ok Kaeacan: W erinadig: Matecoqdongy = Peeaic 280 SedaNe: Bed Was Ros Trcesagedion ROoodean Qogeocc 7 Immigration and Medical Anthropology Leo R. Chavez Immigrants trying to megodate the US medical system give testic ‘mony to the truth in Vichow'sfomous declaration, All medicine i polis." Viewing immigrants as outsiders who are simultaneously lmsiders, the larger sociey often questions the se of medical and ster socal services The sue of medial services for ionigrans and sizes alike, a least inthe United States, is open to uch debate because there is no guaranteed "eight to medical care. Even though ‘ens may eel an enudement to medical care, many ave unwiling to {ran ths to immigrams. Asa consequence, immigrants secking rd: fea eae fae restrictive policies, nancial tet, and ctvenshp requite- ments. Moreover, immigrant often enter the labor force atthe boton, here low incomes, lack of medial insurance, and te avaiable time resent obstacles to thelr use of medical services. hort, immigans ue disadvantageously embedded ina pobticl economy of heath care ‘characterize by pervasive structural inequalities (Racmer 1909; Morsey 1996; Whiteford 1996). Iisa challenge for anthropologists, pati I those taking aerial approach (Leek and ScticperHughes 1896), ‘explore te influence of eleure on immigrant we of US medicaleR Cuan fie services without minimizing dhe wemendous role these strut {ors play in the lives of immigrant. This chapter highlights several Important problems that occur when immigrants interact with the US medical yates (abo sce Hirsch, Chapter 8) 1 will draw on my ov research and that of others for examples of sues that aise fom the ‘confrontation of imigrants cultural belies with te receving sock ‘co's medical beliefs and practices, che sigma of disease when aoc ‘ted with particular immigrant groups, strucural obstacles faced by immigrants seeking medical care and the eitations of interventions at the india instead of societal lve. “Anthropological interes in inmigration is both old and new Fane Boas, the totemie ancestor of American anthropology, provided a classic example of anthropological research countering public repre sentation of and taken forgranted assumptions about immigrant ‘characteris, Hit esearch om Southern and Eastern European mie rans in the early wentieth century directly challenged existing sien tie and commonsense setertions about the lik between immigrant? pphyeal/bodty structures and shapes and their moral and incellestal povential Using dhe methods popula a the time, Boas measured the sade ofiuigrans children (an example of the “second generation” study s in vogue in immigration eeseareh today) and compared then vith the immigrants measurements He found that te second genera tion did not resemble che immigrant generation in ead shape. AS Kraut has noted, “Bows concluded that nutriion and osber aspecs of living conditions determined these “racial characterises’ more than Ihre” (Bose 19113; Kraut 1904). A few yeas ate, in the 19205 the Mexican anthropologist Manuel Gunio carried ost investigations into life and working conition# of Mexicans in the United States (Camio 1980, 1981). The poignant narrasnes he collected fiom Mexia workers provide compelling evidence forthe harsh, unlaaly working Conditions they endured and the sell nd poial barriers to inte srtion they encountered. (See Chaves [1992] for x discussion of cou temporary ling and working conditions for farm workers in Southern California, Sce ako Goldsmith (1989) Despite these early examples of interest in immigration, anthrope- Iogleal esearch on immigration waned, perhaps because ofthe massive ‘eduction in immigration during the Great Depresion and World War boar ow ano Menica. Asrumorocoe 1M (Pedraza 1996), Jus as inflvential was anthropology profesional |demtiication asthe seienceof the Other (ead “primitive “les techno logically advance, less complex political organiation"), of none ‘Western cultures and socities that had tobe “salvaged” before they sed avay asa real ofthe puave, honiogenizing march of mover ‘iy An anthropological interes in immigrants teturned in the later decades ofthe twentieth century corresponding to worldvide increases inthe wansnation ‘movements of refugees and people weking eco- ‘nomic opportunities (retell and Holle eds 2000), In the United ‘State, immigration Nows have inereaed ately sce the mid-19605, reaching about one milli legal and undocumented izunigrans year bythe end of the twentieth century and tothe etl ewentyfst century (Pedraza 1996). The movement af people has not affected only the United Sates: ithas had global repercussions (Castes and Miler 1998), Immigration has given antheopologite a window into the raafcae ‘ions of people's crosing national borders. As the word experiences what has become glossed under the concepts of globalization and ‘wansnationalism, anthropologists, and many others, want to under stand the implications of the rapid and increasingly efficent moves ‘went of people, capital, goods, and information across increasingly porous national borders. In any ways, these movements are com ‘steucting a world of linkages, bridges, connections and hybridizations, all of which re forcing a redhinking ofthe national order of thingy” (aii 1992). At the same time, inigraate often receive an ambi Tent welcome when they cross those borders (Chavez 001). Ground zero in this ambivalence frequently centers in the domain of medieat ‘are (andi utilization) and competing, ofa eat different, eultarat bli surrounding health, les, ad wellbeing In sum, focusing on immigrants can throw into atak relief many sheored ‘medical anthropology and andvopology in general IMMIGRANTS AND CULTURES GROSSING BORDERS ‘The movement of people has implications forthe physical and ‘mental health of those who move aad thove among witom they estar lsh chemselves. The history of European contact with native peoples in the Americas provides a tragic example of this. The indigenous Americans suffered masive population declines after Eutopeansaed in dhe New World. They were felled aot xo much by strength of fms as by the silent, unseen germs and viruses brought by the ‘Eucopeans and dheir animals. American Indians had no natural immu nities for many European dieases, even children's disemes considered ‘elatvely harmless, such a# meatle,evine Mu, and chicken pox. The Jose in thsman life x almost beyond our abilities to imagine, By rome ‘sates, a8 many 480 percent of certain American Indian popula tions died after = succession of epidemies and plagues, sometimes before they even met Europeans. Disease went ahead ofthe Buropear clearing the land of much of the native population and weakening is ‘apabiliyto witha the invaders (Keaut 1994. Unfortunately, mie es, colonists, andl misionaries (and even anthropologists) who come inco contact with people in remote arcas of the world, such a the ‘Amazon, continue to introduce deadly epidemic o natives (Chagnon 1997). In dhe Americas, ironically, the Europeans acquired valuable ‘medicinal knowledge from the native shemans, or medical specaiss, nha were very adept atthe we of indigenous plants to creat illnesses “Hndreds of indigenous deuys have been lited inthe Pharmacopoeia of (he United Stats of America andthe NetowalRormadary (Keaut 1998), “Today's immigrants ae ler likely to come from Europe and the industrialized nations than from: less industrialized countries in Asia and Latin America. Anropologists have long studied in the places hese today’s immigrants were boen. They have writen extensively on practices of folk healers, the we of folk medicine, the nature of okie nesses, and indigenous belies about the body and what it means to be ‘healthy (Rubel and Hass 1986), Not surprising, immigrancs bring wie them belief, behaviors, fears, prejudices, values, and established ‘ssumptions shout both the physical and spirtl words that may not ‘ocrespond te dominant cultural realities in the society at rye. This specially true when their belies and cultural sumptions