Решила все таки свой "шедевр" выложить тут, ну сама себя не похвалишь...)))
может кто заинтересуется и почитает, ну уж очень щекотливая и интересная ( для меня) тема.
Букфф очень много,еще и английских ) но дорогу осилит идущий ))
Может эта работа поможет кому то изменить свое отношение к медицине, а может просто станет интересно.
Коментарии конечно приветствуются.
Social and Behavioral Issues in Public Health
December 14, 2014
Inequality of Healing
Gödel's Incompleteness Theorem states "A formal system cannot prove that the system itself is consistent (assuming it is indeed consistent)" which relates to the status of public health care today because, although the framework of the United States' public health is sound, it hasn't been properly implemented to meet the demands of today's overwhelming diversity of population. What exists today is a result of a singular approach to healthcare that could be labeled as inequality of healing. This inequality appears across the spectrum of religious, ethnic and racial groups, and it is based on lack of awareness by the public healthcare professional with respect to cultural differences and beliefs that spring from deep-rooted ethnic traditions and practices.
As it exists, the structure of the public health system in the United States is the combination of scientific knowledge of sources and control of disease, as well as public responsibility for the control and spread of health threats. (3) Although the practice of medicine in the United States dates back to the 1600s, the first organization of medical professionals in the colonies was chartered July 23, 1766 in New Jersey and developed to "form a program embracing all the matters of highest concern to the profession: regulation of practice; educational standards for apprentices; fee schedules; and a code of ethics." The New Jersey Medical Society is the oldest medical society in the United States. (2) Its regulation of medical code of ethics, fee for visits, appearance and regulatory were implemented countrywide and shaped the public
system as we know it today. (2)
When America opened its doors to European immigrants, the first arrivals were discovered to be in need of health care and doctors to treat epidemics and diseases brought to the newly opened land from overseas. In 1732, Bedloe's Island in New York harbor was "temporarily commandeered as the first quarantine station."(22) The official powers of New York City and its pre-revolutionary population were afraid of the spread of small-pox, worrying that "other malignant fevers may be brought in from South Carolina, Barbados, Antigua, and other places, where they have great mortality." (22) In 1786, the owner of the Island permitted to use his property as "a temporary quarantine station."(22)
Since 1800s, the regulation of medical code of ethics, fee for visits, appearance and regulatory were implemented countrywide and shaped the public system as we know it today. (2) The first Federal Quarantine Act was passed in 1878 and was created to prevent the introduction of infectious diseases into the United States from foreign ports. The yellow fever had an outbreak in the Caribbean that year, and the act was passed largely in response to this epidemic. (23)
In the following years, Congress passed additional legislation to prevent people with infectious diseases from entering the United States. (23) In 1879, Congress established a National Board of Health to set rules for quarantines. In 1891, The Immigration Act barred the entry of persons with "dangerous contagious disease."(23)
Since the arrival of first immigrant to the new world, immigration has played a tremendous role in shaping the health care system in the United States. Immigration is a worldwide phenomenon, and nowhere has this been more acutely observed than in the United States. Today, our vast influx of immigrant populations has resulted in the movement toward globalization. (4) According to Merriam-Webster dictionary, globalization is "the development of an increasingly
integrated global economy marked especially by free trade, free flow of capital, and the tapping of cheaper foreign labor markets." Generally, immigration occurs from countries with lower standards of living to those that offer better wages and opportunities for upward social mobility. However, wars and famine may precipitate the movement of hundreds of thousands of people into other countries. (4) Not surprisingly, arriving immigrants to our shores need healthcare. Let us examine three major waves of immigration and how our healthcare system has responded.
There have been three major movements of immigration- both by those coming to the continental USA and those re-locating within it:
1776 - 1924 when 22 million people moved to US from South Europe.
1920-1960 Great migration also known as largest internal migration when six million African -Americans moved from the South to North.
1960-Present and still ongoing. Asian and Latin Americans combined account to 81% of the people permitted entry. (4)
Nowadays, we have even greater diversity among immigrants arriving to the United States, including Europeans, Asian, African, Middle Eastern and others. They come with a wide spectrum of health needs. Medical screenings are often conducted at community health centers, state or local health departments, and in private clinics. Many physicians are unfamiliar with screening recommendations and diseases endemic to immigrants' countries of origin and may feel unprepared to deal with medical issues affecting these populations."(24) Health care professionals are frequently unprepared for language, social, and cultural barriers. (24)
It is important to remember that immigrants left their homes behind, but brought their culture, traditions and beliefs as well as their archetypes of healing models with them when they arrived into the new world. The United States of America has welcomed the most diverse
population in the world onto its shores. (5) Though this fact adds immense cultural richness to our national identity, it also differentiates, and sometimes isolates, these various ethnic groups in US because each has their own beliefs and values- especially in their view of health.
