David Jims PSC 353 – Latino Politics Fall 2008 Research Project Latino Health and Healthcare Latino healthcare is a new, but controversial issue, not only because of the political, legal, and social challenges created by the influx of Latino immigrants, but also because federal, state, and local governments have failed to display a cohesive effort to develop solutions that address the unique issues faced by this growing segment of our population. Numbering well over 40 million today, Hispanics are the fastest growing minority population in the country. Their population continues to grow and is expected to rise annually by around 1.5 million. By around 2030, one in four U.S. residents are expected to be Hispanic or of Hispanic origin. (Tienda) Although the number of Americans who identify as Hispanic has increased, there has been no apparent corresponding increase in the funding or standards of healthcare, health education, and insurance targeting that demographic. Since obesity, cardiovascular disease, and diabetes are but a few examples of the rising health concerns (especially among second- and third-generation Hispanics), there must be a fiscal and social response to the fundamental demographic change in our communities. In fact, the cost of ignoring the health concerns of this expanding segment of our population will be far greater than addressing it, and will ultimately be absorbed by the already over-burdened American taxpayer. We must first identify the major health concerns and barriers to care that exist for such a large population of immigrants and subsequent generations. One of the major health concerns for the Latino community is their decline in health once they come to the United States; the question remains, why is this happening? One cause may be acculturation; Hispanics slowly but surely begin to live the relatively unhealthy ―American lifestyle‖, which is viewed with a mixture of envy and resentment across the globe. Acculturation is defined as 1. A change in the cultural behavior and thinking of a person or group of people through contact with another culture, or 2. The process by which somebody absorbs the culture of a society from birth onward. (Encarta Dictionary). Acculturation, as an important tool for immigrants and the immigration process, can dampen the national pride one feels towards their country of origin. It occurs in Latinos who are immigrating to the United States today, as it did for many Europeans 100 years ago. It is important to note that these times are both similar and different. The Latino immigrants have much the same background as many of the Europeans; that is, they come from large families with low incomes, and (oftentimes) are desperate and need money to support their families. Another similarity is that the people who had lived here for a generation or two found that these new immigrants were a detriment to their way of life, as can be said for today. However, the differences are derived from a change in modern American culture. Many of the European immigrants arrived in a country where the cultural mores were similar to the ones at home. They were also surrounded by many other immigrants who were facing the same challenges that they were facing themselves. The country was in a time of change, with less established laws and practices. Today, Latino immigrants often find themselves more alone, and faced with the challenge of adapting to a culture far different from the one they recently left. Like their European predecessors, one of the major ways Latino immigrants can find acceptance into American culture is through acculturation and assimilation. The danger in this is that while they are becoming more and more like citizens of the United States and less like citizens of their nation of origin, they are becoming less healthy. New Latino immigrants have been found to have much better health than citizens of the United States. The scary thing is, that while they assimilate to the culture in the United States, with the subsequent changes in diet, music choice, and media, more proficiency in the use of the English language, increased knowledge in the history and culture of the United States, cultural identity, and association with U.S. values (Lara, 372), Latinos become less and less healthy. This decline in health can be primarily attributed to changes in diet. Dietary changes are leading to a huge spike in obesity and diabetes problems among recent Latino immigrants. These changes come from many challenges that arise from coming to a new land. Food availability becomes one of the largest issues. A Mexican diet, for instance, primarily consists of corn, chilies, beans, tomatoes, and fruit. These foods tend to be natural, fresh, relatively cheap, and accessible. In the United States, much of the food that we consume is heavily processed, more expensive, less accessible in certain areas, and can be made with lots of preservatives. Cost increase in produce and fresh, organic foods can deter Latino immigrants from getting access to foods that they were used to eating in their native country. Cheap foods (i.e. ones that are more heavily processed and can have a much higher amount of calories) can be more readily available to low income families. ―Hispanics in the US are eating fewer complex carbohydrates and more simple sugars, fat, white sliced bread, vegetable salad, mayonnaise, flour tortillas, sweetened beverages, snacks, sweets, and meats.