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Seeing Diabetes Through Patients’ Eyes

Using anthropological tools in public health

By Ze Zhang

Published February 11, 2014

Asian Americans are a rapidly growing population in the U.S., representing close to 20 million people, with 46 percent growth rate from 2000 to 2010, according to the U.S. Census. Despite this growth and rise in chronic diseases, health practice research among Asian American populations is still largely limited due to its diversity of subgroups and the lack of public attention and resources.

Current global trends in the diabetes epidemic suggest that Southeastern Asian populations are especially vulnerable to diabetes. In 2011, scientists anticipated that diabetes prevalence in Asians in America would increase 103%, with 111% increase in cost to a staggering 27.4 billion by 2025. Moreover, compared to Chinese living in Asia, Chinese living in the U.S. also have higher rates of other associated conditions like hypertension, hypercholesterolemia, and cardiovascular diseases (CVD). Recent data on the prevalence of type 2 diabetes in Chinese Americans have shown increased susceptibility to disease with low obesity prevalence compared to the non-Hispanic white population in the U.S. Responding to the alarming prevalence of diabetes in Asian populations may require some new tools in the public health toolbox.

To understand immigrant chronic disease management in the U.S, we need to acknowledge that the process of acculturation to the U.S. environment plays a significant role, in terms of dietary readjustment and exposure and adoption of multiple medical systems.

Anthropology can help us better understand the meaning people attribute to their illness and wellbeing, and medical anthropology delivers a way to examine the cross-cultural interpretation and understanding of healthcare in the United States.

For example, medical acculturation is a particularly relevant issue in recently arrived immigrants as they begin to face challenges in gaining healthcare resources, and start to evaluate and incorporate different medical systems that exist in the U.S society to fit their cultural and financial interests. Studies have even shown that the process of acculturation itself can potentially compromise health outcome and disease management in immigrants.

Therefore, how should health science researchers respond to the negative impacts of acculturation, and effectively contain a diabetes epidemic in Asian populations?

In public health research today, we commonly see practitioners referring to communities by their rates of various diseases or addressing individuals by their particular level of risk factors for diseases. Anthropologists describe these numerical data and views on disease prevalence and causality as an etic perspective, which emphasizes what the observer considers important, as opposed to the view of the group they are observing.

This perspective is an important part of understanding disease. But, can we really understand the needs of immigrants without learning from their perspective?

To unravel the complexity of immigrant healthcare, we may benefit from the use of medical anthropology approaches, or the study of the way in which culture and society are organized or influenced by issues of health. An ethnographic approach assessing individual condition and experience would give us a better vantage point to explore how cross-cultural understanding and interpretation of causes, nature, and effects of illness may influence one’s health outcome.

Here, an emic narrative of the immigrant experience or the perspective of “the observed” would give us access to their internal interpretation of illness, and firsthand knowledge on the needs of the community.

Understanding obstacles faced by immigrants from their perspective can help us reframe the guidelines and interventions pertinent to chronic diseases. In type 2 diabetes management, how do we make appropriate dietary recommendations like restricting rice intake to a population that has historic, symbolic, and ritualized inclusion of rice in their daily diets? The recommendation itself—reduction in rice intake—can be particularly distressing.

For example, how do we provide acceptable food substitutions to families that may eat communally? Perhaps, consuming brown rice instead of traditional white rice could serve as an acceptable middle ground for both physician and patient, and have more practical outcome than cutting rice intake altogether.

As we begin to uncover the patients’ experience and expectations around diabetes, we will begin to see what they consider to be integral in managing illness, their problem resolution strategies, and their treatment goals.  In the process, we may also gain shared credibility from immigrants and practitioners necessary to devise a mutually acceptable plan for treatment. In doing so, we could also see enhancement in patient-provider relationship, which is arguably a crucial step in setting immigrant healthcare in the U.S. on the right track.

The aim of using anthropological tools in public health research is not simply to describe a particular cultural problem, but to provide sensible guidelines, recommendations, and cultural insights to clinicians, public health workers, and dietitians when working with culturally complex diseases like diabetes.

Incorporating ethnographic fieldwork would provide insights into practical disease management from the previously underexplored Asian immigrant perspective, giving tangible prevention methods that can be understood within a cultural context. By adding social science to the toolbox, we may be soon on the path to answering the needs of increasing public demand in immigrant healthcare—Asian or otherwise.

Edited by Joshua Brooks

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The views and opinions expressed on this website are solely those of the authors and do not represent those of the Department of Epidemiology, the Mailman School of Public Health, or Columbia University.