Global Public Health and Marginalized Populations: Sexuality, Disability, Age, etc.

 05/28/09

This week because we talked about the evaluation and ethics of global health work I thought it would be good to wrap up the discussion about the health and rights of refugee and documented and undocumented immigrants in the United States by talking about the ethics of refugee and immigration policy. I think that U.S. refugee and immigration policy towards a country are often time de-linked from the political and economic policies also targeted at the country. And until we make the connection that many U.S. foreign policies undermine a country’s sovereignty and often destabilize its economy, I don’t think that we will understand the ripple effect of these policies and how they often disturb and displace peoples by turning them into refugees and immigrants. Because I talked a lot about refugee policies and health, I’ll offer how foreign policies historically directed at Southeast Asia have affected immigration. I also would like to briefly talk about Haiti.

Starting in the 19^th century the Vietnam, Cambodia, and Laos were established as the colony of French Indochina. During the first Indochina war staring in 1945, these countries were invaded and occupied by Japan. However, at the end of WWII, colonial interest again took root in the restructuring of these countries. This precipitated in the signing of the Geneva Accord and Vietnam being partitioned into North and South with the U.S. government throwing in their military and political support of the Southern government led by President Ngo Dinh Diem. Both sides engaged in military cross-fire; however Diem refused to hold the national election which had been worked out in the Geneva Accord, fearing he would lose. This was after Diem had rigged the elections to win the presidency for the Southern government, which was supported by the U.S. government. Though the government of Diem was very much corrupt and repressive, it was still backed by the U.S. because of fears that they entire region of Southeast Asia would be taken over by Communism. In turn, U.S. involvement in the region undermined the opportunity the country of Vietnam to determine its own sovereignty. The events that transpired next, of course, led to Vietnam War and afterwards a huge influx of refugees into the U.S. Furthermore, in countries like Laos, which were supposedly neutral during the war, the C.I.A. recruited Hmong mercenaries to fight along the Ho Chi Minh trail that ran through Laos. These individuals and their families were then persecuted after the war and had to flee after the fall of Saigon. In the case of the Vietnam War, the history of colonialism in the region and fear of Communism fueled European and U.S. foreign policy in the region which was a main catalyst for the war.

I would also like to offer the work of Paul Farmer in Haiti as an example of how U.S. foreign policy has clearly undermined the stability of a region and been a catalyst for the influx of Haitians into U.S. I think that most of us are familiar with Paul Farmer in the sense that he connects health inequities and disease to social inequities and poverty. But in his book The Uses of Haiti he discusses how invasion of Haiti in 1915 by the U.S. government, the support of the corrupt and repressive government of Papa Doc Duvalier, barring of refugees into the U.S., sequestering and detainment of Haitian refugees at Guantanamo Bay, armed humanitarian intervention in the area, and forced financial restructuring by the IMF have all affected and lead Haiti to be in its current state of instability.

What is meant by all that was just said? My hope is that in the near future when we are faced to look at the current immigration issues in the United States and make many key reforms we are better able to understand the factors that fuel current immigration to the U.S. Immigration and other issues are not contained in a vacuum. Much of the immigration into the U.S. is a direct result of U.S. foreign policies directed at countries with the outpour of immigrants.

1. Chang, Sucheng. “New Immigrants and Refugees, “Asian Americans: An Interpretive History
2. Le,C.N. The 1965 Immigration Act http://asian-nation.org/1965-immigration-act.shtml
3. Farmer, Paul. The Uses of Haiti

For my last blog (or second to last?) I wanted to take a look at health for older persons in a specific country, and I chose Kenya mainly because of personal connections there (I traveled there last year and am still in touch with some of the people I worked with).  I thought focusing on a specific region might be helpful in putting elderly health issues in a social and cultural context.  What I found was that efforts were being made, but with few documented results so far.

With the help of HelpAge International, a global nonprofit that looks out for the welfare of older persons, delegations of older people met with policymakers in Kenya in both 2007 and 2008.  They asked that the government to:

-Implement the recommendations of the Madrid Plan of Action on Ageing and the African Union Policy Framework and Plan of Action on Ageing.