‖ (Gray) McDonalds, and other fast food chains, replaces fresh, home-cooked meals. Also, Hispanic families tend to spend more time together and rely on each other for support and help. More often than not, Hispanics spend more time eating together and spending more of their down-time with one another than Americans. By coming to the United States, many Latinos must work long and strange hours in order to keep the influx of money enough to support a sometimes very large family. This disparity in schedules leads to different eating habits and can result in Latino families no longer being able to eat meals together. Another reason why there are relative health declines as more immigrants move here is that second-generation Hispanics are more likely to engage in risky behaviors. Findings indicate that ―more acculturated Latinos (those who are highly acculturated) are more likely to engage in substance abuse and undesirable dietary behaviors and experience worse birth outcomes compared with their less acculturated counterparts.‖ (Lara, 374) This dangerous outcome is not always the case however, but unfortunately abuse of substances is higher among women than men. This can include drug and alcohol abuse, which is more visible the longer families have been in the country. This behavior can also be attributed to acculturation issues. ―Acculturated Hispanics were nearly 13 times as likely to report using illegal drugs as non-acculturated Hispanics.‖ (Oregon) The same is true for acculturation and drinking, since ―research also showed that acculturated Hispanics were almost twice as likely as non-acculturated Hispanics to report current binge drinking and more than three times as likely to report drinking continuously for days in a row without sobering up, also known as bender drinking.‖ (Oregon) But acculturation does not always lead to negative behaviors. It is shown that, through acculturation, ―the ‗protective‘ or positive effect of acculturation on some health care use behaviors (e.g., cancer screening) has been accounted for by higher educational and income levels among the more acculturated.‖ (Lara, 376) But this is somewhat limited to immigrants who become educated and successful. The necessity lies in educating larger groups of Latino immigrants who may not know of the risks they face. But, these acculturation risks are part of the immigration process. What should not be part of the process is the government‘s lack of participation in helping Latinos gain better access to quality and affordable healthcare in all parts of the nation. Underrepresentation from the government at federal, state, and local levels can be extremely hurtful for the Hispanic population, especially in rural areas, where they are severely misrepresented. Places like Kennett Square, PA and other large agricultural areas are continually bringing in immigrant labor to work in fields, factories, and warehouses to keep their businesses booming. With the growing population, healthcare coverage becomes important in these rural places that may have little or no Spanish-speaking healthcare providers. The language barriers are a stifling block for Latino patients, especially in rural areas where there are fewer translators provided by hospitals. People who get treatment in hospitals in rural areas are more likely to have family members translate, which can more often than not lead to ill-informed patients. This is due to the translator‘s unfamiliarity with medical terminology; while translating, they tend to translate words that they understand and leave out the important medical terms. This can be dangerous because ―25 to 50 percent of words and phrases are transmitted incorrectly by informal interpreters.‖(Torres, 109) It‘s important to know all of the different side-effects of medicines that must be used, and any other procedures that can be taken to assure competent medical care. By missing out on these important facts, Latino patients tend to get poorer treatment. The reason why more interpreter services are not more widely used is due to the large costs that can be incurred. ―The annual cost of interpreter services ranged from $1,800 to $847,000‖ (Torres, 109) which is often not on the budget for small hospitals in rural areas. Studies have shown that areas with large increases in Latino population place a huge demand on interpreter services: ―About half of respondents indicated ‗high‘ or ‗very high‘ demand for Spanish services in emergency departments (50.9 percent), followed by outpatient (33.8 percent) and inpatient (28.7 percent) settings.‖ (Torres, 111) ―Brochures (46.7 percent), posters (36.2 percent), cards (32.9 percent), and telephone voice menus (27.6 percent)‖ (Torres, 113) were the primary types of reading material that were displayed around the hospitals. Oral interpretation is one of the most vital ways to communicate with a Latino patient, but sadly the most used ways of oral interpretation are ―bilingual employees whose primary role is not interpretation (79.0 percent), telephone interpreter lines (68.8 percent), and friends or family (47.8 percent).‖ (Torres, 113) Almost ninety percent of hospitals also stated that they had Spanish documents which were given to patients in order to help with the language barrier. ―The primary documents in Spanish were the Patient‘s Bill of Rights (81.1 percent), consent forms (72.4 percent), and health education materials (71.9 percent).