come into contact with the culture of biomedicine, ‘Anthvopologats speak of biomedicine ava cultural stem because, religious systems ideological sens, and even common seme, biomedicine lathe “capac to expres the nature of dhe word andi shape that world to [ts] dimensions" (Geere 1978; Rhodes 196166; Sce also Cliford Geera’s (197%, 1988] dxeusions of cultural yen) The ethnomedcal tens of mimigrants can difer from biemediine inicio ‘booeast0y AX Menient AvnoroLocy Ss undament ways. Moter iomeciine eae om the Caren Yromis of 2 mint boty dichonny Au Lack aad Sehepes tegen (499685) noe in omen, “body and lan unea ae {ae an separable ene em ee in etre bay oe sin. By contrat. may etinemeiea cn et eae Sng oa, min and, and hereto nes canon cred Femi on eames Forse migrant the wpiritl and the physi ae Hake Lethe and form the ator underaning any ncaes ane 2mptoms dt cach Ton ote, iia thenshest Sg roles asi ith wt he tee commen, po ‘fem cileras Thiet ein ind pent coe ce teron clin cone whe US temedil fem Isao rayhavcltueepcc ble abot hae, an wees csiarespeicespecatnsofpantteaerincneson When avs fra seal ares US hepa emergency roms te en ‘sy ot emir atendg pcm and sal Ths especly ‘ofr kites or ature nen In thei boo, Te Cal nnd Soa, Sons and Hughes (19849547 st 18 nen but cen thoy spr aa Seas eer alr, past and pent uote hao anos caturetaundtne Tale 7 sages but soot na ca pea urged ty prctonen bation po ‘sive among the clare of nef many nmi the Ue Sete Acacia thatchlneesarchtlomrautappuion sa ‘nit and pracsones a ne, to camp teed whos spewed), a wel aor epelois ant te selon Aipteween de pital yan he el sl "a Th pit Cte ond Yn al Se Fain (197) ha trodes prgeant example how cles can cle wen ne fsck medical care. Tis the soy uta Enon ony Mere Calfornia On ay Lisa young ch note ae Sates radenly began experiencing sre, Bomtiing wae sands ase beth paren bed hte Lisanne lagher by hen he was Spend y the oul oe af cang soar What derloped oer ary year af inteseton nh docs nes, other media peroael sd soil yore ste era0 n cusvez Tamers | ‘Sul Fu sees Rod ama emigrants in the Unite States Farinas Gnnty frig Spine Rie ape) Pore en ean epg, Som moe? ras pc ye a, eto, Ve cn ree se Tam snevica, Angers generate. ittSacs “Boe gate. Seles ge te nse, “ concn ‘gee epr ran, wiconmioune fgg Seen ome ‘Chima ‘Cepemei e ctargeofsemen, sm aman genre tie fae ‘United Stes cag teint wa ‘e — secu, eae tener we ‘Southeast Asia. ‘ill recede into the bos es . van Si pero ies vaae Siar Acumen ace es ieee UdSiecs ong ee ach nna Aetna depen kneel cet Mote ciee ses eer tits onal) "ed Saes atibyey Hong Sete eer omnes pep) ii oces aaaaseeee Gee ppt Hace ee oe cas aie, Oca tata ges ne "onic dosent nso analy te oan mores Sintyng oven ue ‘Grea ciaa, orn pac web apie ier *ietiheectantn there * ed galing (Sowce: Aap rn Stone Hages 108547 Tnoucasrion Ano Meoicas Astinorovocy Dopital inthe Mesced area ia sory of the dcp cultural misander standings that can arise even among wellesning, concerned people. ‘The story aso reveals the power struggle that emerged over the pa. ents’ compliance with the doctors’ advice for media reaent. Lia's parent feared the doctors and did not understand the pu pose ofthe powerful drugs that had such visibly negative elects on ‘heir daughter. They were reluctant to discus thee fears with snedical personnel and quiet administered her medicine in a manser dhey believed more appropriate, which meant not giving her dhe medicine sometimes. The doctors turned to Child Protecuive Services, which Femoved Lia from her parent care and placed her in foster care Although she was eventually retrned, this ha! a devastating effet on doer parents, who never understood liow anyone could ere for their daughter better than they. From the doctor” perspective it was impor ‘ant that Li's parents and the Hmong, n genera understand who has ‘ina aatoriy over a person's medical wellbeing. One ofthe doctors ho treated Lis explained why he beieved that removing Lia fre hes rents was necesary “felt that there was eton that needed to be earned, I don't know if chi isa bigoted statement, but fam going to ‘37 itanyyay: I felci was important for these Hmongs co undersand that there wet estan elements of medicine that we understood better ‘han they did and that there were certain ules hey had to follow ith thei hid’ Hes. wanted dhe word to get out inthe commuiy tha it they deviated from tha, it was not acceptable behavior” (Fadiman e797, Rather than take an adversarial approaci t patientphysician interactions, medial andhropologits uch ay Arthur Kleinman (1980, 1986) advocate that physicians aka few simple questions of patiens in order to understand their explanatory movlel: What do yo cll the Problem? Wht do you think caused the problem? Inmigeant patents ‘arely ae it a pasion to ask physicians and other medical personel ‘hese questions. Their interactions with physicians ate often limited beeause of the short ime allocated for patient visit lack of English shill and fear that such questions might imply a lack of respect forthe oct’ knowledge andl authorey (Chater 1984), ‘The story of Lia and her Family ako indicates the hosile context ‘surounding the provision of medical services to iunigrans, Whening te en aes the Heng een Meds en Thun couese pope such spac Sew gvoran the Tike fore ehing tne soming to he United Ses Finan TOW. The Hmong wee Ames sert syn Ls where they Tong common during the Vietnam War yer The Hmoog ea xctenge fr ging the Unied Se woul ke creat them and thei fancy However pic opinion soothe ‘Roce ot mmigaon ean cole thetr eeponietuting mei reat png Gown ea settan a the aspal wese {inane commented, and yen ere otaged nthe Hong aed coming ee, Otol Oo green ito) tive Se comet at baught tse none pope ino or Try sold get the ner aye? ve gota young Ih ttendho wane gta US edvetion avant wor Hea ge respec Hany jn hn ere fn rope and sue ie tomato hae eng he They apy ee” Wem appmveta te high sate epesson among the Hong saenspE nat you men? Tiss hemen fr hem! They hes tie tay con pop They eon drink ter Som a. open ae. Thy get eguae checks addy neve have 9 work able Tes thse people por soe Faian 19725). Ades Ahan tam theo anime movement ad publ pk hevtegeing migra oe seers ‘tos suet migrant sot eal andes ‘an greatly afect the course of ilies and even life expectancy. The ‘work of Arthur Rubel and bie colleagues (Rubel, O°Nel and Aron 1984) on Mexicans sullering ftom sa, o soul Loss, underscores the poner ofbeliel Believing thatone stick alicted, or suxcepableto dir | ‘aee can have physical implications and determine the course of an ile hess. Sesto siflerers became sicker an in some case, died eater than ‘hers sflering the same health problems but not experiencing 80 | “The relationship between min and body isa powerful one we donot filly understand, “Anocher example of the power of cultural beliefs was provided by Davi? Phillips, a sociologist who examined the influence of wad tional Chinese beliefs about birth years and their relationship © ‘iseaes (Bowes 1998298). For example, Chinese medical and ato, Inoucaanio AND Menical Axrioronor logical weachings posit tht people bom in ire year—which has a 6or 72s the final dligi—do not do wellwhen they develop hear conditions. People born in an earth year—ending in § or are more susceptible to diabetes, pepe wleers, and cancerous growths. People horn in a metal year—ending ip Jor f—do not do well when suffering from bronchitis, emphysema, or asthma, Philips and his ociates indirectly tested these belief by examining the California death records of 28,169 adule Chinese and 412.632 Anglo controls between 1969 and 1990. The Chinese-American death records were further divided into two groups. One group consisted of thote who were born in China, resided in San Francisco or Los Angeles, ancl did not have an atopy (2 procedure shunned by fellowes of traditional Chinese medicine). The seaond group consisted ofall the others “The researchers found! that Chinete American generally died ea lier than Anglos if they ad the