-Complete and ratify the draft national policy on ageing by 2009.

-Provide universal non-contributory social pensions for all people aged 60 and over by 2015.

-Provide healthcare specifically tailored to the unique needs of older men and women.

-Provide free medical care for persons over 60 years by 2010.

-Review government employment policies – particularly those on retirement age, which should be increased to 60

The Kenyan government seemed very receptive to these ideas.  They scheduled follow-up meetings and promised to follow through.

However, despite 90 minutes of online searching through Google and various ageing- and health-focused NGO websites, I couldn’t find any information on what happened with these petitions in terms of either government action or real effects.  This seemed odd considering that two important organizations involved, HelpAge and the UN, have a very prominent and professional online presence. 

I was also surprised at the lack of media attention.  I couldn’t find any mention of action on elderly health in the international media (I mainly looked at the BBC and New York Times).  In the Kenyan “Nation” there were two articles from around when the delegations met, but nothing since then. 

There’s an excellent chance that this apparent lack of follow-through is due to the recent political trouble in Kenya.  However, the lack of attention paid to the follow-through even by international organizations is a little disturbing and shows just how low a priority elder health care is, particularly in Africa.  Hopefully some more information about these developments will come soon.

As I was scanning the internet looking for a topic to wrap up my final blog, I came across an interview reported in the National Alliance for Hispanic Health. The interview was aired on CNN and was on the topic of Latino teen sexuality and pregnancy¹. As I began to research the topic more and more, I began to realize that almost every factor I had touched on in my blog was present in this topic. I do not think that teen sexuality as a whole is the result of all the Hispanic challenges, but I think that in the careful analysis of one particular health factor it is easy to see how all of the other larger influences combine.

In one of my previous posts, I mentioned the fact that across the country, Hispanic teens have a higher rate of STIs and early pregnancies than both their non-Hispanic White and non-Hispanic Black counterparts². In an overrepresentation of their population, Latinos make up one quarter of all new HIV cases among 13-18 year olds in the country. Latinas are much more likely to give birth between the ages of 15-19 and much less likely to use contraception than any other major ethnic group in the United States³. The question is why.

As usual, the socioeconomic situation of the Hispanic population plays a large role. In many cases, Hispanics do not have the access to proper contraceptive care. Alternatives to condoms such as IUDs, patches, or pills require a primary health provider, and as such are largely inaccessible to a large portion of the Hispanic population—particularly the migrant workers. Likewise, even when preventative measures such as condoms are readily available in the stores, there must be a certain level of sexual education before they can be used properly. This educational barrier is especially noticeable at the youngest ages near the end of middle school when a shocking large percentage of Latinas have their first sexual encounters¹.

Interestingly enough, when interviewed the overwhelming majority of Hispanics (91%) responded that early pregnancies would inhibit their chances of success and that they would strongly prefer to go into college instead of having children¹. This apparent disconnect between expressed values and observed behaviors is a sign that the levels of unprotected sex are more complicated than a high level of irresponsibility.

One possible factor expressed by the study was the apparent disjunction between the message parents express to their sons and their daughters. In the survey, Hispanic females reported an expectation of virginity and purity while Hispanic Males reported a message of aggressiveness, possibly stemming from the ideal of “machismo”¹. Lack of open communication also plays a role in this dilemma. For women it is seen as embarrassing and impolite to openly discuss sex, and men are expected to respect women by not breaching the subject. This lack of communication about sexual issues can lead to problems in the future such as unsafe sexual practices, lower rates of condom use, and early sexual initiation².

Like every other factor, acculturation and acculturation stress play a large role in the sexual lives of the Hispanic youth. As explained in a previous blog, acculturation stress tends to lead Hispanic parents to be more authoritarian and less permissive. This can lead to problems stemming from their children rebelling against their parents’ more conservative values⁴, and a lower rate of using contraception for fear of discovery when engaging in sexual activity¹.