‖ (Torres, 113) What‘s also extremely important when looking at a hospital‘s level of care and efficiency with Latino patients is whether or not the government has provided assistance to help with the growing problems. About a quarter of the hospitals involved in the study said that the CLAS (National Standards on Culturally and Linguistically Appropriate Services) standards were not useful in creating a policy for a working language assistance program. CLAS standards are ―standards [that] are primarily directed at health care organizations; however, individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible. The principles and activities of culturally and linguistically appropriate services should be integrated throughout an organization and undertaken in partnership with the communities being served. The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14).‖ (National) Most of the hospitals involved in the survey reported that ―funding for interpretation and translation‖ (Torres, 114) was their largest barrier to success. Of the responding hospitals who were successful, there were some interesting and varied ways of dealing with the problem, none of which were exactly the same. Solutions ranged from business proposals, written policy, staff and interpreter training, partnership in budget-tight areas, and full-time interpreting. (Torres, 114-116) Other potential solutions can include mandating a nation-wide test which will certify people who wish to become interpreters at hospitals, which is a much harder job than is seen at first glance. Others could be to increase the amount of documents that have information in Spanish regarding all different types of treatment options and things along those lines that better inform Spanish-speaking patients if there are no interpreters to help them understand their situation. With the declining economy it seems less likely that the United States government will want to dole out more money on education and training programs that can be controversial, but it‘s important that when we make it out of this economic funk, we realize our obligations to our newest citizens. At that point, the government can initiate funding to all hospitals to establish a cohesive plan for interpreter services for those who need it. Funding remains the key issue in whether or not movements such as rural hospital assimilation are successful. It remains the issue for other types of institutions as well. Lack of funding can reduce productivity, a result in other large business organizations also. There are a number of large corporations whose aim is to find health solutions for the growing Latino population. These groups are usually accessible via the internet or phone, but that can prove to be a problem for people who need the most help. These groups include National Alliance for Hispanic Health, National Hispanic Medical Association, Pew Hispanic Center, Medline Plus, Hispanic Health Council, National Council of La Raza, and Hispanic Health Initiatives, to name a few (there are many other health advocacy groups which cater to a larger audience as well). Many of the smaller groups such as Hispanic Health Initiatives, which is based in Central Florida, hold educational events concerning diabetes, cancer, obesity, and family health. Their goals and programs are aimed to ―teach preventive medicine, disease management and behavioral changes known to promote healthy lifestyles.‖ (Hispanic) These educational tools make the organization a resource to the community. HHI states that they work with Latinos in Central Florida, many of whom are uninsured or under-insured. HHI also ―utilizes culturally sensitive and linguistically correct health literature and professionals,‖ (Hispanic) which can be a large help to the Latino population, because, as stated before, language barriers are some of the most difficult to overcome. ―Referrals to free or low cost medical services link the medically under-served to health services existing in their communities;‖ (Hispanic) a long-standing concern for Latino citizens is the quality of the professionals they seek help from. By advocating certain doctors, it not only helps HHI‘s constituents, but it also ensures that the doctors retain a large patient base. These services give confidence and allow Latinos in Central Florida to make informed and conscientious choices about their health. Access to help in more localized areas, such as the one from HHI, can make a dramatic difference to the populations of these areas. Much of the problem is the lack of these organizations; if one exists, one may be unable to attend meetings due to strenuous schedules. In order to address the problem, we must either create many more localized organizations, or we must extend the outreach of the larger non-profit organizations (NPOs). These NPOs are disjointed, in my opinion, and would better serve the Latino community as a larger, cohesive group that focused on changing laws and providing health services in a more accessible way. Accessibility and funding are the biggest challenges for companies who are working to help the increasingly large Hispanic population. Increases in funding for NPOs can only happen if research is performed that indicates that the efforts produce positive results. But, there are a few institutions that are fighting for the growth of Latino organization in healthcare. Groups such as The Latino Coalition are fighting for very specific goals; these goals are comprehensive and can be attained with funding and collaboration. The group lists eight steps which should get them started in the right direction. First, they want to enlarge market-based choices to decrease uninsurance by giving tax credits to small businesses, grant tax breaks for people who do not have access to employer-subsidized coverage, encourage wellness savings accounts, and create a ―one-stop shopping center‖ for health and healthcare coverage. Second, The Latino Coalition will begin creating help centers for health in heavily populated Latino areas. These centers will be used for development, interventions, and