Today we have another important and interesting contribution to our ongoing series on race and health in Philadelphia. Oni Richards-Waritay, executive director of the African Family Health Organization (AFAHO) discusses how cultural and linguistic barriers can lead to poor health outcomes.
-- Michael Yudell
Research indicates that the health of immigrants to the United States worsens the longer they are here. For example, many members of Philadelphia’s African and Caribbean immigrant and refugee community are healthier than other residents upon arrival in the U.S. But their health deteriorates the longer they stay here.
How is this possible in a nation that is supposed to have the best healthcare in the world?
Part of the answer is that as newcomers assimilate, they adopt the unhealthy dietary and physical activity habits of longtime residents. The other part is that quality healthcare is not accessible to everyone, particularly those who are low-income, Limited English Proficient, have no health insurance and live in “health deserts.” This inevitably leads to many being forced to use emergency rooms as a source of primary care; a lose-lose situation for both the patient and the over burdened health system.
The Mayor’s Commission on African and Caribbean Immigrant Affairs reports that there are nearly 60,000 African and Caribbean immigrants and refugees in the city. At the African Family Health Organization, which provides services to nearly 900 people a year from 30 countries, we constantly witness the challenges that this population faces in accessing quality health and human services.
Barriers to healthcare as well as low-quality healthcare contribute to health disparities and poor health outcomes in immigrant and refugee communities. Though access to Western medicine was limited for some in their home countries, they had access to fresh foods; opportunities for frequent outdoor activities; and traditional medicines, which focused on prevention. Prevention plays a critical role in improving health, yet it is rarely the focus of medical care in the American system, partly due to the lack of adequate time that health providers have available to spend with each patient.
Doctor office visits are sometimes compared to “speed dating,” even for those immigrants and refugees who have a good grasp of the English language, health insurance, and are able to successfully navigate the often complex healthcare system. Many tell us that, despite going to the same provider for a year or more, they have yet to develop a rapport that encourages meaningful dialogue due to the rushed and impersonal nature of time spent with their doctors. And now that everything is online, health providers seem to spend more time looking at their computers, as they quickly type in answers to their patients’ questions, than with the people sitting across from them. This can be intimidating and isolating for anybody; for an immigrant or refugee, it might justify claims that providers now are more concerned with curing disease using medication rather than healing and preventing it in the first place.
Imagine for a moment that you are not fluent in English; already have some distrust of the health system; have no health insurance; are not culturally familiar with Western medicine, and not very literate. What is the likelihood that your experience with a medical provider will be positive and effective? For many, the chances are slim. That’s why one of the services our organization offers is a medical escort to help our clients get through some of their language, culture, and navigation barriers – a difficult task to accomplish when using only a telephone interpreter.
Providers often don’t get that interpretation is not just linguistic, it is also cultural. When patients shake their head to indicate “yes,” for example, that does not necessarily mean that they understand what’s being said; it might simply mean that they’re doing what they think they should be doing. Many immigrants and refugees revere medical providers and see them as “all knowing.” As a result, they might blindly follow instructions without raising the kind of questions that educated people who grew up here would instinctively ask.
And when providers do not truly understand their patients, they miss critical opportunities to intervene before a serious condition develops. A typical example is the prevalence of Hepatitis B in African immigrant communities. A provider who is unfamiliar with this pattern might not screen for the virus, which can eventually lead to liver cancer if left untreated. And using body-mass index (BMI) to discuss obesity in African or Caribbean women is often ineffective; BMI at this point may be a household term in the United States but it is an alien concept in many parts of the world, where body types also may not match what the tool is intended to measure to identify unhealthy proportions.
Health care in the U.S. can be among the best in the world, and nowhere more so than in Philadelphia, with its concentration of top academic medical centers. But it often serves immigrants and refugees poorly, just at the time when their adoption of an unhealthy Western lifestyle is worsening their health. It is imperative that the health-care system be changed to ensure quality care for all, regardless of insurance, education, ethnicity or linguistic capabilities. The Brookings Institution reports that there are nearly 500,000 foreign-born residents in the Philadelphia metropolitan area. As the region continues to become more diverse, it is important that providers understand the needs of the communities they serve -- and make a concerted effort to become culturally competent and sensitive if reducing health disparities and improving health outcomes is their goal.
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