Even considering the behaviors independently of parental actions, there is a clear distinction of behavior based on the level of acculturation of the Hispanic youths themselves. This relationship is somewhat complicated and counterintuitive. On one hand, the least acculturated Hispanics are the least likely to engage in sexual activity. This is fully in line with the idea of acculturation, and the theory that the most un-acculturated population will retain the conservative views towards sexual activity held in their home country³. On the other hand, the use of contraceptives increases markedly with acculturation. This is also logical, as many forms of contraception, condoms in particular, are highly unpopular traditionally in Hispanic cltures². As such we see a pattern where Hispanic youths are at higher risk of engaging in sexual activity as they become more acculturated, but at higher risk of experiencing negative effects of sexual activity the less acculturated they are.

The same protective factors that we have seen before also hold true for this situation. As could be expected, the more cohesive a family, the less likely a Hispanic youth is to engage in sexual activity before a certain age. As such, bilingualism is once again a huge protective factor². Likewise, it would seem that increasing dialogues in Hispanic families might be one of the best ways to prevent early pregnancies and STIs. Education for the parents will also play a large role, as it will allow the parents to educate and enter into discussions about sexuality with their children.

Throughout these past seven weeks I have introduced Hispanics as a marginalized population and described the many facets of their barriers to good health. As a population, they are unique, and it is important to realize this when making any kind of intervention or policy change. The effects of acculturation, nationality, and region within the United States make it impossible to make health generalizations about the Hispanic population. Yet, given their current state, and the fact that in the near future they will make up a significantly large percentage of the country, they cannot be neglected. Regardless of the changes enacted in the future, any effort will have to come from the community itself given the highly cultural nature of the Hispanic challenge, and given its complexity any intervention will need to be mindful of the many factors influencing the Hispanic population in order to have any hope of serving this highly marginalized and rapidly growing population.

Martin

——————————————————————————————————————–

1. Basu, Moni. “Survey Delves into High Birth Rate for Young Latinas.” CNN: Living Well. 19 May 2009.
2. Deardorff, Julianna, Jeanne M. Tschann, and Elena Flores. “Sexual Values Among Latino Youth: Measurement Development Using a Culturally Based Approach.” Cultural Diversity and Ethnic Minority Psychology 14 (2008): 138-46.
3. Meston, Cindy M., and Tierney Ahrold. “Ethnic, Gender, and Acculturation Influences on Sexual Behavior.” Archives of Sexual Behavior (2008).
4. Wagner, Karla D., Anamara Ritt-Olson, Daniel W. Soto, Yaneth L. Rodriguez, Lourdes Baezconde-Garbanati, and Jennifer B. Unger. “The Role of Acculturation, Parenting, and Family in Hispanic/Latino Adolescent Substance Use: Findings From a Qualitative Analysis.” Journal of Ethnicity in Substance Abuse 7 (2008): 304-27.

This week I will review the main issues from previous blog posts and bring up some global trends that appear in the interplay between homosexuality and health.

In my initial searches, I found source after source showing that gay people generally have poorer physical and mental health than their heterosexual counterparts.  Delving further, I found that homosexuality itself did NOT cause bad health outcomes, rather, society’s response to homosexuality (stigma, discrimination, hate crimes) led to worse outcomes.  It would make sense, then, that regions less welcoming of homosexuality would generally have more illness (emotional, mental, social physical) among their gay populations.  Accordingly, I investigated regional variations in attitudes towards homosexuality, and found that Muslim countries, especially in Africa, tend to be less welcoming, and often mandate capitol punishment for homosexuals (clearly, a bad health outcome).  To my frustration, there are virtually no studies on gay health from any developing countries, so I was unable to truly compare the health of homosexual populations globally.  However I feel it’s safe to assume that gay people in welcoming countries (like Canada) are generally healthier than gay people in countries where their sexual orientation is punishable by death. 

Because of the deficiency of data, my more detailed investigations could only focus on countries where studies were actually conducted: mainly the U.S., Europe, Australia, and Japan.  I found that poor health of the gay community comes in many forms, from blatant hate crimes and discrimination by physicians to much more subtle problems, like internalized homonegativity causing low self esteem and increased rates of depression, suicide, and substance abuse.