ated pairing of beth year and die tase, When examining deaths among Chinese Americans oy, those with the atrologicaly iMated pairings of year and dines died from 1.3 years 49 years sooner than Chinese Americans muffering from thesame diseases but not born inthe “bad” years Whe the two groups of Chinese Americans were compared along the dimension of trad ‘ional/modera, women bom in a eatth year who were more likely hold traditional views died 8.3 years eavlier than other Chinese- American cancer vets, radio 1 Chinese-American women born Inthe metal year who sullered from bronchitis, emphysema, or asthins ied 8 years earlier than Chinese Americans wih he same nesses bnutborm in ether years. Although tire indirect evidence, immigrants lie appear to influence the severity of their ilnestes, For anthrapol its, this research raises more questions than i answers becae ii tcl on aggregated data removed from individual fe histories, How ‘nd wy do belits about birth yar intence lines jeer? Did ‘knowing the birth yar ofa patent affect dhe way others rete hi oF her? Did knowing the beth year's asocaton with particlar diseases fect the way palents sought and/or followed medical treatment? Docs this evidence suggest that these belief are founded on rth that |e donot perceive or understand? | Foreign” medical belies can become widespread and penetrate | taintream thought: When the Gkinese fist came to America i thenineteenth century, dir use of medicinal plants, animal part, and seupunctare was strange to non-Chinese and rarely sought outske ‘Chinatown (Kraut 1994). Today, acupancture is subject of common sdgcourse and is increasingly sought by nowAsian Americans. Many medical nsorance programs pay for acupuncture treatment. What was ‘once the subject of septic and humor fs now widely accepted 2 an erative effective medical practice. Knowledge of waditional Chinese ‘medicine has eeled in the United States in response to growing ines ‘stn alternative medial practicesand as part ofthe cultural baggage of those mh immigrate here, Tadonaldoes not mean “unchanging,” for practices in the home county are also influenced by history and devel ‘opments in rational medical practices abroad that find their way back (@ran 2000), “The complex multidimensional and mulidrectional changes experienced by immigrants, the receiving soles, and the societies “nck home," wih whom imisgrants may mainain important contacts arcoften reduced toa dizession aboutasinllaon and acculturation, terms, ORen itis ‘hil are peal presente simple, unidirectio sumed that over tne immigrants wil shed as quickly as possible the ‘altura belief and behaviors they brought with them in exchange for "jmesican” beliefs and behasior Suite Orezco 2000), However, itis sometimes more appropriate and healthier, for immigrants to retin some oftheir beliefs and bebsvor. Ruben Rumbaut (19973) has se marized the protective aspect of mans beliefs and Dehaviors of ieo= {grant which har led to a number of paradoxes in the medical Titerature Highigk Mexican and Asian immigrant women come tothe nite States with healthful behaviors, ineluding eating 2 healt det and diinking od smoking les than USborn women. Although these ‘women are poor and often deliver without adequate prenatal care, their chien ae, eelatively speaking, born healthy, wth low rates of low birth weight (Matkces and Gorell 1986; Rurmbaut and Weeks 1999; Rumbauc etal, 1988, Willams, Binkin, and lingenan 1986; Yu 1982), Tntime, however, thie behaviors tend to become “American They are ‘noe likely to take alcohol, smoke cigarettes, eat hgh ft foods, and ‘engage in shy sexual hor, Consequeady Less postive birth out comes are covtelated with astimilaion. Siilaly, Mexican immigrant ‘rome are les likey than Anglo women or African American women -beenariow ano Meoteat.Anruoronoc to get breast cancer. Perhaps related to diet, exercise, and increased Income (Vernon etal. 1988; Vernon et al. 1992), their isk increases wrth more dine ithe United Ststes Japanese men in Japan smoke at ‘ce the rate of American men bata diagnosed wth hing eancer at Dual the rate. For Japanese men inthe United Stats, this rate also Increases with time. The reason ino totaly understood but might be sociated with dietary changes, including driaking es green tea, nd the ses of ling in a society with markedly greaterincome inequality ‘han in Japan (Bezrucha 2001). As Rabat (19972) has noted asin ‘ation can be bad for an imsaigran’s health “The entra beliefs immigrant bring with them are not the only things problematic frm the perspective of receiving societies. A rece sing problem has been the assoclation of iramigrant wit disease, ‘which socalystigmatizes them as a theeat to the public's health. Recent examples include linking AIDS t Haitian immigrants, went ppubologies to Cuban immigrants and malaria to Mexican immigrants, but this fs not a new problem. In 18703 California, whites blamed Chinese immigrants forthe spread of sallpox In 1900, San Francis Chinatown was condoned off by ropes and guarded by police in 32 tempeto quarantine the Chinese, who were belived to be the source of Dubonie plague (Kraut 19%; Shalt 2001). In 1906 New York, Mary ation an tis immigrant, acquired the nickname “Typhoid Mary ‘hich became smonyrous withthe health thes sociated with imc grants (Kraut 1994). In the frst decade of the twentith century, Tralians were associated with ourbeaks of yphol in Philadephia and pollo in New York (Kraut 1994). The larger public often viewed these and other “ess desirable” immigrants as threats to public health, « ‘eat isomonphic with characteristics such as foreigunes, lack of Ijgiene, and mental inferiority. The sercening of immigrants fr om tagious diseases was central component ofthe Elis sland experience in the late 1860s. The 1924 immigration la mandated thatthe eon- sate inthe immiggane’s countey of origin conduct medical exant before the immigrant’ departare forthe United States (Kraut 1994), ‘The social stigma of earring unwanted disease has eft it mark on ‘contemporary immigrants well Inthe exey years of AIDS, ite wae [known of ts origin, Haitians, however, became associated with AIDS and were the only nationality tobe listed av ars factor forthe divease,Leo R.Cuavre ‘rising questions about their suitability for immigration and their abi ity to donate blood (Farmer 1992). The Cuban refugees who came in the Masel boat lift of 1980 were stigmatized by characterzations of criminal insanity and homovexuality both of which were asociated vith theeas tothe public and its health (Bormeman 1986). Mexiean Tmmigrants have ben asociated with rampant fri, threatenig the public health by uvesburdening its medical and welfare systems (Chavee 1907, Jonson 1995; Zavells 1997). Once acquired, the signa ‘of cing a heath menace can be dificult to shed. Such characteriza tows can mash actual health needs and he structural factors that cause 1 health among immigrant, particularly power, crowded living con ditions, dangerous oceupations, lack of medical insurance, and the ‘burdens avociated wih pariah stu. CULTURAL MODELS AND DISEASE ‘Les studied unl recently has been the way immigrants lis aout biomedical tecognlzed diseases ditfer from those of physicians and other biomedical practioner. Hetwoen 1991 and 1993, was co principal investigator a karge study to examine Latinas (both imi fgrant and USborn belief and atdtudes about breat and cervical cancer and thet use of cancer screening tests (Chavez etal 198: ‘Chaves, Hubbel, and Mishrs 1999; Chaver etal. 1997)-In the fistyar, ‘we conducted ethnographic incrviews with thireynine Mexican and ‘wentyeight Salvadoran immigrant women and compared thee responses with those of orentyseven USbom women of Mexican ‘descent (Chicana, twentyaeven Anglo women, and thirty physics jn northern Orange County, California (Chavez etal, 1995; Chavez, Hubbell, and Mishra 1909; Martinez, Chaves, and Hubbell 1997; -Mesulin, Chavez, pel Hable 1996). These interviews were based on snowball nd organization: based