art of successful aging and longevity”.
The Center takes pride in the cultural competency of it’s staff and volunteers and strives to make a positive impact in each and every member’s life by channeling resources towards community awareness, education, screening, coaching, and research. Along side is the Palo Alto Medical Foundation’s (PAMF) PRANA (PRevention & AwareNess for South Asians) wellness program, developed by the South Asian Wellness Task Force, led by PAMF physicians Ronesh Sinha and Latha Palaniappan. Dr. Sinha also treats high-risk South Asian patients and runs wellness programs for corporate clients in Silicon Valley. His book The South Asian Health Solution is a revelation. We spoke about his specific concern,
“The connection between stress, inflammation and chronic disease has become quite clear to me in my practice”.
Many of his patients have the obvious metabolic risk factors for heart disease but there is a growing number of remarkably fit and healthy patients that have experienced a heart attack due to bodily stress induced by their overly regimented exercise schedules marked by inadequate periods of rest and coupled with an intense silicon valley pace of life (evidence points to a key protein found inside cells called NF-kB, that upon activation by chronic stress, turns on multiple genes involved in triggering inflammation).
Much is hidden, so let’s visualize an Iceberg to put everything I’ve spoken about in perspective. Dr. Jerome H. Hanley, a clinical child psychologist and the director of the division of children, adolescents, and their families (South Carolina Department of mental health), beautifully conveys similarities between a person’s culture and the Iceberg. Peoples’ language, food, religion, dress, to name a few, are on the surface, and present an opportunity for respectful interactions. What’s beneath the iceberg are challenges/threats that the health care system faces today: theory of disease, decision making process, motivations, physical space, locus of control, age and gender roles, and many more. He believes cultural competency is an ongoing lifelong process fueled by our own experiences and learning along the way.
For my South Asian community, preventing a sudden catastrophic health condition by uncovering and treating emerging, sometimes fatal, hidden risks by creating a slow but steady mind shift from traditional ways of looking at disease, all delivered in an empathetic, respectful, compassionate and responsive manner, should be the new standard of care.
Image Courtesy, The South Asian Health Solution, by Dr. Ronesh Sinha
Priya Talreja is Melon Health’s Research and Program Designer. Melon Health participated in Techstars++ program at Mayo Clinic in Rochester in September 2016.