I also (reluctantly – I hate it when AIDS is called a “gay disease”) researched the connection between homosexuality and HIV/AIDS, and found that about 18% of HIV transmission comes from intercourse between gay men.  There are two main causes driving these transmissions: anatomical and social factors.  Anatomically, anal sex holds a higher risk for HIV transmission.  Socially, homophobic stigma often means that gay men do not receive funding or education about HIV prevention, and those who do have resources available may be afraid to seek them for fear of being marginalized.  The tragedy of this finding is that the social causes of HIV transmission among gay men are all completely preventable.

Overall, it seems that the health disparity between homosexual and heterosexual populations overwhelmingly is caused by cultural rejection of homosexuality.  The degree of denunciation of homosexual orientation varies from country to country, yet it is definitely still a global phenomenon.  The fact that preventable societal factors are causing poor health for millions of people is pretty depressing.  On the other hand, it is uplifting to realize that we can improve the health of millions of people by changing how society reacts to them! 

Over the past 7 entries of this blog, I have covered a myriad of health-related issues that affect Asian Americans. Although I wasn’t able to cover all of the topics that I wanted to (i.e. hepatitis B and liver disease), I hope that I was able to at least discuss enough issues to make the case that Asian Americans are marginalized within the US healthcare system, and healthcare professionals have a lot more work to do before they are able to provide the type of care that best addresses the needs of Asian Americans

One particular factor that has consistently contributed to the difficulty of improving Asian American health has been the fact that it is an aggregate group made up of very disparate subgroups. While I do believe Asian Americans should try to unite themselves as more of a singular group for the purpose of having greater political authority in pushing for legislative reforms in healthcare, Asian Americans must demand a more specific approach from health professionals in the actual practice of medicine such that treatments and diagnoses can be better tailored to their needs. I believe that part of the solution to this issue is for healthcare professionals to do more outreach to local community leaders within the subgroups who can communicate with their constituencies to better identify specific health needs. Because language can also be a major issue when providing care for Asian Americans, collaboration with community leaders and groups can be vital to facilitate the dissemination of health related information to people.

Healthcare professionals must also do a better job of simply getting to know the Asian American population and conducting more research about their health needs. In several of the topics that I wrote about in my blog, I could not find that much information about particular issues either because only a few studies existed or no information existed at all. For instance, Asian Americans are oftentimes entirely excluded or not factored in when researchers are gathering information for nationwide studies and surveys about health issues, which consequently makes it significantly more difficult for health professionals to provide care.

To give a specific example, a study that was recently published in the May issue of the American Journal of Public Health examined the effects of racism on the mental health of children and involved more than 5,000 children in Birmingham (Alabama), Houston (Texas), and Los Angeles (California). However, the study put the children in only in the following categories of black, Hispanic, white, or “other” despite the fact that there are significant numbers of Asian Americans in two of the cities, Houston and Los Angeles. Instead of having an attitude where smaller minorities are simply grouped into a vague and uninformative category, researchers should take greater care to be more specific in their work, particularly when other data has shown that Asian American girls are at the highest risk for depression and suicide among young and adolescent girls.

While these types of solutions would require greater effort on the part of healthcare professionals and researchers, I believe that healthcare work demands and requires being meticulous because the stakes of impacting people’s health can be very high and a lot of change for the better can happen if things are done the right way. As a member of the fastest growing minority group in the United States, I look forward to seeing how healthcare professionals respond to the needs of Asian Americans in the years to come.

1. http://www.usatoday.com/news/health/2009-05-05-race-depression_N.htm?csp=15

 Dr. Reicheter talked about how psychiatry isn’t just about medicine but also incorporates anthropology, spirituality, philosophy, and religion.  In researching the mental health of refugees and victims of trauma the past eight weeks, it has become clear to me how central the issue of culture is in this discussion. I did a previous blog post on culture in global mental health, and I wanted to further pursue the topic of traditional healing this week.

