Volume 60, Number 3 - Summer 2009

 

By Carlos Garcia, MD

The saying “Never forget where you came from” resonates in my mind, especially when I treat Latino patients. I grew up in various poor communities in Southern California—we called them barrios—and was raised in a traditional Latino family where Spanish was the main language spoken at home. We attended church almost every Sunday and got together with family and friends practically every weekend for one festivity or another. Both my parents worked, but my mother took care of the household and made sure my siblings and I had our regular check-ups. 

I was exposed to the medical world repeatedly because I suffered from recurrent ear infections in early childhood and from epileptic seizures in late adolescence. During my many visits to family doctors, specialists and hospitals, I was both patient and interpreter as I tried to relay all the pertinent information to my parents. As I recall, no other interpreters were available. In fact, no one in the medical environment even looked like me or my family. 

These early experiences inspired me to attend medical school and eventually to choose family medicine as my specialty. As my grandfather used to say, “Whatever you do, do it with passion and all your heart—con pasion y todo corazon.”

When I began working for Kaiser Santa Rosa in 2003, I was pleasantly surprised to see how many Spanish-speaking members Kaiser had. However, I was disappointed to discover that many of them were seeking medical care at local community health centers because they felt more comfortable with staff and providers who could communicate in their own language. 

According to Census Bureau estimates, Latinos comprise 20% of the population in Sonoma County, 24% in Santa Rosa, and 35% in California. Latinos throughout the United States are a diverse, young and fast-growing population. Their average age is about 26, and their impact on the economy is increasing, partly because they are the labor force behind several billion-dollar industries. 

Latinos are the fastest-growing ethnic minority in the United States, and in 2005, they surpassed African-Americans as the country’s largest ethnic minority. Almost half the births in California are to Latino parents. According to recent projections, the Latino population will be the majority in California by 2030 and possibly in Sonoma County by 2040. 

Overall the Latino population is fairly healthy, partly because of their young average age. However, they face many barriers related to health insurance status and medical access. Latino adults are more than twice as likely as other Americans to lack health insurance, with an estimated 35% of Latinos uninsured, compared to 16% of the general population. 

Latinos also shoulder a disproportionate burden of certain diseases. They are twice as likely to have diabetes as Caucasian patients, and the rate of cervical cancer in Latino women is twice that of Caucasian women. Likewise, the rate of testicular cancer in Mexican-American men is twice that of Caucasian men. Many cancers in Latinos are detected at a more advanced stage than other groups. They also have a high incidence of AIDS. Their death rates are higher than Caucasians’ rates for several conditions, including chronic liver disease (75% higher), diabetes (66%), HIV (195%) and homicide (107%)

Latinos also have a greater prevalence of overweight, and their rates are going up as they acculturate to American society and diet. This trend will lead to increased risk of cardiovascular disease, diabetes, hypertension, gallbladder disease, and some forms of cancer.

When treating Latinos, physicians should keep in mind the many traditional therapies and belief systems found in Latino cultures. The therapies include herbs, home remedies, and traditional healers, such as curanderos and sobadores. The belief systems include several “folk” diseases, such as:

• Susto (fright illness). Seen after stressful events such as accident, surgeries or injury, and thought to lead to serious illness such as diabetes, cancer and stroke.
• Golpe (injury/hit). Thought to lead to cancers at site of injury, e.g., breast trauma or head injuries.
  
• Nervios (nervous anxiety). Stems from negative life issues, family stresses or interpersonal relationships.
• Empacho (stomach-wall sticking disease). Childhood disease in which certain foods or substances are thought to be improperly digested and become stuck to the gastric wall. Empacho is believed to lead to symptoms of anorexia, colic, diarrhea, nausea, emesis and bloating. 
  

It is important not to criticize these beliefs but rather to acknowledge them while still pointing out why certain herbs or methodologies may not be safe. One good example is asarcon, a powdered folk remedy for empacho that can lead to iron deficiency anemia in children. 

Acknowledging Latino cultural values is another important element for successful clinical encounters. These values include:

• Personalismo. Latino patients tend to care deeply about their relationship with their doctor. They expect personalization of care and an emotional connection. 
  
• Respeto. Doctors are highly respected in Latino cultures, which often translates into patients not asking many questions and nodding even though agreement may not be complete. Mutual respect is also expected. 
  
• Familismo. Family comes first. In certain situations, strong family support systems can be used to ensure proper treatment adherence and healthy outcomes. 
  
• Fatalismo. This value can be thought of as “God’s will.” Latino patients may express feelings that nothing can be done anyway, leading to noncompliance with certain recommendations. Cancer and diabetes are examples of diseases that spell death to many Latinos. 
  

Kaiser Santa Rosa—which has about 15,000 Latino members (12% of membership)—has expanded or implemented several programs that address the needs of the Latino community since I joined the facility in 2003. Some of these programs are described below. In the words of Cesar Chavez, “We must be aware of the needs of our community by knowing and recognizing the people within it.”

Interpreter Services. This service, directed by Merry Zavala, has been active for the past decade. We have eight Spanish-English interpreters who cover all departments, both inpatient and outpatient, from 8 a.m. to 8 p.m. They field more than 14,000 patient requests a year. They also helped translate patient instructions and communication guidelines on our campus and set up a dedicated Spanish appointment phone line. 

Field of Dreams. Developed by Edie Urteaga, this program can best be described as a community mobile wellness intervention effort. Since 2004, we have reached out to the community at wineries, factories and other businesses and have brought screening and education to over 1,000 employees, many of whom are Spanish-speaking fieldworkers. The goal is to promote health prevention and wellness and develop community awareness of these issues. The program includes screenings for hypertension, diabetes and HIV, as well as discussions regarding healthy diet, STD prevention, worksite injury prevention, and cardiovascular and diabetic risk reduction. 

Consulado Latino de Kaiser. This council consists of Latino members who meet regularly with Kaiser staff to improve the quality of medical care to the Latino community. The council provides valuable feedback on our services. Among their many insights, they have told us that Latino patients:

• appreciate not being asked questions about legal status
  
• are not all agricultural workers
  
• want to establish rapport with their health care providers
  
• have ambitions, life expectations and life goals
  
• value strong family ties and remain united in that way
  
• are respectful and want to be treated with respect
  
• are diverse in terms of culture, language, geography and socio-economics
  
• prefer to speak their own language whenever possible
  
• are private
  
• do not appreciate being called amigo by people they do not know
  

Clinica Santa Rosa. This newly opened clinic, where I serve as clinical director, is fully bilingual and culturally appropriate. More than 70% of my patients are Latinos, and about 80% of them prefer to speak Spanish when receiving health care. The clinic’s mission is to create a welcoming environment that brings cultural awareness and sensitivity to our diverse patient population. We hope to enhance our services by offering health-education classes and computer training in Spanish, and by recruiting more Spanish-speaking volunteers. 

The five Fs—faith, family, friendships, food and festivities, and futbol—are the bedrock of Latino culture. Although these ideals are not all-inclusive, they are a fair representation of the Latino community, which is mostly a tight network of friends and families. Word of mouth in this network is more powerful than radio, television or publications. 

Physicians and other providers can use this network to offer better education and resources regarding preventive services and wellness exams. We need to change the traditional philosophy that you visit the doctor only when you are sick; such a change will help curtail the many unnecessary ER visits and in the long run help diminish the complications and costs of diabetes and other chronic diseases. 

Finally, the medical community needs to do a better job in providing culturally competent care to all ethnicities, not just Latinos. Such respect not only benefits patients but also serves as a model for the larger community, which likewise needs to do a better job in recognizing and honoring our cultural differences.