Cynthia I. Macri, MD, FACOG
Back in the '90s, my gynecologic oncology fellow published a paper about how equal care results in equal outcomes, or survival rates, in the military cancer network compared with the civilian sector. This paper paved the way for many studies on health disparities based on race, ethnicity, insurance status, appearance, and more for every specialty. Health discrimination beyond access to care is still fairly widespread, and unfortunately officials in all organizations incorporate biases based on personal experience; stereotypes of whole groups; and, perhaps worst of all, professional cynicism when making policy decisions on which innovations to try and which research programs to support and fund. This results in more studies revealing the same things: that discrimination continues, and different groups face different barriers.
My COVID-19 pandemic experience and my current experience on the Maryland governor's Commission on Suicide Prevention—specifically now the rollout of the 988 suicide hotline—tells me that there is much work still to be done, even in a state where diversity is a celebrated part of the landscape. When discussing solutions for COVID-19, the nation has spoken loudly and proudly about how many problems would be solved by the information available online, but often that information is primarily accessible by computer and available only in English or Spanish. This left out—and continues to leave out—a large percentage of people who do not have internet access and do not speak English or Spanish. The result of the lack of inclusion or targeting of different communities is that those groups were then labeled as unvaccinated, vaccine hesitant, or vaccine resistant. In reality, among those who were labeled as such were older Asian people who wanted to be vaccinated but didn't speak English, weren't computer savvy or connected on social media, were afraid to go out because the news was showing older Asians like themselves being beaten up, or were worried that they would get COVID-19. In addition, many of the unvaccinated did not have transportation to mass vaccination sites or the time to wait in long lines, especially if they had to rely on their working children to take time off work to drive them to vaccination sites and wait with them in long lines.
I see similar problems in my work with the Commission on Suicide Prevention and the 988 suicide hotline. When I asked members of the hotline's working group what their plan was for cultural and linguistic services for multigenerational Asian households, their response was that the lines would be answered in English and Spanish, but anyone who needed help in another language would be referred to the medical translation service. When addressing issues such as suicide, simply translating resources into the necessary language doesn't suffice, because an understanding of the cultural aspects of mental health, suicide, life stressors, and more cannot be gained simply through translation. There needs to be a commitment to developing a cadre of professionals who know the cultural nuances for local demographics and groups, the words that should be used, and the images that should be described. Communities need professionals who can relate to the needs of groups that have been excluded and pushed to the margins, who have lost hope that their needs will ever be addressed.
On the happy side, during the pandemic, I volunteered with the Maryland Reserve Medical Corps and vaccinated hundreds of people at the Chinese Culture and Community Center, a long-standing clinic in Gaithersburg, Maryland, that offers aid to any underserved person in the community. Prior to the pandemic, I was volunteering there to offer women's health services, seeing older women who had either never had a Pap smear or who had not had one since coming to the United States. Many, if not most, were uninsured and were offered the opportunity to enroll in Montgomery Cares (a group of community-based health care professionals who provide medical care to uninsured adults in Montgomery County), the Kaiser Permanente Charitable Health Coverage program, Medicaid and Medicare, or the ACA. Even though I didn't speak the same language as many the underserved and uninsured patients I've seen, I was able to give them culturally proficient care from someone who they felt comfortable with in an environment they felt safe in.
I would like to call attention to the possibility of some solutions. One of these solutions is funding. Smaller grants in smaller communities may be able to have a big impact on public health by educating, screening, and serving groups that are left out by larger public health efforts. For example, the Chinese Culture and Community Center is now a central part of the pandemic response and a consulting clinic for many other services because of the way in which we mobilized for our county during the pandemic. Providing funding for smaller organizations or groups such as the Chinese Culture and Community Center and their community-based partners, which are staffed by people who know the immediate needs of their communities and are positioned to provide or facilitate culturally informed care, could make a big difference locally.
Another solution is to connect patients with culturally informed care. This means ensuring that health care professionals understand how to identify the intersection of many different factors in their patients' lives that go beyond race and class. For example, when I work with Asian and Asian American patients, I make note of and account for different aspects of their lives, such as whether they live in a multigenerational household, what their economic responsibilities are, and social norms that may affect how they communicate their needs. Asian and Asian American patients, like people of any culture or race, have different needs, different resources, and different approaches to their own care. If there's anything that my experience has taught me, it's that ensuring that each patient receives culturally accurate and appropriate care begins with understanding their culture, and that this is not difficult if we as clinicians shed our own biases and listen attentively to our patients.