Most people with mental health issues in other countries are cared for by their immediate family members.  Traditional healers often come next.  People oftentimes don’t always feel comfortable going to Western counselors that are brought by foreign aid.  Dr. Reicheter talked about the role of Buddhist monks helping patients with PTSD in Cambodia. A really fascinating book that I found, Handbook of Culture, Therapy, and Healing, also touches on other examples of culturally-based therapy and healing, including:

-spirit dance ceremonials/rituals

-traditional healers involving spiritual practices

-traditional Chinese healing

-Japanese Naikan therapy and Morita therapy

-Indian conceptions of mental health, healing, and the individual

-Native healing in Arab-Islamic societies

-the healing arts (I have looked at this in my past blog posts, particularly with dance, and also mentioning photography)

Many cultures have traditional healers.  The role of these indigenous healers in comprehensive community-based programs is fascinating.  What do they do?  What are they like?  Are we utilizing them enough?  Are they effective at all?

There has been a lot of debate, interest, and mystery on shamanistic healers.  Recently, Krippner (2002) analyzed the way that Westerners have historically viewed and understood shamans over time.   Older writings dismissed them for a long time, labeling them as psychotic, ignorant, and even malevolent.  In 1934, a man by the last name of Benedict had a hypothesis that one society’s madmen may be another society’s healers, but this has been refuted by people who have studied medicine men in Mexico, Nepal, Siberia, and the United States. This view is now changing in some ways.

One interesting factor with traditional healers is that, particularly in cultures in which shamanistic tradition is represented and magic is important, healers are both sought out for help but also feared, since they are said to have special powers – which can be used for good or ill will.  There is a mixture of awe and fear that affects the relations.

“Krippner describes shamans as precursors of psychotherapists, but also of magicians, physicians, performers, and storytellers. Thus, the role of healers in their societies is inclusive, complex, and multifaceted; it encompasses therapeutic activity, but goes beyond it in a variety of directions. In Krippner’s view, the intensive study of shamans’ operations holds the promise of enriching the understanding of neuropsychology of consciousness, the psychology of social influence and modeling, and the cultural plasticity of psychological therapy” (Gielen 8).

These discussions, as well as the list of various types of culturally-related healing above, demonstrate the breadth of this issue.  They remind us that Western medicine and our conceptions of “mental health,” “medicine,” and “psychiatry” are just a small part of approaches to health around the world, many of which have been in existence for thousands of years.  How do we judge their effectiveness?  Who’s to say whether certain healers are right or wrong – gifted or crazy?  How can we incorporate culture and indigenous healing into our global health efforts?  There are many ethical, philosophical, and practical questions for further exploration on this issue.

Bemak, Fred, Rita Chi-Ying Chung, Paul Pedersen. Counseling Refugees. Greenwood Publishing Group, 2003.

Gielen, Uwe Peter, Jefferson Fish, Juris Draguns. Handbook of Culture, Therapy, and Healing. Routledge, 2004.

Lindow, Megan.  “Calling All Healers.”  Time Magazine. 16 July 2006.

 <http://www.time.com/time/magazine/article/0,9171,1214944,00.html>.

“Spiritual Healing Around the World.” Time Magazine. 20 May 2009.  <http://www.time.com/time/photogallery/0,29307,1878443_1842216,00.html>.

This weekend, I was lucky enough to have the opportunity to travel to Las Vegas on vacation with some of my closest friends. Amid the silicone, fake tan, and tattoos, I couldn’t help but notice that along with gambling, drugs, and alcohol, there is a booming commercial sex industry. While I doubt many women employed at the popular strip clubs work on against their will, I imagined the brothels on the outskirts of the city might be a different story. Upon arriving home I began to research the topic, and found some interesting and relevant information.