As defined here, health "... is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." (6) This definition has not been amended since 1948 (7) and by now, desperately needs culturally specific extensions, which would enable healthcare workers, as well as the rest of us who make up the matrix of American life, to have a broader understanding of what the word "health" means to a Muslim, a Mandarin Chinese, or a Native American.
We Americans have scientific knowledge of the origin of a multitude of diseases, their treatment protocols, pharmaceutical remedies, therapeutically or surgical procedures as treatment. Our options for a vast array of illnesses and conditions are current and tested for effectiveness. We have confidence in the newest advances in modern medicine, believing that the most innovative way to be healed is the best way to heal. This results in a forward-looking and open-minded approach which has evolved into the most common conception of public health as liberal in regard to access and biomedical in regard to health. (8) However, we, as a society on the move forward, tend to view whatever is behind us with disdain. If we hear about a protocol that doesn't involve high-tech or high cost remedies, we tend to see it as related to "medieval times" and disregard it or label it "grandmother's way."
We tend to forget that time-tested techniques still have application today. Because a method of healing is ancient doesn't mean it's lost its application. For example, traditional Chinese medicine evolved over thousands of years and originated in ancient China. (9) The National Center for Complementary and Alternative Medicine reports that estimated number of
practitioners using Traditional Chinese Medicine which includes acupuncture, "moxibustion, Chinese herbal medicine, tui na (Chinese therapeutic massage), dietary therapy, as well as tai chi and qi gong (practices that combine specific movements or postures, coordinated breathing, and mental focus)," was about 10,000 in 1997. They served more than 1 million patients each year. According to the 2007 National Health Interview Survey (NHIS), "an estimated 3.1 million U.S. adults had used acupuncture in the previous year." (9)
Muslims implemented the Hippocratic philosophy of Premium non nocera, meaning: first don't harm in their medical practices and it reflected the teaching of their religion as early as the beginning of 7th century. The Prophet Muhammad's [peace and blessings of Allah be upon him] words, "Your body has rights over you" paved the way to innovative advancements in the medical, pharmaceutical, and health fields. (11)
Avicenna was one of the most significant thinkers and writers in the Islamic world and his influential work in medicine had tremendous effect in the pre-modern era. His books on medicine were used worldwide. (10) They are still studied today as historical evidence of early healing methods.
On this continent, Native Americans' medicine was based on the understanding that "... man is part of nature and health is a matter of balance." (12) Native medicine can be as old as 40, 000 years. The largest surviving piece of Native American medicine is ceremonial and ritual. Surprisingly, it included many sophisticated interventions such as various forms of "…bodywork, bone setting, midwifery, naturopathy, hydrotherapy, and botanical and nutritional medicine." (12)
Based on the above-mentioned facts, the question arises, "Why do we think that the dominant way of practicing medicine is the proper way?" The problem of inequality in health care is not
nearly as far-reaching as the problem of cross-cultural communication difficulties, differing concepts of what constitutes good or bad health, methods of healing, varying hygiene awareness and practices, as well as concepts of physical self.
These facts bring up a curious issue that deserves to be investigated. It is axiomatic that current practices in biomedicine shape our culture and our perception of medicine. If there are different concepts of health, how can we change our policies and procedures to accommodate a polyglot of populations and make sure the distribution of healing is equal?
First of all, I believe that public health would truly serve our population- both immigrant and native-born- if each state found ways to make sure that everyone has equal access to adequate health care. For the last 200 years, Commissioned Corps officers, who are the federal uniformed service of the U.S. Public Health Service (PHS) "involved in health care delivery to underserved and vulnerable populations, disease control and prevention, biomedical research, food and drug regulation, mental health and drug abuse services, and response efforts for natural and man-made disasters as an essential component of the largest public health program in the world." (1) "Today, Commissioned Corps continues to fulfill its mission to protect, promote, and advance the health and safety of the nation…" (1)
With that said, people from local communities continue to trust doctors of their own ethnic or religious groups and choose to go to the hospitals and communities centers where they can find health professional who speaks their language, have a translator services available and understands their culture.