demonstration projects. These could also be used to educate youth to look for jobs in the medical fields because of the lack of Hispanic medical workers. The centers will also focus on receiving money from grants to help support the programs as well as create a community based bank that can be used for specific purposes regarding community projects, etc. Third, by increasing awareness and outreach, they hope to get as many children who are eligible started on Medicare or Medicaid so that they utilize all of the funds from the United States government that are available to them. The fourth step is to create a national multimedia center that will work to inform people around the United States about The Latino Coalition‘s goals, what they can do to provide care, and how to access them. This media center will also be an important tool to have political leaders get together and talk to their constituents about problems and solutions that will be faced from a political standpoint. It will also be important because it will be an excellent way to inform Latinos of the new innovations or potentially harmful/deadly diseases or illnesses. This can easily be done through television stations such as Telemundo or Univision. Step five would include expanding the initiatives designed to guarantee a workforce with different healthcare options. This step would also include more opportunities for student financial aid. Sixth, The Latino Coalition wants to reform medical malpractice. Medical malpractice lawsuits dissuade qualified physicians from working in underserved areas as paid physicians or volunteers. This is important to amend because ―20 percent of the U.S. population currently resides in primary medical care Health Professional Shortage Areas (HPSAs), which include minorities living in both urban and rural settings.‖ (Valdez, 35) Seventh, by creating better information for the Latino population, they wish to create incentives for adoption that can be given to the large number of teen Latinas who are pregnant. The Latino Coalition also hopes to establish standards to be set for information technology, set up privacy regulations and identity verification procedure, and promote information technology to the community. Lastly, in order to continually obtain enough funding for this type of venture, they must continually keep progress posted regarding Latino health and healthcare. This can be done by including midterm reviews that are accessible to the public, by improving the collection of data so that analysis and reporting are more accurate, and distribute fact sheets regarding Latino health. (Valdez) I think that the most interesting aspect of the Latino healthcare issue is the government‘s lack of (or seeming lack of) empathy and help for Latinos, especially those who are here illegally. Despite their lack of legal documentation, they are human beings, and I believe that it‘s our government‘s job to help keep all people safe and healthy regardless of their citizenship status. Secondly, I believe that they are a vital but ignored segment of our economy. My hopes are that the United States government can establish a comprehensive reform policy to make it easier and safer for illegals to become naturalized citizens of the United States. If that is not a complete solution to the problem, I only hope that issues such as healthcare and safety for illegal immigrants can be addressed through social awareness and education. Groups such as The Latino Coalition and Hispanic Health Initiatives are moving in the right direction and require more attention. Quality mental health services for Latinos are also underdeveloped. There are many stigmas that must be addressed within the Latino community, as many people have few options for mental health care within the increasing populations of rural areas. Important issues such as: distrust based on experiences of oppression, exclusion and mistreatment language barriers and expectations culturally insensitive and biased assessment, testing and intervention modalities conflict in value structures and constructs regarding family, children, and elders overcoming stereotypes, lowered expectations, and issues of merit (Soto) must be addressed to battle acculturation stigma associated with mental health. The listed above issues are not only found in mental health, but all different types of medical concerns. It is found that ―Mexican Americans who were less acculturated relied more on general medical providers for mental health care than on mental health specialists.‖ (López, 1569) Social factors also play an important role in deciding whether or not to get treatment; for example, the ―conceptualizations of distress, including nervios, and the social context—for example, the availability of social and professional support—are related to help seeking among rural Mexicans.