Brian Altonen, MPH, MS

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Note: this page and neighboring pages are from older teaching materials used 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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This page is the first stage in developing a method for analyzing cultural health patterns within a given region, assigning risk to the patterns of diseases, medical claims, case management events, and various medical (V and E) codes assigned to medical data developed for a given region. The focus of this review is culturally-rich or culturally-defined social settings or regions. Its purpose is to develop a method for evaluating and comparison two or more regions of varying culturally-defined population settings.

A number of pages have been devoted to evaluating ICDs linked to regions and culture at this site. A large scale study of regions was posted which was focused on health care in the Pacific Northwest. This page consists of about two dozens of brief reports detailing the results of special studies performed of this region over a twenty year period. A number of other pages I developed review health and disease with different socioeconomic issues in mind, such as poverty and disease, chronic disease patterns and health, disease incidence and prevalence in relation to where families reside, the relationships between race or ethnicity and types of diseases acquired due to racial differences, and numerous other examples of the relationships that inherently exist in any medical system due to social inequality and disease.

On some more recently developed pages I wrote on the use of population pyramids for disease modeling and preventive health planning, the role of managed care versus other forms of care on population health in general, and the use of spatial techniques for analyzing disease patterns at both the small area versus large area level. Some of the outcomes of these projects were in turn used to develop this study of a section of the western Great Plains, in particular the relationship of this methodology to the potential that exist for the new health care programs being promoted as of 2013, the managed care plans required by federal agencies. For the regions in and around Colorado, as discussed briefly on previous pages in this section, one of the ways to monitor disease patterns that is in need of extensive development is the application of methods already in place for epidemiological and quality assurance/quality of care research to better understand the different impacts poverty or socioeconomic status (SES), regional demographic patterns, social and income inequality and race or ethnic have on the health of the subpopulations defined using these characteristics.

On a previous page I define the four major classes that can be defined for differentiating diseases from each other to apply the disease data to population health and SES inequality research (the order of these is changed slightly):

1. In-migrated–infectious and non-infectious diseases carried in
2. Culturally-bound–linked to cultural belief systems and typically requiring sociocultural support by family members and friends
3. Culturally-linked–linked to anatomical-physiological causes that are usually genetically related
4. Culturally-related–common diseases for which culture plays an important role in how the people tend to have higher prevalence rates or more severe examples of cases; culture plays a role as well in impacting health care provisions, which may also make these diseases worse.

I also defined a way to review populations as subgroups or groups of people bearing certain relationships to each other based upon the size of the research area referred to and the variations in culture, human behaviors, medical histories and and amounts of good health versus bad health in these given economics and health care coverage based medical regions. Six major regions were defined for use in interpreting area-derived data, with the much larger groups and areas applied to large regional or national studies, the mid-level groups and areas linked to middle-size area single to multiple states settings, and the smallest groups to service districts identified for health care provider groups and large scale businesses, and local to very local small group health care providers. Of these, the smallest three groups are best evaluated using the cultural approach to evaluation regional health behaviors, practices and service patterns, with the smallest group favored in most occasions when dealing with culturally-related public health concerns or issues.

For this part of the analysis, two population groups were identified as in need of evaluation when it comes to quantifying the success or failure of a public health care providers’ program and a disease control or prevention program. These two levels of population health service define for us where changes need to be made locally in a given care system. These two most important aspects of locally sponsored and administered health care are as follows when it comes to producing successful local small area assessments with public health goals in mind:

• Cultural, referred to as Neighborhood on this page,
• Community

Culture and Heritage

To identify cultural groups in a given area, the easiest thing to do is turn to the processes engaged in for producing the US Census. The census has several centuries of development history and a highly tested series of methodologies used to define people and populations. For quite some time, census records focused primarily on certain ethnic groups, and with time allowed for more and more groups to be included in the possible response to the surveys. Most recently, the developers of the US census enabled people to select more than one choice for their response. Assuming the responses to all census surveys are truthful, this may add power to the role the census plays in understanding how various types of people are distributed about this country. But the addition of multiple selection options set the stage for several problems in epidemiological research for both culturally and personally defined health issues as well as purely demographic or population density related issues.

