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.
Cultural Metrics — Part 1 . . . is a continuation of the following series:
- Applying Culture to Managed Care Metrics
Cultural Metrics — Part 1
Over the years I have varied the way in which I review culture and medicine. For nearly twenty years this was a central theme for my courses taught in pharmacology and health at Portland State University in Oregon, relating culture to plant medicine and plant chemistry in order to define the basis for many claims being made about plant remedies. The reason culture has to be applied to better understanding medicine related to how people as patient perceive the form of health they are receiving, its place in their personal philosophy about health and disease, and how much control they have over the influences and outcomes that the specific forms of medical care they are receiving wil have upon their bodies.
Diseases and medical conditions, as well as how we engage in improving our personal health or not, are the primary factors that determine our long term outcomes when it comes to health and longevity. The primary cultural component of health in the United States is defined by the allopathic system, which bases its theories and methodologies on the most advanced, most proven scientific processes used to prove and disprove certain ways to modify the body and its disease state, and to improve the quality of life people have in this paradigm on health care. But there are also individuals out there who don’t possess the full knowledge base that the physicians their care have, and so as a result open their mind to other ways of interpreting the health of the body and the forms of care it needs. It is these people who have beliefs and attractions to other methods of practicing medicine that engage in the less traditional forms of therapy and improvements of the body. Even though certain parts of the dominant form of medicine in this country allow for and at times even believe in these other forms of healing, we don’t often see these two different avenues taken to improve health merged into a single professional allopathic or regular medical discipline.
Culture has its way of adding even more contingencies to how we interpret ourselves, our health status, our need for care, and the types of care we need. Culture helps us to define our own acceptance of our current state of health, our overall appearance, our ability to be active and to reach certain goals in life, our abilities to make our selves better or not. Culture defines how and when we decide to turn to health care when staying healthy becomes a major stumbling block in life. Whereas culture in general, as a whole, defines our first reactions to becoming ill and as we search for medical help, it is that more personal or private culture that we are raised with by family members that provides the additional support we need whenever we need to engage ourself further in various ways to become healthier and perhaps better in a way not normally revealed to us by the world at large.
The Health Belief Model for providing care and promoting disease prevention and the elimination of unhealthy behaviors follows this premise. This model states that individuals, people, culture and our surrounding environment define whatever belief system we have, and how we use this belief system to better ourselves or allow our body and health to get worse. Now, not everyone likes to think that diseases can somehow get better due to what you believe in and make a part of you life. There are some things that no matter what we believe, they will not go away, like a deterioration of the body due to genetic trait, the loss in certain biological functions due to aging and tissue breakdown, the loss of circulation and/or nervous system function due to changes in receptors, inbred geographic and morphological features inherent to our 5-part addiction receptors, or the basic make up of our myelin sheaths. We also find it difficult to prevent certain activities that we know can ultimately make us worse physiologically, such as poor diet, lack of exercise, tendency to engage in chemically-related activities. But still, there are some aspect, at least for most of these, that certain forms of belief systems will either result in better health due to active engagement, or worse health due to inactive engagement.
In cultural medicine, the driving force for some of these HBM-related and non-HBM related events are related to pure physiological and genetic traits at one end of the spectrum, and to purely culturally- and personally-defined behaviors and events at the other end. It is even possible that some of these hard core physiological, morphological, chemically argued reasons provided for such happenings as addiction and certain human behaviors, will be eliminated in a generation or two from the common medical literature and its attached chemical marketplace (drug claims and ads). We allow these changes in older, less effective drugs to occur due to our beliefs in overall systems improvements–such as a better understanding of autoimmune disease or the genetic reasons underlying certain physical disease events or traits, and ever certain psychiatric and psychological states and diagnoses. Not that I am saying these methods for developing therapies and treatments are wrong. I am stating this mostly in order to point out that culturally-derived theories, be they of traditional western medicine origin, or from indigenous, African Caribbean, Oriental, religious and dozens of other cultural philosophies. These other traditions also important roles in defining how and why we consider ourselves as sick or healthy and how each of us tries to proceed when the goal is to get healthier. Perhaps not in all cases does this part of the patient’s psychology play into how he/she will get better with care, but in many of the cases of public health problems that exist, there is a role that human psychology and culturally-linked support or lack thereof play in how, how fast and which way a patient will get better, or not.