sampling Interviews were conducted inthe intersiewees" guage of preference and ypealy lasted fem ‘0 to four hour, In yar two of the study, we used these ethnographic interviews to help develop telephone survey that was administered to ‘random saunple of immigrant and US-born Latinas and Anglo women throughout the county (Chaves eal. 1997; Chavez et al 2001) The telephone survey totaled 80 Latinas, most of whom were born in Mexico (58 percent) or the United States (328 percent), with several Inowcrariow ao Meoicat ANraoroLocy ‘Latin American counties abo represented, most notably El Salvador (3 percent) and Guatemala (2.7 percent). In year three, we developed and tested an intervention program targeting beat cancer beliefs and Detuviors. Our findings suggested that the perceptions of Latina imi grants and physicians about cancer ik fxctors can be workds apart, ‘hich has implications for decor patent communication, adherence to prescribed regimens, and the efeeiveness of iterventions to alter ‘exiting belie, As part of the interview, we obianed from each informant alist of| possible factors that might increase a woman's canes, os, of ge ting breast cancer. (See Chavez, Hubbell, and Mishra [1995] fora ful discussion of the methods used.) We then selected the most salient fc- ‘or listed foreach group of women and arrived at wenty-ine isk fae tors. We asked each informant to rank the factors and to explain her oderng, Table 7.2 shows Mexican immigrant wotnen's tops ranked tisk factors and the cop ss for physicians. ‘Mexican immigrant women’s mos important isk factors for beast cancer were hits or braises tothe brea, excessve fondling of the reas was sth, The relative significance given to these wo risk actors suggests the importance of physical sess and abuse a8 a caite of can erin the women's culeral model, Aone Mexican immigrant woman) said “Bruises to the breast are bad. The breast are very delicate 0 en a child sucks on the breast ana leaves bis, it's bad Hitt the breast ean also cause cancer And when the husband massages ot squeezes the breast or sucks on it that 00, can eause cancer” (quoted In Ghavez etal. 1995). For Mexican immigrant, lck of medical aenton ranked secoud. Aone Mexican immigrant woman indicated, tie elects clear sense ofthe political economy of medicine: “ don’t have insurance. In my opinion, if one doesn’t have insurance, it's bad because, well, here cures are expensive, and, well, you know; sometimes for many people ‘hat we earn is not enough even to eat ard lve. So when we have these ‘ype ofillneses, we don't go wo the doctor becaure ofa lack of money” (avoted in Chaves et 1985), ‘They also emphasized cigarette smoking, birth coutol pills, and ‘rest implants, These risk factors suggest thatthe lifestyle choices ‘omen make can posbly lead to breast cancer,Luo R. Cuavez Tam 72 “The Six Highest Ranhad Breast Cancer Rish Factors for Mexican Immigrats anid Physicians in Orange County, California ‘Alesican Inoigrant Physicians! ish Factors ‘Women's Ranking Ranking i Hits /bruises tothe breast 1 6 Lack of medical auention 2 n Smoking cigarettes 3 10 Birth controt pills 4 13 Breast emplants 5 5 Excessive fondling of breasts 6 ~ Hered, family history 7 1 Getting older 2 2 Hang first child after age $0 a 8 [Newer having a baby 2 4 Obesity v7 5 Hormone supplements 16 6 Fe occ (Source: Chaver eal. 1995) Physicians emphasized risk factors found in the epidemiological lit ‘erature. As Table 7.2 indicates, physicians ranked heredity or a family history of breast cancer first and foremost, followed by getting older (aging), having a first child after age thitty, never having a baby (the preceding two relate to not having the periods of interrupted estrogen production that occur during pregnancy), obesity, and hormone sup: plements (continued exposure to estrogen) ‘As Table 7.2 suggests, the correlation between Latina immigrants) views of important tisk factors for cancer and those of the physicians is aan inverse one. The tisk factors ranked as important by the immigrant Latinas were ranked as unimportant by the physicians, who claimed these to be superstition of off the radar of contemporary epidemiolog- ical research. The risk factors the physicians ranked as important were generally ranked as unimportant by immigrant Latinas because they ‘were unfirniliar with such notions or did not see any relevance to breast InmiGRATION AND MEDICAL. ANTHROPOLOGY cancer, These and other findings contributed to the development of questions examined as part of the broader survey conducted in year two of our study. ‘These divergent models of breast-cancer risk factors suggest the difficulty immigrants may encounter when attempting to communicate ‘with physicians, Immigrants and physicians may not understand such, about each other's views. Tuner (1987) has suggested the existence of a “competence gap” in biomedical knowledge that impedes effective communication between physicians and their patients. This gap can go both ways. Physicians may not be aware of the beliefs informing immi fgrants' views of disease and risks, Immigrant Mexican and Salvadoran ‘women might have viewed certain rsk factors as unimportant because of a lack of basic biomedical knowledge. Also, immigrant wornen have definite beliefs about behaviors that, in their view, constitute possible risk factors for breast cancer. These beliefs may derive from a multitude of sources: knowledge transmitted among family and friends, popular ‘media, conversations with health practitioners, and cultural beliefs that are much broader than cancer itself, Indeed, Latina immigrants often located their discussion of cancer in the moral, gender, andl material contexts of their ives (Martinez, Chavez, andl Hubbell 1997) SOCIAL AND ECONOMIG FACTORS INFLUENCING ACCESS TO MEDICAL CARE In the United States, immigrants confront a medical system under assault from many directions, which can make obtaining medical care a major challenge. Frequently, this access is relative to the resources immigrants manage to acquire through their participation in the US labor market. We wanted to investigate this in the study of Latina beliefs and attitudes about cancer. Sociodemographic data collected in year two of that study suggest some of the immigrant women’s basic medical needs, shown in Table 7.3. Latino immigrants in Orange County have, on average, demo- graphic characteristics that set them apart from the US-born popula- lion, and these characteristics have important implications for their medical needs, As mean ages in Table 7.3 suggest, Latina immigrants are significantly younger than whites. This trend toward an aging pop- ulation, especially among non-Latino whites, is expected to continue,Lao R. Cuavaz Tam 7.9 Sociodemographic Characteristics of Latina Inemigranas, Latina Citizens, and White Wionen in Orange County, A Random Sample Telephone Suroey, 1992-1993 Pr Cindoce Lape Ween pened iaeipane No Nes Nass Dene Chartrsa Wola nos ™ “ % Childeen <18 Ting with respondent st se ae Medanyeaeofacooting 9 ° 8 i Neian guage an Sealant score ‘ose wo a2 NA urn Wok Sat , ' , “ Empoje ane Bs e , Stopioretyaane Ie 0 @ 1” %Hlomenaker “ a " i Unemployed acting 10 6 ° : work Unemployed sat 9 16 . 