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Note: this page and neighboring pages are from teaching materials designed for a lab on GIS and the corresponding lecture/discussion series developed on ‘GIS, population health surveillance, epidemiology and public health’. Since this project is currently being further developed it may at times be locked up for changes or implementation and “brand-related” concerns.
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Cultural Metrics — Part 3 . . . is a continuation of the following series (with links):
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Part 3 — Applications of ICDs and other codes to Cultural Medicine reviews
Defining Groups. Each of the following topics to be reviewed has two sections. The first pertains to their history and application in general. The second deals specifically with midwestern and especially Colorado topics.
To best understand ethnicity and culture in a given region, we first have to turn to the contemporary census data and then historical data. The recent census information provides insights mostly into the first listing of cultural groups, and a little more information for the second list focused on major religious groups. Historical, anthropological and sociological/ethnological reviews fill the gaps for smaller ethnic and religious groups. A third list that is helpful is of the smaller, more localized or sectarian like groups noted for the region, but this knowledge usually requires field work as well.
Developing A Cultural Healthcare Program
The kinds of cultures can start with the major groups defined for the region, and then involve religious cultures and finally subcultures. For example, the typical race/ethnicity evaluation is carried out, for the whole area, followed by the two or three major religions with important public health related practices, and finally the higher risk subcultures, some defined by income and neighborhood history, others by age-related lifestyles or belief systems and living practices (teenagers).
When looking at particular cultural groups, there are these basic questions for which answers must be obtained to understand the overall public health related history and future history related to that group’s activities and history.
The nature of these questions goes back to the four primary disease types define for cultural disease patterns in general:
- In-migration disease patterns
- Culturally-bound disease patterns
- Culturally-linked disease patterns
- Culturally-related disease patterns (diseases that impact everyone, but this culture more due to socioeconomic and cultural gap related reasons)
Some of the classifications are expected to demonstrate an overlap. One of the most important concerns pertains to infectious disease states that are immunizable making their way into this country. Concerns for this issue pertain to the following, in reducing order of concern: small pox, pox-related infectious disease patterns excl. chicken pox, measles, polio, diphtheria, pertussis, rubella and mumps. Infectious diseases that are immunized against and which are also of a ubiquitous nature can be excluded from this part of a cultural public health review, such as tetanus, influenza.
In-Migration. In-migration disease patterns and cultural behavior based disease patterns can be identical. Examples of in-migrating diseases include those that are due to an organism with a particular ecological requirement of an external nature; these organisms and their diseases are generally not infectious or spread that easily from one person to the next, and are due to living in the external environment for some time. The African diagnosis kuru, a result of traditional diets in certain parts of Africa, is one such example. The hispanic condition chiclero’s ear is due to a fungus infection set in due to residing and/or working on the Yucatan Peninsula; it is hard to spread to others by person to person contact. For certain parts of the US rhinosporidoidosis and coccidiomycosis are also examples, with spatial distribution patterns dictated by the ecology of their fungal causes.
Tuberculosis is one of the most important examples of a disease with combined human ecological, migratory and lat-long defined spatial distribution patterns. An in-migration of tuberculosis in a 65 years old adult male for example in the Pacific Northwest is no different than the same diagnosis in an American citizen anywhere else in this country, with the exception that the behaviors related to history and prevention of diseases with the poor are often very different. The in-migration of tuberculosis as a disease atypical for the U.S. has much more value and concerns attached to it by epidemiologists, than a new home-grown species of mycobacterium, which could be just as fatal and even drug-resistant. The attitudes we have about in-migrating cases, versus locally grown cases, are quite different from one another. The newly arrived case from afar is treated like it was an inbound Ebola virus case, or some livestock tick related disease, whereas the ever prevalent homebound disease requires less epidemic, more endemic-related thinking and philosophy when it comes to redefining your public health policy. When in-migrating diseases also have an indirect relationship with another category of American born cases such as congenital tuberculosis, or a localized resurgence in West Nile fever, or the re-emergence of enterotoxigenic E. coli with a bovine origin, the news of these public health problems often reach the next level of public health concern, and becomes a mass media topic.