‖ (López, 1570) The stigma associated with receiving help for mental issues runs deep, and can be felt in groups other than the Latino population. With the increases in mental health diagnoses in the past few years, it is hopeful that the Latino population will also access mental health services. It is productive for mental health patients to talk to a doctor who is of the same ethnicity. An awareness of issues and values within an ethnicity can only enhance services to that ethnicity. Thus, it is essential that more education and acculturation take place so that doctors of all races can become helpful in different parts of the country. Jose Soto, Vice President for Affirmative Action, Equity and Diversity at Southeast Community College Area in Lincoln, Nebraska, thinks that we must follow these steps in order to achieve the desired goal of providing quality mental healthcare in rural areas (he includes urban areas as needing assistance too): an inadequate distribution of mental health professionals and program support staff with adequate and relevant training focused on effective treatment strategies and programming to meet the mental health service needs of Hispanics/Latinos in rural communities; the dearth of empirical and evidence-based data formally documenting the health/mental health status, needs and access problems for Hispanics/Latinos residing in rural communities; the unavailability or inaccessibility of primary and specialized services that are of high quality, comprehensive, community-based, culturally competent and linguistically accessible, and integrated with primary prevention efforts and the broader system of services; inadequate or no transportation to access programs and services available in the immediate regions; a shortage of competent bilingual mental health information and service/care providers; and complacent and culturally insensitive systems of service/care that do not understand, accommodate, nor utilize the alternative models of culturally-based illness and treatment that exist in, and are critical to, effective mental health interventions and treatment with Hispanic/Latino communities. (Soto) These goals are a great step in the right direction, and I believe that we must decide to use these criteria other areas of healthcare reform targeting Latinos and Latino immigrants. The challenges our nation faces as it accepts another generation of citizens from other lands are, by no means, small or easily surmounted. However, it should be apparent to all of us that our fastest growing population; that is, Latinos and Hispanics, deserve our attention, as well as our concern and respect. It is our duties as Americans to accept these challenges, and work to provide support and resources to those individuals who come here for a better life. Ignoring these challenges, or fearing the unknown, can only lead to the failure of our nation, which is ultimately a tragedy for all its citizens. Funding has, and will be, their biggest issue, which is why the United States government must step in and provide what is needed to help these hardworking organizations succeed. So we have to do something to help this growing problem. As it stands ―the 77 million Americans who had no insurance for all or part of the year left healthcare providers with $56 billion in unpaid bills. Most of that bad debt — $42.9 billion — was absorbed by a medley of government programs led by Medicaid and Medicare‖ (Carroll) which are paid for by the American taxpayer. The time for debate as to the necessity of addressing the issue is over; we must, in good conscience, act immediately. References: Carroll, John. "Counting the (True) Cost of Covering the Uninsured." Medical News, Inc. 2008. Medical News, Inc. 23 Nov. 2008 <http://www.medicalnewsinc.com/news.php?viewstory=195>. Gray, Virginia B., Jeralynn S. Cossman, Wanda L. Dodson, and Sylvia H. Byrd. "Dietary acculturation of Hispanic immigrants in Mississippi." Salud Pública de México. Oct. 2005. Instituto Nacional de Salud Pública. 23 Nov. 2008 <http://www.scielosp.org/scielo.php?pid=s003636342005000500005&script=sci_arttext>. ―Hispanic Health Initiatives, Inc. – PROGRAMS & SERVICES.‖ Hispanic Health Initiatives, Inc. 25 November 2008. < http://www.hhi2001.org/6.html>. Lara, Marielena, et al. "ACCULTURATION AND LATINO HEALTH IN THE UNITED STATES: A Review of theLiterature and its Sociopolitical Context." Annual Review of Public Health 26.1 (Apr. 2005): 367-397. Academic Search Complete. EBSCO. [Library name], [City], [State abbreviation]. 28 Nov. 2008 <http://navigatorwcupa.passhe.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h &AN=16580478&site=ehost-live&scope=site>. Livingston, Gretchen, Susan Minushkin, and D‘vera Cohn. ―Hispanics and Health Care in the United States: Access, Information and Knowledge.‖ Pew Hispanic Center. 13 August 2008 < http://pewhispanic.org/reports/report.php?ReportID=91>. López, Steven Regeser. ―A Research Agenda to Improve the Accessibility and Quality of Mental Health Care for Latinos.‖ Mental Health Care for Latinos. Psychiatric Services. December 2002 Vol. 53 No. 12. <http://psychservices.psychiatryonline.org/cgi/reprint/53/12/1569>. ―National Standards on Culturally and Linguistically Appropriate Services.‖ U.S. Department of Health & Human Services: The Office of Minority Health. 12 April 2007. 13 November 2008. < http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15>. Oregon State University. "Hispanic Drug Use Rises In US Culture." ScienceDaily 13 August 2007. 13 November 2008 <http://www.sciencedaily.com /releases/2007/08/070812173257.htm>. Soto, Jose J. "Mental Health Services Issues for Hispanics/Latinos in Rural America." In Motion Magazine 30 May 2000. Tienda, Marta, and Faith Mitchell, eds. Multiple Origins, Uncertain Destinies : Hispanics and the American Future. New York: National Academies P, 2005. Torres, Myriam, Deborah Parra-Medina, and Andrew O. Johnson. "Rural Hospitals and SpanishSpeaking Patients with Limited English Proficiency." Journal of Healthcare Management 53.2 (Mar. 2008): 107-120. Academic Search Complete. EBSCO. [Library name], [City], [State abbreviation]. 25 Nov. 2008 <http://navigatorwcupa.passhe.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h &AN=31459124&site=ehost-live&scope=site>. Valdez, Josh, and Robert G. De Posada. Strategies for Improving Latino Healthcare in America. Latino Healthcare Taskforce, The Latino Coalition. Borderhealth.org. 21-44.