Anne Fadiman, in her moving and important study of health of one Hmong family, titled The Spirit Catches You and You Fall Down, makes an exceptionally detailed portrait depicting the life of Hmong community in the town of Merced in California. Her book is a wakeup call to
many of us who consider only one way of healing- the biomedical way- disregarding traditional beliefs and other understandings of health that are not our own. The victims of cross-cultural miscommunication, similar to those portrayed in this work, lack adequate and quality translation, the way a little girl named Lia Lee did. Her life and death stand as a symbol of collision between two cultures and a lesson to all of us. (14)
If one needs statistical proof of Fadiman's portrait of a failed healthcare system, note this American College of Physicians' report: "Overwhelming evidence shows that racial and ethnic minorities are prone to poorer quality health care than white Americans, even when factors such as insurance status are controlled." (16, 18) According to the Center for Prevention and Health Services some physicians rate their African-American patients as less intelligent and more likely to use drugs and alcohol. These biases have impact on care provision. (25)
Other important variables that impact health care disparities were first noticed by W.E.B. Du Bois, an American sociologist, historian, civil rights activist, and editor in his classic 1899 work, The Philadelphia Negro. He listed the contributing factors as poor heredity, neglect of infants, bad dwellings, poor food and unsanitary living conditions. (25) Here is proof that a noted American observer of society saw inequities existing in his own community between ethnicities.
In recent years, other sociologists observed the impact on health care for those with low socio-economic status and lack of education. The detailed analysis of these factors is completed by Barbara Ehrenreich in her book Nickel and Dimed: On (Not) Getting By in America. In her experiment, she tried to survive as a low wage worker living in different states and working two- three jobs at the time. Being a single elder woman she could barely make it from pay check to pay check. Her rent payments were high and living conditions are unbearable. Her co-workers with children had even worse conditions. Besides rent payments and food they had problems
finding cheap day care for children or someone to help watching them while they work several jobs. It was practically impossible to have an adequate health services without insurance and without money. It is very hard to think of own health condition when the roof and food are the initial problem that needs to be addressed.
Socio-economic status had a great effect on health outcomes. The cultural norms, traditions, beliefs, and language barriers also have an important effect. According to the Center for Prevention and Health Services, "even when they have the same health insurance benefits and socioeconomic status, and when co-morbidities, stage of presentation and other confounding variables are accounted for, members of racial and ethnic minority groups on the United States often receive lower-quality health care than do their white counterparts."(17, 18)
Cultural traditions, sensitivities and public stigmas are especially influential to health outcomes. (18) An example can be seen in certain American Indian tribal beliefs. Some hold the belief that talking about illness can cause the illness, and therefore, don't discuss medical conditions with their doctors. (17, 18) "Many American Indians continue to practice tribal religions and traditional medicine. One study reported that 70 percent of Navajos living on the reservation use traditional healers, while another found that approximately 28 percent of Indians living in Milwaukee and the San Francisco Bay area continued to use traditional practitioners." (19) "A Practical Guide to Culturally Competent Care" suggests that healthcare professionals avoid prolonged eye contact with Native American patients because, to them, it is a sign of disrespect. (19)
There is another very important suggestion made by the "Practical Guide to Culturally Competent Care," which is similar to the one mentioned in Anne Fadiman's book and should be learned by every health care professional who is involved in patient's diagnostic procedures. It
states that "…traditional and scientific medicine are not mutually exclusive, the patient may have come to you following diagnosis by a tribal diagnostician. Because tribal diagnosticians use different procedures, the patient may be unfamiliar with the technique of identifying the specific location of pain. Rather than asking, 'Where is the pain?' doctors are urged to ask the patient to point to the most intense area of pain." (19)
It is also important for healthcare professionals to remember that health doesn't have the same meaning for all cultural groups. For Eastern civilizations, health means psychosomatic harmony. The pervasive Chinese life philosophy is the theory of yin and yang. "The central thesis is that the universe consists of two basic principles or natures, Yin and Yang. (20)" Yin is feminine, negative and dark, whereas yang is positive, bright, and masculine. Their interaction influences the destinies of creatures and all animate things. This means that when yin and yang are in harmony, a person is considered to be healthy. "According to the Yin-Yang theory in Oriental healing arts, health is a state of physical and spiritual harmony ruled by great natural principle. Disease and sickness stem from a disturbance in the Yin-Yang principle." (20)
"From an Islamic perspective, health is viewed as one of the greatest blessings that God has bestowed on mankind." (21) Healthy living is part and parcel of Islam. The Quran and the Sunnah outline the teachings that show every Muslim how to protect his health and live life in a state of purity. (21) For instance, daily prayer comprises both physical movement and mental concentration. The obligation to pray five times a day helps to promote a good blood circulation, breathing and muscles and joint movements. (21) Following strict rules and regulations of Quran and Sunnah which promote the harmony of physical and spiritual state is considered to be healthy. "Muslims adhere to the teachings of Islam; they would automatically lead a healthier lifestyle." (21)
In order to support Muslim's perspective of health, healthcare facilities have to accommodate a proper praying place. The simple mark of Kaaba direction would be a great help. According to the Encyclopedia of Islam, Kaaba is the cubical building or a stone and is the sacred location in Islam. The location of the most sacred place as it is the direction of prayer, or as we Muslims call it, qibla, which can be simply marked as East or North East in US. This little accommodation enables the faithful to know in what direction they should pray and makes Muslim patients feel better about themselves and possibly improve their recovery. If Muslim patients are deprived of the possibility to pay respect to God five times a day and prepare themselves to pray in a proper way, they cannot be considered devoted Muslims as per an Islamic perspective. As a result, they do not consider themselves healthy, no matter what the attending physician or medical findings say.