6 sect work snaived 0 1 ‘ M 7Pemploeaiine a) » » emplyedparctime 1S 3 * : % Unemployed seetngwork 16 > 6 Unemployed ot 3 ‘ ‘ 2 wesing work sete o 2 » is wl ne ochi9000 1% “ “ 1 Seas sats " a 2 : 5 $2,003.90 4 ° fs te 26859. i % a % dea rnc rate a a ” ® 3 Gover Medici, Mess 5,821 » 1s “ Soeieaywinered OL ® wo i B Noregule some ronal cte a we ‘ 2 ‘Peveentages may not ak up 10 100 hecasse of zoundng. Source: Chaves et IMMIGRATION AND MEDICAL ANTHROPOLOGY with people sixty-five and older expected to increase to 87 percent of the population by 2050 (US Bureau of the Census 1996). The United States will find ever greater proportions of its medical expenditures going toward geriatric eare and illnesses related to aging However, the majority of immigrants are concentrated in the younger, working-age bracket, especially in the fificen to thirtyfour age group. Few immigrants are sixty-five and older, Latinas are generally younger than Anglo women. In the study, Anglo women were, on aver= age, in their early forties, approaching the end of their reproductive years. Latinas were in their early thirties, but their age varied with immi- gration status, most undocumented Latinas being in their late twenties, Latinas were in their reproductive years. An indication of this is the proportion of Latinas who had children under age eighteen living with, them. As Table 7.3 indicates, more than 80 percent of Latina immi- grants and 62 percent of Latina citizens were living with their minor children, compared with only about half the Anglo women. Although this proportion is high for Latina immigrants, it would have undoubt- edly been higher if we had included the Latina immigrants who left their young children in their place of origin. ‘The age structure of immigrants indicates that medical needs cen- teraround maternal and child health care for women and workxelated problems for both men and women. These demographic trends also suggest an area of possible future conflict in the politics of medical care: To what degree will maternal and child health eare—increasingly associated with immigrants—become less of a priority in a society beleaguered by the needs of its aging native population? Acoess to medical services in America, especially for non-emergency medical care, depends on the patient’s ability to pay. Lacking a govern- mentsponsored, national health-care system, which would guarantee services for all US residents, patients must prove their ability to cover expenses. Patiemts can cover medical costs out of pocket, with a direct ‘ash payment for services rendered, an exchange more suited to care from a private physician than a clinic or hospital, where medical costs ‘can quickly become exorbitant. Often required for medical services, especially from hospitals, is proof ef thivd-party payment guarantees, which translate as private or governmentsponsored insurance programs. Immigrants are usually ata disadvantage when attempting toao R Cuaven meet these financial tests, primarily av vesule of the nature of thelr {ncegetion into the labor market. However, not ll immigrants are ‘equally disadvantaged. Undocumented imnigeamts are les likely than legal niga al Latina citizens (moaty US-bom) to acquire the Financial wherewithal and insurance coverage necessary to open the ‘oor 1o medial care, Again, let me turn to data Ihave collected in ‘Orange County, California, to ilusteate chee points Orange Coun is particularly yoo place to examine inues of immigrant access to medial services because its one ofthe wealthiest counties inthe tation an boasts good acces to health services (Warren 1990) “Latina immigrant in Orange County bring with them a range of Inumnan capital assets These inlence their participation in the lor market, which, in tra, alfeets their aequsiion of the resources {income and medical insurance) needed for medical services. Two {important factors are education and Suitaiey with the English an sage, As Table 73 indicates, Latina immigrants (both undocumented And legal) had a median of nine years of education. tn contrast, Latina tlzens and Anglo women bad a median of one year and two years of college, respective} In addition, Latina famigrants scored low on standard language acculturation index composed of five questions pe marly related to language ase. An undocumented immigration states isalo 0 factor limiting labor market participation, especialy mobili. ‘The information on the work status of women interviewees and heir husbands provides insight into the disadvantaged position of ndocarnened immigrants in particular (Data were collected during peti of tecesion in southers Cabfornin}) With about one-quarter of Undocumented Latinas working fllime, they were the most kel of al the women we surveyed not to work outside the household. On the tater hand, they were more likely to work parttime. Most of the Spouses worked fulltime but not inthe same proportion as the oer groups Their spouses were also much more likely to Work parttime than the spouses ofthe oer women. En fc, shy were Seve times Iikely to work parttime asthe spoures of Anglo women and Latina ci- zens and two-andarhall times a likely as the spouses of legal imi grants. Both undocumented Latinas and thei spouses were also more Tiel to be uneanployed and seeking work than ll others. These dita ‘suggest that a lack of leg ingestion status places immigrants in “ecearion ano Mraicat AnrOrORDEY “diadvantaged postion inthe labor market. Fiing steady, lle “employment can be difficul for them, a least in comparison wit legal Immigrant US citizens. Alo note that, compared with Anglos, fee Latina immigrants surveyed were vetted, reflecting the disparity in average ages. Income data for the fs es ofthe women me surveyed stoned inverse correlation with changes in citizenship status. Most (76 per- ent) of undocumented Latinas clustered in the under $15,000 per year category Legal Latha immigrants managed u move imo higher income categories, but most (77 percent) had annual household incomes under $25,000. In contra, citizen Latinas were found mel ‘more often in the higher income categories, and Angles predominately in the highest income category All Latina immigrants have generally low incomes, which, whe combined with thelikclinood oftheir having, cfldcen ving with Uhm, suggests tha they would encounter dificul: Hier covering ow of pocket the cot of ther familys medial care need, Undocumented Latina immigrants nete also the mo likely oak medical insurance. As Table 7.8 indicates, few undocumented immi {ante had private medical inurance, which ie sypially a benefit of ‘employment. Some did have governmentaponsored insurance, usally prenatal care of Medi-Cal fr their US-born chien, Over, ough, 61 percent of undocumented Latinas were uninsured, lacking one of the main keys that opea the door to omemergency medical cae Legal immigrants fred beter, but more than a third lached medical Insurance. Interestingly, one out of tea citizen Latinas didnot have medical insurance, wherea almost all Anglos had aces to some for ‘of medical insurance. Not surprisingly, many undocumented inmic ‘ams did nothave ategula source of medical cae. Latina legal inmi- -rants were more likely to have regular source of medical eae, and almost all citizen Latinas al Anglos had regular source of medical ‘are. A regulae source of medical care is highly correlated with health status, and Incking such a relationship indicates a problem area in aedical service, ACCESS TO MEDICAL CARE—A TWO-TIERED SYSTEM? ‘The sty of Latinas and cancer sheds ight on aditonal aapect| ‘of access to cate that are, no doubt relevant wo oder groups aswell IF‘we exatine the types of services te by those women inthe study who dic ot have a regular source of medical ete, a patern emerges that correlates wih the esourees income and medical nsurance)svallble to immigrants and citizens. As Table 7.4 indicates, undocumented Latinas rely first on public health ents and hen on hespital ourp- tient clinic, fllowed by private physicians who can be paid in eth “with no questions asked.” Fora few undocumented Latinas, hospital emergency rooms are the primary source af eae, and thi a cosy alternative. Latins legal immigrants euen to private physicians most ‘often, but not tothe sme degree as Latina citizens and Anglos. Latina egal immigrants alo rely on public health lines and hospital outpa- Yimin, with some belonging to health maintenance organizations (HMOs). For Latin ciizens and Anglo, private physicians and HMOs axe the moet important sources of regular medical care. To a certain teste, these patterns siggest that a twortiered stem of medical care texte one for dke medially insured and one forthe uninsured, for whom acess to medical care sa constant problem (National Heald Foundation 199). For Latina immigrants