In western rangeland communities, there are numerous disease patterns that never reach such a level of publicity. If so, we should see more reports published about case clusters of horse-generated tinea cruris (“jock itch”) in western cattle country, or cases of brucellosis and “mad cow disease” due to the numerous bison and elk in the region. The same is true for a host of other organismal diseases ranging from Giardia, to Listeria, to Salmonella, to certain forms of Shigella. Even though some lifestyle-place examples of these diseases do develop out west, the cases we hear more often about are related to big and small scale farmland and dairy communities, especially those devoted to organic meats and milk production. As a Pacific Northwest issue for example, public health concerns like these arise due to local community health popular culture movements. In the northern Midwest, it is possible the large numbers of tropical diseases found to exist so far north might be due to either rapid south-to-north movement away from the Tex-Mex border into this region, a possible reason Chiclero’s ear manages to make its way so far north without raising much concern or demonstrating a dense case history to the south, and a possible reason three isolated outbreak settings for tropical born yellow fever are located so close to the northern states border.
The same logic can perhaps be related to several other culture-ICD related infectious and non-infection microorganismal disease patterns. In the Pacific Northwest, an in-migration path for several unique inland born African origins disease patterns are seen, in particular for kuru. If we interpret the eastern country pattern of sickle cell carriers to be a consequence of a long history of in-migration linked to slave trade, and then compare that distribution map with the kuru in-migration map, we see two very different in-migration or cross-migration routes for this country. This demonstrates a primary reason to produce these maps. The same can be said for the several other infectious/non-infection disease in-migration maps related to Pacific Rim travel by Oriental and Russian people and diseases–the Chinese-related Pacific Rim diseases do demonstrate west coast Pacific Rim centered patterns for that half of the country, the Japanese patterns demonstrate west coast and central inland niduses due to post-war behaviors, and Russian patterns for disease migration show a much higher dependency upon the east coast cities, with little evidence for Russian livestock for example bringing microorganismal diseases onto the west coast the Pacific Rim routes. Similar analyses were made for South and Middle America in-migration routes and disease behaviors, and Australian disease in-migration patterns. We can only see these paths by mapping all the cases, not by sampling the cases due to the limited input and interactions between corporations with regard to sharing their datasets.
Cultural Bound Diagnoses. One of the major benefits of this cultural population health monitoring program pertains to problems that surface related to culturally bound conditions. Culturally bound conditions require a personal belief, a close-linked cultural heritage or history of this condition with matching belief system, and a sociocultural setting capable of providing the stimulus needed for such a belief to be generated and continue to exist. Culturally bound conditions arise due to the traditional teachings of a given neighborhood, community or other closely knit sociocultural setting. These teachings are normally suppressed by new world culture and the teachings of US doctors, but can re-emerge and be strengthened by those of a traditional cultural upbringing witnessing these events and/or by knowing about the local or family beliefs about the causes for these events.
It is the social experiences and beliefs about these diseases that in turn increase their credibility as a physical and mental medical condition for a given community. This acceptance of the belief in turn makes it possible for new cases to erupt by way of developing similar associations between a person’s mental and physical state. What normally ensues in such cases are reports of more experiences and an onset of still more conditional responses personally and socially to these claims. More individuals experience the condition or syndrome, more cases proving its existence are found, and finally, controversy develops followed by an attempt to solve this problem once and for all.
In hispanic cultures, the belief in diablo is perhaps one of the more common examples of these beliefs published in the literature. Diablo is more a belief in the existence of an unusual being in the wild, but results in the traditional environment for other culturally-bound cases associated with hispanic culture not to develop, such as susto, aire or even increased reports of cases of epilepsy, an indigenous requirement in some cultural settings for a child or young adult becoming a shaman.
There is sometimes a fine line to be drawn between culturally-bound syndromes and traditional psychiatric or psychological, behavioral conditions, with two distinctly different diagnoses, one cultural-bound the other not. Examples of this problem include the following:
- Insomnia :: Sudden Unexplained Nocturnal Death Syndrome (Laotian)
- Reactive Depression :: “Broken Heart Syndrome” (Hawaiian)
- Complex Partial Seizures :: Pibloktoq (Inuit)
- Dissociation Complex :: Amok (Vietnamese)
- Dissociation complex :: Diablo (traditional Mexican – Aztec/Mayan)
Ideally, a culturally-bound diagnosis will have a paired traditional allopathic diagnostic entry to be applied as well. The major difference in western philosophy versus a particular culturally defined philosophy is seen in how the treatment program is developed. Western allopathic culture derived methods may fail to produce a cure, whereas the traditional philosophy rapidly eliminated the disease state. This process of curing the condition represents a continuation of its causes related to onset, namely a personal belief in the possibility for such a comndition, accompanied by the sociocultural support of such a belief system, which in turn leads to development of a socioculturally acceptable curing or healing practice for the condition.