While prostitution is illegal in Las Vegas along with the rest of the United States, it is tolerated. Walking down the strip and seeing tons of men handing out flyers, one can imagine it doesn’t take very long to be taken to a rural brothel(1) or have someone delivered to your hotel room . The overwhelming demand from the male customer based drivers the multimillion-dollar international industry (1). Linda Smith of SharedHope International reports that 1 in 5 of the prostitutes working in Las Vegas is a child, and that many women are victims of an underground illegal ring of sex trafficking (1). Most women don’t work independently, but instead report to a pimp or a brothel. SharedHope has campaigns in many cities across the world, including Las Vegas, to reduce the industry demand, find and punish perpetrators such as pimps and call services, and rescue and rehabilitate victims (2). The legal catch twenty-two is that it that the culture of tolerance for the illegal activity of prostitution fuels the fire, yet it is crucial to treat victims of the commercial sex industry as victims, not criminals.  SharedHope is attempting to rescue victims while simultaneously busting the illegal framework that fuels the industry.

Even women that are not trafficked and held against their will are often caught up in a cycle that they cannot escape. In an interview with Annie Lobert, a former prostitute who founded Hookers for Jesus, she explains the cycle. She explains that girls can become completely caught up in the money and culture of prostitution, are easily brainwashed by their pimp, fall into drug addictions that can fuel the fire, and often they become “so wounded from what they are doing, they have such low self worth and self esteem, that it is harder for them to come out of the gutter”(3). While Lobert’s opinion has extreme religions undertones and is certainly one sided, she makes a good point that simply because some women aren’t victims of trafficking doesn’t mean they aren’t victimized, controlled, manipulated, and stuck in a cycle they cannot escape.

I know I’ve done research, and concluded myself that legalizing prostitution may have important positive implications for the safety and health of women around the world. However after spending the weekend in a place that treats commercializing women’s sexuality so nonchalantly, I’ve begun to feel more uneasy about this than I had previously. Of course, if a woman wants to work in a strip club, I don’t have any authority to tell her it is wrong. But sometimes I feel as though the inevitable objectification of women is contributing to gender norms that are constraining and discriminatory against women, especially considering the norms of silicone and plastic surgery. And then there is the question of actual desire to work in the industry, as opposed to lack of money, corruption, and no other option. On the other hand, maybe as our new-wave feminist ancestors believed, there is some element of power in the choice to embrace and commercialize one’s sexuality.

Interview with Annie Lobert

Sources

(1)    Smith, Linda . Interview NBC News, Lase Vegas, Nevada. 10 October 2007.
(2)    SharedHope International. <http://www.sharedhope.org/>
(3)    Lobert, Annie. Interview, ABC News, Las Vegas, Nevada. 12 March, 2009.

In most of my blogs I focused on examples of specific interventions in place to help marginalized populations. I addressed organizations and protections that deal directly with health problems. For example, BRAC and the Health Bus work to improve health conditions of marginalized populations. The Ryan White HIV/AIDS Program deals specifically with treating HIV/AIDS. In my last blog I expanded to discuss the Commission on Social Determinants of Health. This laid the groundwork for broadening the scope to consider social factors.

From research this week I realized that in order to best address health disparities people need to consider underlying social factors that lead to marginalization and poor health. This can be achieved using the field of social epidemiology. Some people describe certain interventions as “putting a band-aid on the problem” and this is what addressing health issues of marginalized populations does. It is crucial to attend to the source of the problem, which lies in social causes. Thus, marginalized populations can suffer ill health due to factors that cause their marginalization in the first place.

One source claims “the use of social epidemiology in the study of the health needs of the population – of the urban-marginalized population – appears to be important” (1). Another source, by George Kaplan, argued that social divides can lead to health divides. He stated some of the social problems marginalized groups in the United States face:

Often have lower income
More intergenerational disadvantage and less upward mobility
Live in poorer neighborhoods
Children go to worse schools
More exposure to environmental pollutants
Poorer working conditions
Treated worse in financial and loan transactions
Poorer access to health care
Face institutional and interpersonal discrimination

Kaplan goes on to say “it is presumably these conditions and the associated patterns of exposure that constitute the vectors by which social exclusion leads to worse health” (2). Sandoval et. al conducted a study among urban-marginalized populations in Bahia, Brazil and found that the health issues they faced had their origins in social factors of the country and changed along with socio-political-cultural changes. They thought that such social factors could be taken into account when setting policy for health (1).