without a regular source of medical care, ‘the use of medical ervices alo depends largely on their medial insu sauce coverage. The uninsured with no regular source of medical are often search out a private physician who will uke cash up front for ‘minor health problems. For some, dhe barter, including costand even a general lack of knowledge about how to acces medical services, can prove to be too formidable, On March 28, 1989, ve year-old Sanda Navarrete died in Orange County of chicken pox, childhood disease ‘hati rarely fal in dhe area. Her parents were undocumented im {grant from Mexico who did not tke her toa hospital unit was woo late to save her. They had been in the United Sates only a short ne and did not hnow where to find medical services (Chaver, Fores and Lopes Gates 1992) Unforsinately, for many immigrant eo lack med ical iirance and experience episodic illness oF injuis, dere may bbe no alternative to the hospital emergency room asthe primary source co medical services, However, emergency oom costs ean quickly out strip immigrants’ meager resources, and hospitals are then Teft wih ‘unpaid bills (Gark eta. 1994). ‘Not aurpisingy the polite surrounding the provision of medical ramen, Sines of Medial Care forIomigrant Latinas Latin Cts, and White ‘Women Sx Orage Cnty Wh Haas Sos of Car A Rando Sample Telpone Stroy, 1992-1993 Undo Legal Clirer— Women Nai Nes Neos Noten eve pian 2% a mo, 1 oR ER Hospital oupaientinie 25% Rh uie/commanty ee orbrh center 0% a orp enenjencyroom 4 4 OO Ober se me am, services incding the delivery of babies, stimlate sme of the most contentious publiepoiey debates (Berk et al. 2000; Johnson 1996; Jobason 1995; Mls 1904; Rumbaut etal. 1988; Zavella 1997). For ‘xample, former governor of California Pete Wilon made cutting off undocumented women from prenatal are one of his central politcal concerns (Lesher and MeDonnell 1996) Cabfornis’ Proposition 187 in 1994 sought to deny undocumented immigrant acess to medical anv other social services and to compel physicians and other medical personnel totum in undocumented iminigrants seeking medical ser Vices tothe Immigration and Naturalization Service (Chavez 1997; Martin 1995). Although most of Proposition 187 proviions weve never implemented, because of constitutionally sues, i provides a compelling example ofthe extent to which medical cate, and other soc sesices, for immigrants can become embroiled in public conte: versy and even nat sendmeat (Calais 1996; MeDonnel 1097) Proposition 187 was ultimately a symbolic statement about the public's unease with increasing immigration, but the 1996 welfare reform law actually denied immigrans bot legal and undocumented, access to many medial and social services (Shogren 1996). Medicaidsoe ihsuates the impel of th reform on imran Between 198 TU 7, netic? we of Mead, amperage Po fom for suppor af medal nets doped recip om 998 percent io 32 percent 196 perint edu nthe propo of Ronines sige progean The Mei enonen fr see Sayed steady bloe snd tter mele lor (208 erent 0 90 pet. cen (Ean ae! 128), Ths ecln ccced sng om ss Stee elon 20 percent the poner lee which generally co Sic he owincome ener Athos closing the doo om Stn ter rs nigra le vermont progam he sor rut, hg edly waders rople among esis ota se poly athe long ri, Unteted me {ea protien ect more ony wh tine, Cota ise a Dost cred uihy—ilnes doe ox ing Bewecn izes ae noneiient acing ola conventional reste migrants tien revo home tenet oleracea and capers of remedies Fem ie pnemmentpenpecte the aerate ete (Sr poise peat beauty remedy om Unreune beac rovers scp aera el pbc cms nied pero Pein eco a poasy dangers remediate For ‘lea common fiom in Meso i anions Nexcan i ign he Une Ses mpc dese a ochage oe tichines ese by fod becong tek One remedy dn Mesa Satimporea ote United Sie on is igh eer oe pone fics espe angerou for iden nation, “fake” door {pacing medicine witht Hess) operate ot of nk in in fran neipnerbon Thee work comes to ight when 3 tage Creu athappene in Api nS a, Cala Aree toot chi de! ae eeingteten rom aman Mo a Soon racing wena cnc fone» er ihn Rene (Rena 120), ay people sometines aperse de njeconsof neice at onan to etme tthe back et gh Tool grocey tore beg io sre ad ae spe (Oicone td Bhs 2; Hayes 199; Try 197), Such aces abo ‘Se tii ter ge ses For example Tun, ao Imouorarios Axo Mnicat Aarons ‘on February 22,1999, a toddler died after receiving an injection of peniciin administered inthe back room of gift shop (Reza 1099), Aktough dhe child vas fund t have died from delydaton and not the injected medicine such cases suggest the health rks posed by the we of clandestine medical treatments and highlight the dfculy of finding adequate medical services from conventional providers (Guecone and Blankstein 2002; Weber 190%; ¥i and Jack 1999) However, we sil donot understand al the factors related the wse of alternative health-care providers (Chaves and Torres 199), My own research and that of hers uggest dat immigrants turn to atemative sources of health care for many rearous. Such providers Include spiritual healer who aze elective when illness Believed o be ‘elated to spirits or when intervention with the sprit world sree (Fadiman 1997; Holliday 2001). Some ilneses may also require wad Yional herbal medicines and other paraphernalia found in shops (Goenicas in Spanish) (Holliday 3001), Many folk lleses requ the services ofa culturally appropriate healer who can provide the neces sary treatment or herbal remedies. ln wach ese, immigrant use of healers may reflect a preference based on cultural slates ad appropriateness (Chavez and Torres 1994), This may be particulary tue in the ease of spiritual healers, with whom patents shave religious belies (Chavex 1984; Rubel, O°Nel, and Adon 198), Other times, immigrants tur eo clandestine practitioners or spistal healers for ieicaly related practices tha the larger society looks upon with i ain or sigmatizes, such a8 Female circumcision and animal sacrifice. ‘Wien his occurs, tcan spur societywide debates, even egal caves, ver Ae imi to society’ obligation to tolerate questionable cultural prac ‘ices (ee Shweder, Chapter 9) For Mexican immigrants, medial care in Mexico, which it ot that faraway isan appealing alternative. Reasons for crowing the border inciade cultural factors, such as familia, aby to communicate in a ‘common language, and the convenient availablity of drugs over the ‘counter without a prescription. Inston, Mexican immigrant find that health practitioners Mexico “understand” thei health prob lems, sometimes in contast wo a “bad” experience in a US medical ‘ncounter (Chavez 1984). Net surprisingly the Mexican immigra women (28 percent) participating ia ethnographic interviews for ourLao R. Cuavex ‘cancer study were mote likely than Chieanas (7 percent), Salvadoran immigrant women (4 percent), and Anglo women (4 percent) to have sought care in Mexico for health problems. This proportion is almost to that in a study I was involved with in the early 1980s, which $1 percent of Mexican immigrants (N = 2,013) in San Diego County had gone to Mexico for medical care atleast once since coming to the United States (Chavez 1984) ‘The frequency of immigrants’ use of alternative curers is difficult to determine fully, In our cancer study, we asked informants i ethno graphic interviews and respondents in the broader survey about their use of alternative curers. Of the 538 immigrant Latinas surveyed, 9.8 percent had been to a folk healer (curandevo), herbalist (gerbe), or spit iualist(espiritvasta). This was the same proportion as US-born Latinas (also 3.8 pereent, N= 260). Interestingly, Anglo women (7.1 percent, N = 422) were more likely than Latinas to have sought care from alterne tive healers. More interviewees thought that one or more of these alter native healers could cure certain ypes of cancer: 12.8 percent of Latina immigrants, 15.5 percent of US-born Latinas, and 21.9 pereent of Anglo women. As these findings suggest, not only immigrants seck alternative answers