This is the reason that cultural metrics have to be developed and applied to the monitoring of patient health. We have practiced public health analysis and developed medical intervention based primarily upon a medical school theme–often referred to in the past as allopathy. On the side, doctors allow other cultural happenings to exist, and make it a point to try to document them whenever they can in the medical records. But when it comes to surveillance, or evaluations of patients for what other forms of health care they are receiving, and how these could impact the active programs being funded, only as individuals do providers engage themselves in obtaining the cultural medicine background information. Even then, this information short and succinct, and perhaps not enough to incorporate into any clinical studies. Whereas twenty years ago, the recommendation of a palm tree for treating prostate disorders was mocked and condemned by all MDs and nearly all MD students, today it is not unusual to hear some of the top MDs from the same school of medical students recommend such a treatment to male patients in their 50s, 60s and 70s. The same goes for most specialty doctors, ranging from pediatricians and gynecologists to cardiac disease and chronic autoimmune disease specialists. Such recommendations are less often seen for the more debilitating types of diseases or systems influenced, such as cancer and certain neurological conditions.
In some respects, cultural medicine also pertains mostly to the “alternative” and/or complementary fields of therapy in modern medicine. One popular trend is to try to rename it integrative medicine. Unfortunately, however, ethnicity and culturally defined cultural medical traditions are very infrequently mentioned in the medical records. In some cases, we will see clusters of human behavior patterns (on behalf of the patient, the doctor and the medical records coder) take place, such as having an African caribbean patient residing in New Orleans who practices voodoo traditions on the side and goes to the shop with the word names Botanica more than they commit to a local public health clinic for his or her diagnosis. We rarely saw evidence for a focus on cultural diagnoses in past medical records due to the confusion linked to how to make and code such a condition. With ICD10 becoming a reality, some of these diagnoses will now be more possible, and suddenly appear as part of the routine datasets we are provided with for population health reviews.
With this most recent improvement in ICDs, electronic medical records development and evolution, and the improvements made in Big Data and GIS possibilities, it is not impossible for us to begin to incorporate cultural analyses into any standard annual review process. With well educated providers, administrators, coders, and analysts we can for the first time see the amounts of detail required for cultural medical metrics to be developed. The one malingering issue in this kind of work is how do we accurately define ethnicity and culture in people, and then determine which diagnoses these various labels can most be attributed to? For this reason, if we begin the development of cultural medicine analysis now, early on in the ICD10 period, we can prevent the need for this practice of analysis being developed later once the ICD10 system is stabilized, and suddenly the need be recognized for better, more culturally-centered forms of care, analysis, treatment, and prognoses be developed.
Based on the content of the several sections I developed on Cultural medical anthropology, culturally-linked diseases, culturally-bound syndromes, and cultural geography-linked disease patterns or sets, the following can be defined as metrics potentially applicable to basic population health measurement programs, and more advanced population health measurement programs with subgroups defined based upon culture or ethnicity.
This method of reviewing population health, and culturally-defined sub-groups health, is also briefly mentioned on several other pages related to my older GridEcon approach to evaluating large systems health data (GIS in 2000). For smaller programs and datasets, the focus is on small area, well localized regional health conditions and their related health care needs. This manner of population health analysis is much easier to perform that the much broader approach demonstrated for GridEcon. But some of the premises are the same:
1. Foreign born diseases are important indicators of changes in public health for a region. Four kinds of diseases were linked to this form of surveillance:
- diseases transmitted person to person that we are normally immunized against, namely all the HEDIS Childhood immunization diseases for both 5 year old and <2 years of age groups of patients.
- diseases linked to foreign lands either by in-migrating people or returning travelers and tourists.
- diseases linked to international migration patterns by wildlife
- diseases linked to international commerce (infected pets, plants, foodstuffs, contaminated clothing, etc.)
2. Culturally-linked diseases are expected in the future to be conditions in need of better attention paid to their prevalence and impacts on long term health care. There are numerous examples of culturally-linked diseases and syndromes uncovered for this study over the years. A number of these are important to United States population health monitoring due to their possible non-cultural attributes, namely their inheritability. Examples of these include a number of physiological or anatomical conditions yet to be fully understood, such as cardiac conduction disorders, cardiac and cerebral vasculature conditions, specific anatomical cardiovascular anomalies, and certain inherited blood dyscrasias link to specific regions and cultural groups. The traditional statements made about gastrointestinal cancers, such as the differences between oroesophageal and gastric cancers brought on by one class of tannins (phlobotannins) versus colorectal cancers possibly linked to another linked to another class of tannins (macromolecular polymeric tannins) serves as a good example of this controversy, initiated and tested for in the 1970s. Some of the most culturally-linked diseases, for the time being, are those genetic diseases with partial expression, such as Sickle cell disease and certain thalassemias. Infrequently are teratogenic-like diseases culturally bound due to their normally environmental origin, but some sociocultural settings increase the likelihood that these conditions are expressed, resulting in a very strong clustering pattern in the vicinity of these cultural settings. These conditions border on being culturally bound, and the more they are linked to unhealthy behaviors, the more likely they are best considered culturally-bound syndromes.