Social epidemiology needs to occur alongside traditional epidemiology. Until people can address the source of marginalization it is crucial that there are interventions and protections in place to promote the health of marginalized populations. This approach is analogous to finding the balance between prevention and treatment. Health workers ultimately want to prevent the transmission of diseases but they do not stop treating sick people. They work on both simultaneously, and this is what must be done in this case.

Works Cited:

1. Sandoval, JM, JS Guedes, and RM Dos Santos. “Social Epidemiology as a Strategy to Evaluate Health Requirements of the Population.” Annu Meet Int Soc Technol Assess Health Care In Soc Technol Health Care Meet. 13 (1997): 115. 27 May 2009 <http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102233210.html>.

2. Kaplan, George A. “Health Inequalities and the Welfare State: Perspectives from Social Epidemiology.” Norsk Epidemiologi. 17.1 (2007): 9-20. 27 May 2009 <http://74.125.155.132/search?q=cache:ktWmgkSozIsJ:www.ub.ntnu.no/journals/norepid/2007-1/2007(1)%252003-Kaplan.pdf+social+epidemiology+marginalize+health&cd=4&hl=en&ct=clnk&gl=us&client=firefox-a>.

Week 8: Conclusions

As this is the last post of the quarter, I would like to go back and highlight some of they key points of the blog from throughout the quarter, then try to draw some connections between the lessons I’ve learned in researching for these entries.

We began by attempting to define “indigenous,” but quickly realized that this was no easy task. I gave a few examples of various definitions adopted by different institutions and individuals, but the entry ended with more questions than I started with, after having thought more carefully about how many different definitions there were.

The third week, I cataloged the inequalities experienced by indigenous people in Australia. I chose to focus on Australia because it is a developed nation with no excuse for not providing health services (and other necessary social services) to ALL its people. Before we can improve indigenous health, there needs to be a significant increase in the respect afforded to indigenous populations such as the Aboriginal people of Australia. I hoped that this cased study would illustrate the magnitude of the problem (if even developed nations are still not treating their indigenous populations as equals, how can we expect poor countries to do so?)

Next I wrote about the growing interest in traditional medicine that seems to be taking place around the world, and worked to outline what governments can do to ensure that people receive quality care, even if their only option available is “traditional” care OR if they chose this type of care over “modern medicine.” Some of the most important steps include the development or strengthening of systems to monitor and establish safety standards for traditional practitioners. Additionally, I stressed that government should not be allowed to use the availability of “traditional” care as an excuse for non-provision of modern medicine.  At the same time, I argued, developed nations could be more open-minded about the power of traditional healing remedies, ceremonies and etc., and afford indigenous populations more respect by not discounting the efficacy of many traditional treatments.

By week five, I could take stock of my entries to that point and determine that the overarching problem was clear: dramatic inequity between the quality of life enjoyed by non-indigenous versus indigenous people, primary stemming from a lack of respect for their culture held by other majority groups, including governments and providers of  “western” medicine. I had found this to be a problem of definition as well as underlying social prejudice. One of the main solution I suggested was to train indigenous people themselves to be health care providers, and think of other ways they might become more involved in the health care system and begin to change it from within.

The next week’s entry was a bit of a departure from that train of thought, as I had just been to the Stanford powwow and wanted to write about diets and the challenge of changing traditional attitudes towards unhealthy foods. This brought up the question of culture, and how best to preserve it when it is attached to such unhealthy practices as eating frybread on a regular basis…

After that brief tangent, I got back on track with the discussion of how indigenous people could change the healthcare system for the better by focusing on pharmaceutical companies, medicinal plants and interactions with indigenous people who manage the forests where these plants are found. While plenty of negative examples exist to show how these interactions can be exploitative or otherwise negative, there is also a lot of potential for growth, development, and empowerment of indigenous people that would not even require them to change their cultural norms or values. In fact, they will be rewarded for maintaining their traditional knowledge base, and will gain the world’s respect and gratitude if they share traditional healing remedies. It is now our responsibility to make sure there exchanges are profitable for both indigenous people and “modern medicine” and that such exchanges are conducted respectfully and with full consent of both parties.