to questions about health and spiritual wellbeing. ‘Anglos and other natives turn to spiritual healers and seek the curing power of crystals, prayers, and other non-biomedical alternatives (Baer 2001; McGuire 1988. : Ethnographic interviews in our study with Latina immigrants sug gest that folk healers are good for certain ailments expecially stomach problems and folk illnesses such as empact, mollera caida, biis, and susto. Many Mexicans (26 percent), Salvadorans (29 percent), and ‘Chicanas (15 percent) said that they would go to a curander if prob- lem required it. Ethnographic interviews also suggest that Mexican and Salvadoran immnigranis place much stockin the efficacy of herbal reme- cies, with almost bal the Mexicans (49 percent), Salvadorans (46 per cent), and Chicanas (48 percent) indicating that they would seck care from an herbal specialist. Herbal remedies, especially teas or salves, were suggested for a plethora of health problems, including stomach problems, bile problems, nerves, diabetes, colic, diarshea, skin rashes, congestion, headaches, menstrual cramps, sore throat, kidney prob- Jems, and many more. Importantly, seeking care from a doctor did identi InOHIGRATION AND MEDICAL ANTHROFOLOGY nnot preclude trying herbal remedies, and vice-versa, Although some informants said that they went to an herbal special istor to Mexico, where good herbal remedies are sold in stores and by suect venders, many more indicated that herbal and other remedies are part of everyday knowledge and could be found around the house, ought at a pharmacy, or borrowed from a neighbor. They used teas, especially mine tea (jeréa buena), and common remedies such as aspirin, ‘Tylenol, wood aleohol, Vicks VapoRub, and cold medicines, Informants indicated that they would typically ry to cure, at home of withthe help ofa relative or friend, mostly “minor problems" such as colds, sore throats, flu, headaches, stomach aches, fevers, small cuts, abrasions, and sore muscles. As a twentyseven-yearold Mexican immigrant said, “Sometimes I try to treat [problems) that are not serious [at home]. Let's say someone has a fever: You might try and cure that using ‘Tylenol, or alcohol, That's what we Hispanics use, It’s part of our cul ture. It comes from our parents, who inculeated us, taught us dat sometimes a bath and rubdown with alcohol reduces the [body's] tem- perature. That's why we don't go to a doctor, but try and cure a fever with Tylenol and an alcohol rubdown, and that’s it” Importanuly, immigrants’ social networks serve asa safety net that provides many social and cultural resources, including health remedies, and reinforces ties and solidarity among local neighbors and family (Menjivar 2002). Among our ethnographic interviewees in the cancer study, 18 percent of the Mexican and 21 percent of the Salvadoran. ‘immigrants had tured (o a friend when they needed medical advice. For example, a sixtyseven-yearold Mexican immigrant woman said, “We have a very close friend who has almost forty years working in the "university hospital. And he helps notjust us, but everyone who asks him for advice he is ready to help. He advises us because he knows a lot about medicine because he works in an operating room, and he comes and he sees us and gives usadvice. For example, myson last Sunday had ‘bad pain in his stomach, and we called him [the friend!, and he tot ts that it was his appendix and that we should take him immediately to the doctor" Cecilia Menjivar (2002) has noted that among Guatemalan imuni- stants in Los Angeles, health remedies are also part of the resources ‘transmitted by transnational networks. Our ethnographic interviewsoR Gaara vith Mexican and Salvadoran immigrants support Menjar’s observa lion. A Mesican immigrant sid that, after noting the importance of stains for her gas colon, stomach, and bile, she also took some- thing for herliver which se said" prepared” noting, “They senditto sme from Guadalsjara (Mexico)” A wensycightycarold Salvadoran immigrant said, “The majory of remedies U have brought to me rom 11 Salvador. There are many herbs tht ean be wsed to cure, for exam- ‘ple fr body pas. There are many herbs cere that [how hot we that are sent ome from EL Saad" Tsun, immigrants, sich as those fom Mexico and other parts of Latin America often fd medica services ficult to access, They face shot of social, economic, ad cultural bariers. Howeves,nmigrants tre resourceful often turing to the meaical knowledge of funy and fiends and sometimes of alternative medical practitioners to meet their health-care needs INTERVENTIONS Up to this point, we have examined the interwoven cultural and steuctialfctors that complicate immigrants’ use of medial vervces. Many anthropsllogsts working wich inxmigeants also attempt to "do, something” wih their research, to apply what dey have learned 0 po icy inues or toward improving conditions fr the people with whom they have conducted research (Farmer 1999)."There are many ways 0 accomplish this task, One i 10 work toward changing public polices land laws that restrict immigrant’ use of medical services. Anthro: pological findings can inform legislation an be brought o bear ae Sits Anthropotogiss sometimes work diveely with immigrants in yon-governmental agencies, providing services and knowledge to sis individuals in the aquisition of care, Another approach is trough the evelopment of intervention programs that est 2 theory of howe best to incodice anges ‘Medical interventions often seek to change existing belits and behaviors, pill focusing on the patient. have helped develop and implement an intervention with the goal of introducing biomed belief about breasteancer sks in a culturally appropriate and sek tive manner Although I belive that we were success my expert tencey slo made clear to me both the srengts an weaknesses fsck Tmaucaanio Axo Meniea Antnoro.acy interventions, particularly the focus om individuals instead of the broader, societal factors influencing inmigrants’ use of medical er vices. After a brief overview of the intervention, Iwill dacuseritcal problems wit this approach, Using the knowledge we gained rom ethnographic interviews with Mexican and Salvadoran immigrant women, we developed a intervem ion almed at introducing biomedical ideas about ak Factors for breast, ‘ancer and increasing their practice of breast seltexamintion and routine mammography (Chaves, Hubbel, and Mishra 109; Misra ct. al, 1998). The imervention took into account the population’ rela. ‘vey Tow levels of formal education, low income, and preference for the Spanish language. Bloreover we elt that ic was imperative to ncor- porate the Latins’ beliefs into the intervention rather than dismiss them as silyoF flo. In addition, we were sensitive to de coneept {hat the separation ofalth problems from atrget population's belie! ‘sem and daily routines may diminish the effetvencsof health ed tation elfrts Bandura 1982). Finally, we wanted o desig an iter ‘tion that woud hare the best chance to change noc only knowledge nd atirades but alo behavior, ‘With these considerations in mind, we modeled the intervention om Bria’ theory of behavioral change (Dhdura 1977, 1982) and on Freres empowerment pedagogy (Freie 197, 1971). brief, Bandaras ‘heory predicts that individuals wil change ther self-efficacy (beliefs out ther own power, thei onm ails) alter they have mustered a lk and experienced its efecineness An increaed sense ofeetBeacy eas to changes in bear that may produce improve outonmes For ‘example, a woman is more likey to perform breast self-examination if she fees competent odo it Ia clinician validates woman’ nding, she wf feet more competent in routine self-examination. The inter: ‘eatin aso employs esons Feared by Paulo Fete daring his heracy ‘campaigns in developing counties based on Bandura’ theoretical Derspective. Latinas in our study shate many cultural and. socio ‘economic attributes, such as low levels of formal education, with ‘oup thc have already been helped by his empowering