3. Culturally-bound diseases have the potential for having the greatest impact on the cost of health care in well defined cultural settings, with increase in-migration over time having a greater influence on these health care systems than growth in population size brought on by internal family size increases. Nearly all foreign or immigrant groups have the potential for these maladies. Most culturally-bound syndromes require both personal and social support to form and exist, with the possibility of having their amount of impact on an individual’s health definable using specific metrics or checklists design to document the degree to which these cultural influences are essential and therefore co-exist. Interventions for these syndromes have a dual piece for care that must be considered, and documentation of these events in the database will help to reduce their counts and severity, but also help to define underlying psychological and lifestyle factors responsible for these maladies. This makes them very preventible.
Some of the most prolific examples of culturally bound syndromes pertain to personal psychology traits and habits. Sexual phobias, insecurities related to spousal or significant other relationships, uncertainties about social display and appearances form the bulk of these syndromes. The driving force for these conditions are personal security, fear of social attitude or judgment, and actual interactions of an uncertain nature between the individual with the condition and his/her social environment.
Most of the time, these conditions are completely behavioral in nature, but they can have a strong reliance upon social and family influences. This latter aspect of the condition is what turns these diagnoses into population related sociocultural health related diagnoses. In traditional western US medical settings, the interpretation of these is first based upon traditional western medical paradigms. Phobias, depression, paranoia and schizoidal affects, bipolarism, are all possible diagnoses for conditions that have a unique cultural reason for onset. Insomnia with night horrors becomes unexplained nocturnal death syndrome for Laotian elders, but rarely children. An attack of Aire may be considered the common cold by western MDs. The Pibloktoq of Inuit young adults and Amok of the same for southeast Asian people of the same age range may be misclassed as an affective disorder, a form of dissociation, or a delusion-related condition. When it comes to any diagnoses that has a possible mindbody relationship, the diagnosis is ultimately going to be pure western or mixed western culture in nature, which unfortunately can have a great,influence on how the condition is to be effectively treatment and prevented from recurring.
4. Culturally-rich population settings will have different statistics attached to even the most standard disease sets, such as diabetes, hypertension, asthmatics, cardiovascular disease, drug use and smoking behaviors, STDs, various western culture defined psychiatric and psychological conditions, and even epilepsy. A better understanding of these diseases and conditions requires that we better understand the socioeconomic and cultural, even anthropological status of a community where certain physical medical appear to be accelerated or increased in prevalence due to local cultural beliefs and care systems.
For example, the 1970s Navajo reservations in the West had a significantly greater number of parent-child case relationships for children with epilepsy; this culturally-derived behavior for children with epilepsy contradicted tradition practices of a century or more before in this cultural setting, and was an easily definable cultural behavioral problem in need of interventions that developed due to the community understanding of epilepsy. This behavior greatly contrasted for example with the practice of similar culturally-bound practices for managing children with epilepsy and other medical condition in the northern temperate indigenous community settings and within the Inuit settings. Adding to this possible culturally-bound, preventible behavior is the significant increase in seizure incidence and diagnoses also noted by WHO for the immediately neighboring country of Mexico, versus the US rates, suggesting the possibility that as Hispanic and related cultural settings grow in size and number, that a similar increase in incidence will be seen in the U.S. setting.
5. Genetically-based. Other more culturally-related disease patterns include the higher incidence of developmental, embryological and genetic disease traits linked to specific religious groups that tend to remain close knit socially and therefore genetically. There are also certain chronic disease related diagnoses expected to increase in acculturated foreign born groups.
There is the traditional Darwinian and more recent Neo-Darwinian way of looking at some of these conditions. Their results are defined by health beliefs, personally, in terms of family, and culturally. This follows the health belief model I often attached to understanding the potential impacts of physical and behavioral exposure, assimilation, acculturation, on specific groups with specific disease histories. The classic example taught of this pertains to the Alamedo study of Italian families in-migrated into this country, which over time became more segregated into the rich and poor, and who in a generation or two suddenly transformed from a culture with health elders to one with elders diagnosed frequently with cardiovascular diseases, purportedly induced by their diet. The culprit many claimed was the high fat, sausage rich Sicilian foodways, but public health professional have often expressed their opinions that this may in fact be more of a social behavior-induced problem, focusing on the development of social inequality concerns.