One of the most important lessons we can learn from a review of culturally-bound syndromes is just how much these scenarios and their causality also related to regular allopathic medicine and ICD9 or ICD10 diagnoses. Using an “outside the box” approach to reviewing some western medical diagnoses, we see numerous incidents where it is apparent that culture is playing an heavy role in the increased reporting and incidence of certain human behavior or biopsychological disease patterns. One of the better examples of this in recent years was the large number of cases of Tourette’s syndrome that were in the news in 2012. These stories demonstrated adults bearing tourette’s syndrome behavior. The normal age-gender distribution of tourettes show that it normally peaks in childhood years, and dissipates almost completely by the age of 25, with a few percentage of original cases maintaining that tourette’s syndrome tic-like behavior. This condition, along with nocturnal bruxism, sleep disorders, and various other social behavioral diagnoses all demonstrate nearly identical age-gender peaks, suggesting different manifestations with similar if not identical human thought-related, behavioral causes.
A similar set of cultural bound syndromes struck traditional western communities in the past as well. Around 1800, the condition of Divine somnambulism was first described when a your girl who was “speaking in tongues” claimed to be connected to the spirit world. About the same time, a case of chorea set in socially, when many of the the members of a religious group fell to the ground, as if paralyzed or suffering from spasms, a practice symbolic of various pentecostal forms of prayer, worship self-induced excommunication practiced to this day. Allopathic medicine and allopathic ICD9 or 10 diagnoses bear numerous examples of much the same belief systems generated today. Diagnoses of basic personality traits such as hyperreligiosity, polylalia, social detachment or withdrawal, are all very subjective in nature, and in many ways are no more true than the diagnosis of Hwa Byung by a Korean doctor (MD or TCM/L.Ac), Zar by a North African voodoo priest, Old Hag by a believer in wicca, windigo psychosis by an algonquin, or Ghost Sickness by a Navajo shaman. With culturally bound syndromes, definitions and diagnoses are truly relative, and are generated due to a belief system more than due to some physiological-anatomical argument.
Culturally-Linked. Culturally-linked disease patterns are mostly a product of demographics. There is a possibility that the identification of these syndromes and diseases increases in more heavily populated regions due to numbers and types of facilities in the region such as health or medical educational facilities and teaching hospitals, but also due to larger amounts of diversity, cross-cultural experience and expertise, and the variety of cross-cultural people and settings that exist. An isolated culturally-bound syndrome without family, neighborhood, and community support to back its possibility and existence can make it not only difficult for the condition to present, but also for it to be noticed, reported to individuals outside the immediate community setting, and then be diagnosed and entered into the medical records. culturally-linked diseases have less of these limitations to deal with. This makes it more likely for recognition of the condition to take place as well as an initial misdiagnoses to happen due to lack of expectation or expectations. In some cases, this also means that culturally-linked conditions and disease patterns may remain unrecognized until they result in unexpected hospitalization or mortality. Examples of these include cardiac conduction and morphology disorders associated mostly with African and Hawaiian people, and stress or PTSD-like induced sudden unexplained nocturnal death noted for Vietnamese elders.
Culturally-linked diseases may also include those with a culturally-related genetic basis, although culture is not the true cause for these conditions, only a limitation to their distribution due to human social behaviors. The best known of these include African-linked sickle cell, and the various mediterranean linked forms of thalassemia. Another possible example is a fetal/embryonic developmental condition which demonstrates a heavy aggregation around towns and cities on Long Island. Certain mental health conditions express possible familial-cultural patterns such as schizophrenia and bipolar diseases. The highly expressivee version of a metabolic syndrome noted in western Native American regions is also a possibly culturally-linked version of this condition expressed by other communities as well although in lesser form.
Culturally-related diseases.. Many chronic diseasees are expressed worse in certain ethnic or cultural groups. This is not due to the genetics or adaptability of these people to their surrounding social and ecological settings, but more a result of a complex blendingr of self- and culturally-defined human behavior attributes related to diet, exercise habits, work habits, lifestyle, and self or socioculturally induced poor disease prevention and health care or screening related mismanagement practices. Traditional examples are late screenings of breast and cervical cancer, misdiagnosis and subsequent mismanagement of tourette’S syndrome, epilepsy, and numerous psychological and psychiatric disturbances, and the inefficient internvetntion based treatment for quality of life altering chronic diseases such as diabetes, asthma, IBS, GERD, and rheumatoid arthritis.