To conclude this blog, I would like to restate Article 24 of the UN General Assembly Declaration on the Rights of Indigenous Peoples. I think this statement accurately addresses the challenges I’ve outlined throughout the quarter: how can we both provide indigenous people with the highest stranded of care available, and at the same time respect and make use of their traditional health practices? Article 24 seems to provide for both. Its message is clear:

1. Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services. 


2. Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health.

As you might expect, older persons are especially vulnerable to the negative effects of conflict and natural disasters on health.  Relevant health care is disrupted, physical limitations contribute to malnutrition and difficulty fleeing danger, and ageism leads to a shortage of help from international aid workers.

Health care for chronic conditions that are more likely to affect the elderly, often scarce or difficult to access to begin with, is typically obliterated in situations of armed conflict or natural disasters.  One recent assessment in Gaza (February 2009) found that 70% of patients who regularly visited primary healthcare centers experienced a disruption in their treatment due to the recent conflict (1). 

Physical limitations caused by chronic conditions (and exacerbated by a lack of available care) make it more difficult for older persons to cope with the disruption of their lifestyles due to these situations.  Older persons tend to have more difficulty in relocating as a result of forced eviction or in fleeing danger.  In Croatia, older Croats were sometimes abandoned in their houses, and were consequently burned alive in the houses by Serbs (2).  Obtaining food, which often requires standing in long lines or fighting one’s way to the front of a line, can be especially difficult for someone without the physical strength associated with youth (3).  Young people get the food (and often healthcare) in these situations because they can physically demand it.  This means that older persons are more likely to face malnutrition and failing health.

The most devastating factor in the situation faced by older persons is ageism in international aid.  Relief workers do not view older persons as a priority and have an overwhelming tendency to view them as a waste of time and resources.  Food and nutrition programs rarely take their needs into account; hard grains, for example, can be inedible because of dental or other health problems (4).  Medical interventions rarely focus on the chronic conditions that older persons are more likely to face, like diabetes or cancer, and are more likely to focus on communicable diseases like TB.  The attitude that the elderly are not a priority leads to ignoring their potential to help and to lead.  Traditional community leaders are often ignored despite their knowledge of the community and unique approach to emotional and spiritual healing, and older persons are said not to have the capacity to be candidates for microfinance or tracing (5).

Not surprisingly, the ageism in relief efforts puts older persons in emergencies at a higher risk of depression (and remember, this is within a population already at an astronomically high risk).  One humanitarian aid consultant tells a story of visiting a Croatian refugee camp and finding all the elderly people “in small rooms with beds where they had to stay all day.  They had no exercise and were very depressed” (6).  Her solution?  She used her allowance to buy an accordian, and within days spirits were lifted and they began demanding their rights. 

Though rare, some relief efforts have tried to take into account the needs and potential of elderly populations.  The British Red Cross partnered with HelpAge International in its work in Indonesia after the 2004 tsunami, to design and implement programs that targeted the marginalized elderly population.  These programs recognized the eagerness of older people to restart their lives after the disaster and the contributions they made to their families, and included microfinance for households led by older persons, age-friendly data collection, and age-friendly shelters (7).  These programs show that fighting ageism in relief efforts benefits not just elderly people, but everyone in the community.

1) http://www.globalaging.org/health/world/2009/chronic.htm

2) http://www.globalaging.org/armedconflict/indigenous/report.htm

3) http://www.globalaging.org/armedconflict/indigenous/report.htm

4) http://www.helpage.org/Emergencies/Background

5) http://www.globalaging.org/armedconflict/indigenous/report.htm

6) http://www.globalaging.org/armedconflict/indigenous/report.htm

7) HelpAge International – “Mainstreaming Age-friendliness: A Recapitulation of the Collaborative Efforts between HelpAge International and the British Red Cross Society in Aceh, Indonesia.”