The first problem with the new and old systems of gathering ethnicity and racial data pertains to applicability and validity. A cultural lifestyle and underlying cultural habits are not just defined by these characteristics. It requires a belief system and surrounding state of cultural mores and taboos to define a person’s way of being, his or her personal habits in relation to the kind of lifestyle he/she believes in. However, for the most part, we cannot completely rely upon belief systems and implied behaviors to guide us in our research of population health. An advantage to retaining race/ethnicity in any population studies pertains to background, family medical history and cultural/race/ethnicity related genetic traits that can be linked to such studies. For this reason, it helps to include race/ethnicity data as well as race/ethnicity related data in our studies, using them to develop methods of more accurately analyzing ethnicity, race and culture in relation to important public health issues.

The second problem with culture, race and ethnicity questions, in particular due to the option of selecting more than one answer, is that we have complicated the study somewhat. Again, a person who one generation ago may have checked African America as his/her race or ethnicity may be no more accurate in this response than someone who today clicks two of these boxes, for depending upon the genetic expression of the body’s health state, neither individual may actually bear a racially related disease trait, but still possess some of the culturally linked chronic disease problems linked to a combination of lifestyle choices, such as family and peer pressures regarding how we live, eat, engage in preventive activities, etc., or how we are provided with the opportunities needed to engage in such, in the form of adequate access to these facilities and the income needed to afford some of these much healthier lifestyle practices and behaviors.

There is a certain amount of social, sociocultural, family-related and personal attitudes at play when it comes to defining the lifestyle we opt to experience. For this reason, I anticipate the first problem we will see with certain not-so-well defined cultural health attributes to be hidden somewhat by the noise generated by other datum that are labelled as examples of these social classes or labels, yet pertain to individual who have features not at all anticipated by this ethnicity history. For the time being, this means that some corrections or adjustments in reviews of results may have to be made for making a much more direct link between health and certain activities.

The Human Genome Project and all related studies and services related to this study offer scientists an opportunity for more accurately defining the relationships based on genetics, family heritage, location, culture, and numerous anthropological metrics developed for race and ethnicity biological features. For the time being, maternally defined genome attributes are still considered experimental to some extent, and most certainly incomplete at this point in time, and so due to the limited value of this large regions approach to study race, culture and health, this project remains on the back burner for the time being.

In a review of the internet for methods of classifying large populations of people into culturally-defined subgroups one large scale project in the development process was noted in wikipedia, and is used to initiate this evaluation of regions and culture, in particular pertaining to the midwest Colorado cultural environment.

The following cultural groups were identified as important to the Colorado setting according to this wikipedia review:

• Jewish
• Hispanic
• Native American
• African/African American
• Oriental (originally termed Chinese)

This represents a starting point for this study and is best considered an example of a fairly broad classification system for cultured in the study region. The further breakdown of these major cultural groups based on further study and field experience suggests the following should be used to further define the subgroups to be added to these local population cultural types.

Jewish Culture and Neighborhoods.

In the New York setting for example, the Jewish culture has a variety of subcultures, each with its own lifestyle habits and related health care features and health-related genetic traits. The most important subdivision for a review of the Jewish people within the New York area would and should involve the separation of Russian Jewish cultures and traditions from the much larger population of Jewish residences throughout the state. Another very traditional Jewish culture in the region, Hassidism, has its own social features and its own personal and community health related practices, its own foodways habits, and its own lifestyle, family planning and stress management practices and behaviors.

Within the Colorado setting, the development of such a very distinct social entity for the Jewish lifestyle has not been uncovered.

Hispanic Culture and Neighborhoods.

A major historical feature of Colorado that helps distinguish its hispanic culture and tradition pertains to the pre-Columbian period of the region’s history when these lands were settled by people descended from and/or migrating out of what is now Mexico. These hispanic settings are very different from the more recent in-migrating cultures found throughout the state, and due to these distinct heritage differences, the older Hispanic group of landowners make it a point to remain a separate entity from groups and families arrived in the region during the 19th and 20th centuries. The occupational histories of these two groups are very different from each other, and it is possible that certain health related behaviors and practices might also be distinctly different, even though outward evidence for these differences are hard to identify.