Health Belief Modeling of Syndromes and Disease. To modify these potential impacts, the health belief model was employed, meaning that in theory such changes can be reduced if health beliefs are somehow remaining unchanged. My classic case of this with behavioral, psychological health is the issue with epilepsy. Patients, parents, family and friends are taught certain expectations about this diagnosis, and once it reaches a certain level of severity, ultimate long term poor quality of life outcomes become the expectations, beliefs continuously taught to the you patient with this diagnosis. There is a Pavlovian effect (sorry for the older term here) that defines much of what then alter ensues. In a study of seizures performed decades ago on cats, cats could be trained to have a seizure based on certain behavioral programming events. The way people behave towards someone with epilepsy provides the stimuli needed to re-confirm the expected outcomes of this diagnosis. Such social beliefs encourage less healthy responses in the long run. We can related this reasoning to how the Inuit with pibloktoq behave and progress. They outgrow their pseudo-” and true epilepsy like experiences, because it is an expected consequence of aging for those experiencing between the age of older childhood into the 20s. Similarly, we have expectations with tic syndromes that produce cases of this in adults, whereas global statistics of this diagnosis in the US suggest it is mostly if not nearly 100% a childhood age diagnosis, that either continues into adult life or goes away. The numerous cases of tic syndrome onset in adults in 2010 illustrates this socioculturally-induced increase in diagnosis quite well.
One of the most ironic diagnoses of the early twentieth century pertained to native Americans residing in the western states. Primarily reservation-bound, there were numerous examples of cases with the diagnosis of bradycardia, a considerably slow heart rate, usually below 90 beats per minute. This was an effect of their manner of transportation, on foot, over long distances, ranging from a brisk walk to the ongoing run between places of residence. During the early 1900s this was diagnosed as a physiological anomaly but not quite a disease state. It later was linked to other cardiac and metabolic conditions and considered a cardiac syndrome evolved by anthropological means. We transformed this diagnosis into first the “New World Syndrome” in 1988, and then into a consequence “Metabolic Syndrome” as the bradycardia disappeared and obesity became the major concern.
Throughout all of these events, it was the different aspects defining quality of life that were actually changing, as Native Americans were at first forced to live underfed and in poverty, but decades later afforded plenty of opportunities to be supplied with ample food stores and opportunities to become more sedentary. It was these cultural change that led to the redefining of primary systemic effects, organ system activities and ultimately illnesses developed or created due to these culturally defined lifestyle changes. On behalf of the allopathic view of these changes, a new use for an old paradigm came to be, and New World Syndrome became a part of the Metabolic Syndrome diagnosis, a re-assignment of the causes for this state from cardiac to endocrine, effectively eliminating the former human behavioral component of this theory for the diagnosis. Such a transition is an excellent example of the role cultural interpretation plays in assigning meaning to a diagnosis. Like many other forms of cultural medicine, even western medicine is simply a result of the predominant philosophy for the time, namely that of its own traditions.
This illustrates how subjective the use of traditional cultural versus tradition modern or western medical diagnostics techniques may become when attempting to diagnose, and then treat a culturally bound and culturally linked, and even culturally-relation physiologically induced condition or disease. ICDs and terms used to define conditions and assign meaning to them are very much a paradigm related way of interpreting disease, no matter how detailed they try to be and non-subjective they strive to become. The more subdivided ICDs and other diagnostic flow charts and tables become, the more human and subjective they are in the end, and the more arguable are their interpretations regarding long term effects and recommended therapeutic activities.
Setting this critique aside for the moment, based upon my medical geography, medical anthropology and GIS evaluations of nearly 3000 chronic diseases by age-gender 1-year increments, a national population health grid assessment of 300 to 450 ICDs serves as a good cultural and human behavior health measurement technique. The cultural studies and metrics reviewed in this section can be used to evaluate regions locally and culturally, with or without demographic ethnicity or other cultural data. These reviews are for the time being not expected to be correlated with any national population health statistics of comparable utility, due to the lack of a publicly available dataset for any such similar study like the population health grid produced using more recent data. But these reviews will assist in the basic development of regional cultural population health studies, similar to those developed for the GridEcon ethnology-based population health reviews detailed elsewhere.
Working research theme: Documenting Epidemiological Transition and Cultural Disease Patterns within a Managed Care Setting
Brief Outline in 2011: Cultural ICDs bear the following major ethnic or cultural groups or classes
- Cultural Groups
- African/African American (Muslim and non-muslim)
- Native American
- South American
- Religious Groups
- Smaller Cultural Groups
- Religious vs. Non-religious?
- Cultural vs. Non-Cultural?
- Social-Urban vs. Utopian Rural-Isolated?
I will build upon these lists on the next page.