pedagogy. Freire found that individuals with low educational attainment absorb new information best when is pretend in away chat relates to their current environment and life circumstances, Therefore, the‘educational process shou allow stdent to introduce into the educa: tional sting any abues that relate wo their broader social context and ilfect their belies about the healt problem (in this case, breast cance), “The edvcator then empowers the ssdents to make breast cancer con tool their own problem instead of che edicaors. Through this strategy ved i an interactive the educator and the parécipants become [process dat leads to store information sharing about breast cancer felated beliefs and enables the women o become atively involved ina problesscling proces that may result in their improved eat “The theoretical model forthe intervention stressed the ced for the lamer to “own the problem” Freire developed what he termed a *problemporing” educational method. He contrasted the problem posing method with the banking concept of education, whevein Fimowiedge isa gift bestowed by thse who constr themsctres know cedgeable upon those whom they consider to know nothing” (Fete 1970). He explains that the banking concept einfores the individuals fatalitc perception of ther sissaton and, consequently, does notallow ‘students to shape ther opm acous o achieve needed change. By com ten the problem posing method presents pastcular station to sta dents asa probe to be soled by the group. This mode of learning fencourages the individ 10 analyze dhe way she perceives sali ‘Within this framework, the educational proces involves giveand tke” ‘communication. Inn open dialog with the educator, students can iitetnaize and evaluate critelly the information they receive. Given ‘auc an educational environment, students become intimately involved inthe subject and the solutions that ae developed will ely be applic: able to their own ives ‘We pilovesed an empomesmcnt modelintervention ina. uniersy afiiate! community cline in Orange County. During each sesion, a Iheakh educator posed questions designed wo encourage thought and Alscusion abou the potential impact of breatt cancer on the lves of ‘he participants, about risk factors ad symptoms of ress cancer, ad bout prevention and treatment of the disease. The educator thea guided the group to come up with sokstons to the problem of bres ‘cancer contol. We obtained mesnares of beast cancer-related know alge, atitudes, and practices before, immediately following, and sx trees afer the interention i the experimental group and in com ‘rol group that dd not receive the intervention. Results ofthis pilot te enabled us to determine the effecvenes of the empowerment methodology in improving breastcancer contro among Latinas. ‘The revults of our pilot test have been published elsewhere (Chavez, Hubbell and Mishra 1900; Mishra eral, 1998). Suffice ito say ‘that we were ces in our effort to inedice nev ideas and meth fod to detect breat lumps without denigrating pre-existing belief However, major suength of out approach was also a major limitation, ‘The intervention we dereloped works well ith small groups. I eclies on individuals to transmit their new understandings to relatives ad ‘iends io a snowball effect. This isa very ameconsuming method, Although itmay have etfectively changed beliefs and behavior of in ‘ial, it dil nothing o alter the stractral obstacles encountered by ‘Mexican immigrant women, ad other owincome people, when seek- ing medical erices. We wete faced wit very real diletuma, We could Increase awareness ofthe posiine value of preventive care and use of| canceracreening exams and, thus, the deve to obtain such care However we could do nothing about the cost of medical care, nancial screening, lack of medial insurance, English language skills, and ‘migration status, to name few ofthe survtural barter for Mexican ‘migrant women. ‘Wie did "a litle good” but realize, with frustration, that ony fun damental changes in embedded societal inequalities would hae areal apd lasing impact on immigrants’ Uses and wellbeing (Farmer 199) imately many of te greatest threats to immigrant health and dir use of medical tevices ie ouside their own beliefs and behaviors ‘These are related w the growing gull between the haves and have in American society. Stephen Bezruchka (2001), an M.D. who teaches «the University of Washington's Schoo! of Public Health sumed up the problem well: "Research during the lst decade has shown that he Inealth of a group of people snot allectedsubstancaly by individual ‘behaviors such as smoking, det and exercise, by genetics o by the use ‘of health care. In counties where basic goods are readily avalable, people's ie span depends onthe hieraechical structure oftheirsociety, ‘hati, dhe slae of dhe gap between ich andl poor” Medical interventions focusing on the individual may make positive, important incremental changes inciveual ves. Howeverimmigrants (and many poor citizens) would benefit hugely from higher wages, mandatory medial inmrance provided by employers, a national heakdveae syste, increased funding of ESL (English a a Secon Language) lacs aire enforcement of fairabor standard practices, and even a greatr public recognition that immigrants are wot {dain on social services but ae contebuting members of society. MEDICAL ANTHROPOLOGY AND IMMIGRATION— A MUTUAL BENEFIT Finally, medical anthropology and immigration research are not mally exclusive interest. They are mutually beneficial. My o research has been a example ofthis point An attention to medically related issues and problems has helped me better understand the nmigrant experience, The fist study [conducted om immigration | had, a special component, the wse of medical services (Chaves 1984; (Chavez, Comin Jones 198). ALte time, publi discourse char acterized immigrants, especially Mexicans, as ovesutliing medical resources and becoming a burden on society. Our study sought to introduce empirical researc ino the debate. Eventhough the impets for our reeatch was (oil what we perceived wat gapin knowledge, i ‘quickly beeame clear that health beliefs nd health care were impor tantin the lies ofthe people we interviewed Their experience, fears Jan! frstations applied to them not just ax Smmigrants but also a8 rua beings sfeing ines, injuries, and stresses in their vs. The formidable obstacles they faced in trying to alleviate these problems svete not theirs alone but wete extreme examples of obstacles also countered by lowincome and marginalized citizens ‘is here that immigration studies and medical anthropology are so mutually beneficial ltimstely oth are about understanding the hhuman experience. Because our research secks tobe holistic ints approach and perspective, ts wise to remember that health and wse of medical services are aot separate from working conditions living con- ditions, the politics of belonging to society, and the allocation of resources and benefits. We cannot uly understand the range of mean jngs and imitations of concepts such as cizenship, community, and socal integration without aending te the health and welLbeing of Jmmigrans Inoucxani0% Ano Manica AnriinoraLcy Notes ‘congener rn hi hp spr fr che seminar Aoi opaogy a Cvtermperay ran” nie by ay Fane ana the School Aner Reser in Santa Fe, New Men, rom Oct 4 11, 20 amined al the perp ad he nonmous ewes fo ei gosto gens demas especialy to Nave Foca sh grate fc Cathy Ot’ oh commen Ay Han inh chapter are ine alone, |. Hinman ggg quotione: What do oil the role? What to you think has eae ee eben? Why do ou tinkit started when it a? Wn do you think he ets doe How evee these? Wn hind of ‘etme do you thnk the patent saad ec? What the chet proba nes cmd Ws do you Sear ms about he she? 1 See Drester (100,190) anaes (190) fr a dco o the age face on mat! wee See ao Cera Sade de Sade and lila (190) for be idence of peace de any eget tn aor nga Hom Mec nd Cental Aerie ‘Gupan in Sn Paci conduct he pone sey ee ener 1982 wo March 1988, —_