This same intraethnic cultural or subcultural difference exists in other parts of the United States as well. In the Pacific Northwest for example, the hispanic cultures common to these is region are relatively speaking, the result of recent in-migration and arrivals. A large number of recently in-migrating hispanic cultures possess a very difference financial history and a very different culturally-defined life style with related public health concerns. It general, it seems that a more complete and thorough evaluation of the hispanic lifestyle in any region needs to undergo significant analysis at the regional, local and community-neighborhood level. Foodways vary considerably between different Middle and South American hispanic regions in the world, and as a result some of the health-related risks each of these groups possess could also be significantly different.

Due to the size of the hispanic population within the United States in general, a more detailed retain of this group is required before any significant changes can be made concerning their health care programs and practices. Suffice it to say that local areal studies may be initiated with plans for developing local small area public health programs related to these people, but in the end, a fairly large area comprehensive study needs to be developed to isolate and deal with very well localized health features versus very large area health features.

Within Colorado itself, three types of hispanic communities have been categorized in one of my recent essays. There were large area, politically defined town and urban settings in which hispanic lifestyle predominated and defines nearly all of the local culture, there are areas where pockets of hispanic lifestyle exist and may or may not be different from the nearby communities, and there are these transient hispanic settings where seasonal workers reside primarily, and many members of the hispanic community are more likely to be members of lower income classes. Somewhere between these three types of communities are the hispanic landowners who possess large lots of land and engage in cattle ranching and other forms of livestock and agricultural related land use activities.

Native American Culture and Neighborhoods.

There are several western United States features of Native American geography that relate to how we may interpret Native American public health in the west, in particular within the Colorado setting.

The first important detail of Native American history relates to the mixed histories that exist regarding Native American heritage in North America. Along the west coast, there is a distinct difference historically and culturally between Maritime Native American groups and inland Native American groups. The Maritime groups have a history of greater isolation and more detailed subdivisions of culture than the much more broadly expanded cultural groups of the midwest that Coloradan Native American groups tend to be related to. A considerable amount of evidence also suggests that these cultural heritage differences have a moderate to minimal effect upon health differences in terms of somatic disease (disease developed due to anatomical and physiological physical body histories), but cultural disease traits could be significantly different between the two.

In addition, as a group with a specific history of economic duress in this nation’s history, there are certain lifestyle features that communities share in relationship to poverty, alcohol abuse, drugs and smoking, and exposure to diseases more typical of other developing countries in the world. For example, the Hanta virus became an important concern in the 1990s due to the poor sanitation and living conditions of Native Americans residing in the middle-Farwestern United States region. This resulted in the migration of this disease ecologically into the Pacific Northwest due to local climatic and ecological changes, not people migration. So there are some disease related features of Native America culture that are regionally defined, but culturally dependent, mostly due to socioeconomics and income levels more than any well-defined social and political cause and effect relationship.

This means that review of Native American public health require both some standard public health metrics be developed and some very local ecologically and climatically based metrics be developed. To define Native American cultural differences, it may help to apply some of the basic transportation routes-physiographic logic to dividing this population into its cultural “neighborhoods” so to speak. This definition of neighborhoods in general would serve a preventative medicine purpose related to infectious disease patterns and diffusion behaviors, but also assist in the development of public health related program development.

The Native American cultural medicine and public health studies resemble the problems that exist within the Oriental cultural settings. Place, climate, weather, methods of self-sustenance, foodways, daily living habits, healthy and unhealthy behavioral attributes, religious practice, traditional health care practices and philosophies, and even core languages and communication practices can be very different from one subculture to the next. For this reason, Native American public health reviews even in smaller large areas require applications of both a splitting and lumping taxonomic process.

Another distinct subdivision of Native American people to consider as well pertains to some of the most commonly published topics of Native American public health and epidemiological work. A new branding of issues evolved beginning about twenty years ago due to the rise in certain environmental-linked disease patterns in urban-adapted Native American populations. Asthma is the most important of these conditions.

A number of other assimilation/acculturation linked disease states related to Native American health related to everything from obesity, diabetes, hypertension and heart disease to the most basic population health attributes related to pregnancy rates, tobacco use history, and STD rates, in particular for chlamydia. Any and all ICD-related health attributes related to the New World Syndrome hypothesis published during the 1980s must be evaluated as a culturally distinct entity related to Native American culture, not as the more generic metabolic syndrome diagnosis it has been linked to in recent years for which certain medical diagnoses like gall bladder disease are not as easily linked.