Richard Couto said, "Americans have so little sense of community, we pay a great deal of attention to it."(26) To better serve the needs of our American community, we Americans need to implement mandatory cross- cultural classes in health care facilities, professional schools and make them available online as carrier development credits. We have to change public health policies to reflect the diversities and views of health care in different cultures. We should add to these improvements by hiring more translators to help us discover each individual person's view of what constitutes health.
Paulo Freire, in Pedagogy of the Oppressed, states, "It is necessary that the weakness of the powerless is transformed into a force capable of announcing justice. For this to happen, a total denouncement of fatalism is necessary. We are transformative beings and not beings for accommodation." We have to educate minority, racial and cultural groups about different possibilities of healing outside their cultural and traditional confines and learn from them. We
have to learn that we cannot simply force everyone to a bio-medical perspective of healthcare but carefully and respectfully try to accommodate both the person's view and the prevailing medically proven modalities of health.
There are many ways to reduce health disparities in the United States such as improving economic and social conditions for all citizens, most especially provide educational opportunities. This will help to enlighten future generations and allow unfamiliar medical practices to support existing cultural and traditional differences. There are also ways to reduce cultural, racial and ethnics' disparities in health care. The implementation of cultural competency techniques described by the Agency of Healthcare Research and Quality (27) gives detailed steps of how to reduce cultural health disparities. Here are few steps:
Interpreter services
Recruitment and retention of minority stuff
Cultural competency training
Use of community-based health workers
Administrative and organizational accommodation of such important factors as location and hours of operations.
While preparing this paper, I interviewed Columbia University healthcare professional Luiza K. , who is a research supervisor in their OB/ Gyn department. I asked her opinion of cross-cultural techniques and their implementation in her medical center. I was assured that the cross-cultural training is available and is mandatory as are online free classes for all Columbia University employees. The interpreter services are available for more than 50 languages. Here is evidence of an attempt to accommodate immigrant needs with respect to health care, but inequalities still exist.
As a professional medical interpreter myself, I can confirm that my credentials as a Russian medical interpreter were verified and entered into the system. Luiza K., as a senior employee of ten years and a person making hiring decision, stated, "... between two candidates with similar education and experience for the same position, the preference and a job offer would be given to the one who has knowledge of different cultures, is fluent in other languages and capable of providing additional cultural education to his co-workers." Her words are proven by the statistics of hospital employees. In fact, many health care professionals are immigrants and hold some sort of medical degree from their home country. For instance, Luiza K. is a neurologist from Albania, and here in America, following the required period of training, she became a research worker.
According to Columbia Medical Center web site faculty diversity as follows:
African American: 6%
Asian American: 14%
Hispanic: 4%
International: 7%
Native American: 0%
White: 69%
Unknown: 0% (29)
"In 2004, Columbia University created the Office of the Vice Provost for Diversity Initiatives, charged with the mission of increasing the diversity of faculty, administrators, and research officers, with special emphasis on identifying, hiring, and retaining members of groups historically under-represented in American higher education. The vice provost also works to create policies and programs that enhance the quality of work life and work-life balance of all members of the campus community." (28) This initiative gives opportunity to minority and
oppressed groups to become students in the Ivy League School and to become a valuable faculty member in future.
Based on the data I have presented here, I see reason for hope if health care centers, medical centers, clinics and community centers can implement these suggested techniques- some already in practice- and, with the government's vast sources of funding and network of support, improve the entire picture of public healthcare in America, and, with time and educational outreach, diminish the cultural, racial and ethnic disparities that prevent all of us from accessing the full spectrum of healthcare in our country.
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1. US Department of Health and Human Services. History.
http://www.usphs.gov/aboutus/history.aspx
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29. https://colleges.niche.com/columbia-university/diversity/
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