Culturally-related disease patterns have the tendency to be less monitored or treated due to most of the same reasons these same problems impact lower income communities in much the same way. The combination of culture and low income related reasons set the stage for problems with prevention to set in. This makes developing a culturally-defined intervention system more complicated than just defining neighborhoods and communities and developing new programs. It makes it necessary for the socioeconomic status way of interpreting community health to be developed separately from the cultural status method, and the two be combined once these two independent ways of interpreting population health are developed. A culture-focused monitoring and public health scoring system can then be developed with independent and correlated metrics formulas developed, to define the relative risk of these two possible high risk community settings– culturally based and socioeconomically based.
Research questions
Each of these steps in the analysis of culture-centered population health has a number of underlying research questions that accompany such work. The following are examples of these diagnostic/ICD questions for the above four broadly defined types of analyses.
1. Culturally-bound Disease Patterns.
Does the group rely upon philosophies and attached practices that may be considered “not up to date” or “behind the times” in the current sense?
Does the group rely upon and/or practice heavy migration in and out of its cultural region(s)?
2. Culturally-linked Disease patterns.
3. Culturally-related Disease Patterns.
Which of the social misbehaviors and practices exist as a part of the cultural or neighborhood history?
Which of the social misbehaviors and practices exist, without any culturally-specific reason?
Which of these are mental health indicators for this population?
Which are culturally-bound diagnoses found mostly or only in this region?
4. In-Migration Disease Patterns
Which culturally-related infectious and non-infectious disease diagnoses are related to the region?
Does the group rely upon and/or practice heavy migration in and out of its cultural region(s)?
In other words, does such a region have well defined social and perhaps political borders that limit the flow of people, products and even knowledge in and out of its social setting?
Does the group rely upon philosophies and attached practices that may be considered not up to date in the current sense?
This question in particular pertains to the following important preventive health practices:
- Childhood immunization
- level or amount of refusal
- measles, mumps, rubella, typhoid, diphtheria, tetanus, etc.
With childhood immunizations, it is important to distinguish refusal to immunize from finding related to onset of the disease immunized against. These two spatial distributions are for the most part totally unrelated.
The reasons for this lack of any statistical relationship relate to the one to many problem. Refusal to immunize is one single behavioral practice. Reasons for onset of a disease are multiple, and include other causes not at all related to refusal behavior patterns. We see this lack of spatial relationship clearly with the most fatal of diseases for which immunization exists–small pox. The small pox cases are randomly distributed across the US and demonstrate no strong relationship spatially to the peaks in refusal seen for the Pacific Northwest.
The same is even more so for Poliomyelitis vaccinations, which are clustered in the upper middle Great Plains states near the Great Lakes on over to the western New York area. These cases are at the same latitude as the Pacific Northwest refusal to immunize, so a climatic effect upon polio behavior is probably ruled out, as well as the humidity effect normally associated with the Great Lakes. In some ways, this very small area clustering of the polio suggests and unique environmental requirement yet to be identified. It resembles very much the Rhinosporoidosis distribution, known to be of a locally specific environmental nature.
Religiously based refusal of care
- refusal of surgery but not medical care or preventive care
- refusal of immunizations (esp. for children)
- refusal of all care to children mostly, with individuals allowed to make their own choices after about 18 years of age.
- refusal of all care except emergent and urgent
- refusal of most minor acute care
- refusal of all acute care, due to accident, sudden onset of disease, or chronic disease
- refusal of most to all chronic care
- refusal of all care including emergent and urgent care
Belief in dietary limitations
- health or philosophically based dietary practices (including the standard new age vegan and such)
- religiously based vegetarian or vegan-similar practices (sually 7th Day Adventists and such)
- religiously based practices, in particular Judaic and Islamic in nature
Practice of polygamy (even without licensure involved)
Practice of child (14-17 year old, child-child or child-adult) polygamy, with childbearing goals
Life style related cleanliness
Degree of cleanliness – internally (indoors or household level), and externally (outside the household and community)
Teenage health practices
- Sexual
- Street drugs
- Foodways
- Healthcare Provisions
Traditional cultural ways reduce or prevent for the most part regular medical and social service provisions
Traditional cultural ways are mostly neighborhood-, family-, or self-administered
Traditional cultural ways are complementary, made available publicly for services, and have open business settings such as store fronts and offices
Little to no traditional cultural ways appear to prevail, but some individuals believe in these practices
Cultural Groups
- Native American
- African/African American
- Oriental
- Hispanic
Religious Groups
- Judaic
- Islamic
- Other
Smaller Cultural Groups
- Religious vs. Non-religious?
- Cultural vs. Non-Cultural?
- Social-Urban vs. Utopian Rural-Isolated?
Brian Altonen, MPH, MS 