African/African American Culture and Neighborhoods.

The African/African-American cultural setting has several major subgroups to consider based upon religious upbringing and lifestyle. There are Christian African communities, Islamic African communities, and traditional African communities, each with their own lifestyles and health related practices. In the past, we have had a tendency to merge these groups together, although important differences exist between each of these groups.

The most significant difference between these cultures pertains to the practice of infibulation, a female genital manipulation tradition practiced on young women. This is a tradition practiced mostly by Sudanese African cultures, but can extend across different parts of the mid-continent Interior, westward towards the Ivory Coast.

Christian African communities tend to have a tendency to produce more cases of diagnosed malnutrition and malnutrition-linked diseases, due primarily to the active interventions taken by missionary programs. Christian programs also demonstrate a pattern of foreign born disease in-migration for certain highly ethnic- and region-link microbial diseases like Noma, Yaws, Bejel, and Elephantiasis.

Traditional African history impacts local history primarily as a cultural feature and therefore has the likelihood of producing a number of culturally-bound syndromes. Some of the better known culturally-bound conditions relate to the practice of voodooism, traditional African healing practices, certain forms of herbal medicine use, and certain forms of demonic possession and other culturally-defined conditions.

Oriental Culture and Neighborhoods.

The traditional merging of Oriental cultures into a single group has a number of public health related problems this could result in. There is a significant amount of separatism practiced in Oriental culture due to a variety of political and non-political reasons. Even within what we consider to be a single country, multiple cultures can be defined, each speaking its own language. In Laos and Vietnam for example there are the indigenous and non-indigenous cultures, with the latter residing in well traveled, economically active parts of the country. In the northern backwoods region there are also the Hmong, a culture descended from China that crossed the country borders in order to reside also within indigenous lifestyle settings. None of these three types of cultures fully interact, and are considerably different from nearby Thai and Cambodian cultures. Likewise, the blending of Filipino and Korean cultures with the various Chinese American and Japanese populations (not including the indigena of Russian owned northern Japan) makes it important to try to obtain a better more sophisticated understanding of any small local Oriental groups served by the local public health programs. For some southern Southeast Asian communities, acupressure equivalents are practiced using smoldering moxi sticks or the equivalent to such in the form of smoldering tobacco rolls (iogars and cigarettes). This could mistakenly be diagnosed as a form of abuse or mistreatment by an untrained western medical physician.

Certain regions of the U.S., usually in proximity to big cities and in very active agricultural sections of the country, have a several decade to two century old tradition of managing these different cultural groups in and out of the local, state and federal health management industries. A merging of information gathered officially and unofficially about these events may help to service these parts of the health care industry better in the distant future. By mapping out this particular cultural history of medicine and disease, we are at least provided with more insights into whatever problems such events result in.

Historically, the each of the four major categories of diseases with some relationship to culture have penetrated the U.S. due to American-asiatic history. The most significant infectious disease to penetrate this country during the 1970s was tuberculosis, whereas today we are more concerned about Avian Flu and, at the government level, certain animal born rare and highly fatal diseases. Oriental traditions and behaviors have a long-lasting endurance and survival rate in this country as well. This enables certain psychiatric diagnoses to malinger within health care industries servicing this community, in particular the definition of schizophrenia, and there are certain culturally-linked conditions as well. Aside from Amok and other psychiatric-behavioral conditions, there are certain cardiac disease states like Sudden Unexplained Nocturnal Death Syndrome, and even certain food and traditional medicine linked conditions or syndromes.

ICDs selection

The identification of diseases that might be considered involved an assessment of several hundred ICDs. The first class of ICDs considered culturally-related were those with a foreign

The following metrics need to be considered for evaluating population health for this population group. For each of the four major classes of disease types, the primary ethnic groups defined for Colorado will be evaluated for the most part at the Neighborhood and Community Levels. Further subdivisions may need to be employed resulting in further breakdowns and group formations based on cultural history, socioeconomic criteria and the development of unique subculture types over the years that evolved in this region. Non-Coloradan groups will be used to provide additional examples, as the need requires.

• In-migrated diseases.
• Culturally-bound.
• Culturally-linked.
• Culturally-related.

. . . . to be continued . . . .