The purpose of this paper is to inform community mental health workers of the ways in which one's ethnic background influences his or her role in the health care system. Roles that are investigated are those of patient, social worker, physician, nurse, aide and volunteer. In this way, ethnicity and interpersonal behavior are linked to demonstrate how an individual from a particular cultural background will fulfill a particular role in relation to others in a system or organization. Thinking in terms of roles in the system helps to underscore the complex nature of this area.
If one lists the kind of "pecking order" usually found in mental or general hospitals, one sees that certain kinds of power behaviors are reinforced because of one's place in the system. Leaving aside the roles of administrator or trustee who may have a lot of power, but little patient contact, one must acknowledge the consummate power of the psychiatrist. In some situations, the nurse has next most power, although far less than the physician and in some few places, the social worker stands in the second position.
Even the notion of power becomes more complicated when we extrapolate two kinds of power. The first has to do with decisions made about patient care, and the second relates to power over the patient's body. In the first case, power resides with whomever is around, is in charge at the moment. If it is evening, the nurse is generally in charge. Often it is the aide who answers the patient's call. At that point, the aide wields a huge amount of power. In certain situations, volunteers too, hold power over patients who are too weak or incapacitated to take care of themselves.
Role differentiations are only the most obvious ways to understand the interrelationships between caretakers and patients. Let us confound the situation by describing a typical medical scene in which not only roles but ethnic backgrounds are different. The patient who has had an acute schizophrenic episode is a reticent landscaper of Irish descent. His psychiatrist, is Italian and raised in a large family where the father was ruler. The nurse most involved with the situation is a black woman who was raised in a small southern town where the women had most regular work and were known for their strength. The social worker, who sees all patients and families on this unit is a white Anglo-Saxon Protestant who was raised on the mainline of Philadelphia, and the volunteer assigned to cheer the patient is a Jewish woman who is active in philanthropic organizations. Of course, each of these figures is familiar to some degree. It may sound like stereotyping but it serves to underscore the fact that there are cultural configurations with which we were raised and which we learned and continue to carry as adults. These configurations affect the kinds of illness behaviors that are displayed by patients and the ways in which community mental health workers react to these behaviors.
Part of these configurations is the difference in attitude toward the giving and receiving of help. Each ethnic group has clear ideas of the conditions under which it is considered legitimate to receive help. Talcott Parsons' discussion of the attributes of the sick role states clearly that an individual is allowed to give up certain responsibilities if he must, as long as he tries to get better and cooperates in any way he can.1 His discussion, however, is ideal and does not focus on cultural difference. Even within cultures, there are differences in attitude towards receiving help according to sex role. It is more acceptable in most cultures for women to ask for and accept help than it is for men. Studies on the utilization of mental health facilities in the United States demonstrate again and again that women not only seek help more often then men, but do so earlier in the course of the disease.
Also, in some cultures, it is acceptable for women to be nurturing and caring but not in a profession of high status like medicine. The majority of physicians in China and Russia are said to be women, but upon closer scrutiny the women's positions of barefoot doctor or feldshur are more like the nurse practitioners or physicians' assistants in the United States. Still, the barefoot doctors and the feldshurs carry more power than is traditional in United States medical care. In some cultures, men are only allowed to be nurturing as part of certain professional roles. In the United States, for example, we would probably think it was more acceptable for pediatricians to be nurturing than orthopedic surgeons, or perhaps psychiatrists to be more nurturing than internists. And within those distinctions, perhaps Italian pediatricians are different than Irish. These differentiations are important facets of which to be aware.
Another facet of the relationship of health and ethnicity looks at ethnic differences in coping with illness and disability. An ethnic group which has lived together as a community for a number of generations may cope differently with a disabled individual than one whose numbers do not live near each other and are trying to assimilate into the larger community. When an ethnic group shares a neighborhood and has done so for a long time, a community mental health worker can arrange help for a disabled patient returning home in a different way than he or she can for someone returning to a less cohesive neighborhood.
Even the kinds of diseases recognized in ethnic groups can differ. Some diseases are actually prevalent or most prevalent in one ethnic group. For example, Tay Sachs disease is found only in Jews of Eastern European extraction.2 In the United States, Sickle Cell Anemia is found primarily in the black population. A comparison of the ways in which the health care system has responded to these two diseases is a further powerful example of the link between ethnicity and health.
Tay Sachs is a rare disease affecting 1:3600 live Jews whose ancestry is from central eastern Europe. Its incidence in all populations would be about 1:360,000. Thus, approximately 50 children with Tay Sachs will be born in the United States each year. A simple blood test of each of the two potential pa rents will demonstrate whether they both are carriers. Since the disease is recessive both must be carriers for the disease to be passed to their child. Mass screening programs have been set up in large metropolitan areas where there are defined, accessible Jewish populations. The usefulness of such screening has been proven absolutely. If a couple both carry the trait and want to chance pregnancy, amniocentisis yields a highly accurate method for the detection of the disease, and it is still possible to give parents a choice before the baby is born.3 The programs are primarily staffed by volunteers from the community and carried out simply without a lot of fireworks and with a great deal of community support.
Sickle Cell Disease has been responded to in very different ways by society. Approximately one in four hundred black children will inherit the trait from each parent and develop the disease. The trait is carried by ten percent of the American black population. Part of the difficulty in societal response has been in the confusion of the trait and the disease. Some physicians feel that the presence of the trait denotes disease in itself, and some do not.4,5
In 1972, some say for political reasons, then President Nixon helped enact the National Sickle Cell Anemia Control Act which established a program with the Public Health Service to provide for voluntary sickle cell anemia screening, counseling, and treatment, and "appropriate publicity of the availability and voluntary nature of such programs."6 However, even in the Act, there was confusion about trait and disease. The Act stated there were two million American Blacks with sickle cell disease when, in fact, there were two million individuals with sickle cell trait.7 At first, the Act was supported by the Black Athletes' Foundation for Research in Sickle Cell Disease which sent representatives to Washington to lobby on behalf of an intensive national effort.7 Soon, many black leaders began to talk of genocide and to lobby against mandatory screening efforts.8
Fifteen months after the President raised the sickle cell issue, Congress authorized 25 million dollars for 1973, 40 million dollars for 1974, and 50 million dollars for 1975 to be spent on sickle cell. It is striking to see this kind of allocation especially when it is highly unusual for research to be financed according to a specific disease entity. In an enthusiastic reaction to the national effort to combat sickle cell, states rushed into law provisions for screening sickle cell trait. Some were voluntary, some were not. Mandatory sickle cell laws had been passed in 12 states by February 1973. In response to the Sickle Cell Act, Maryland passed a statute, ch. 695, 1973, which would establish regulations for the detection and management of hereditary disorders.9 This statute was quickly overturned. Connecticut which passed the first legislation for screening for trait carriers, provided for the screening of school children.8 The District of Columbia City Council officially declared sickle cell anemia as a communicable disease in order to pass legislation requiring the mandatory testing for sickle cell anemia of children who are to be admitted to public school.7 This law, too, was overturned.
Obviously, screening for sickle cell-trait or disease became a political football within the medical community, within the black community, and within the legislative community. Judgments were made out of political need, out of a determination to respond to the black community about "their" disease, rather than out of medical technological advancement. These close associations between politics and genetics have been obvious historically, particularly in Germany and Russia in the 1920s.
Thus, the steps to screening for Tay Sachs disease and those to screening for sickle cell can be contrasted. Here are different diseases in different cultures demonstrating the relationship of health to ethnicity on a purely physiological basis as well as on a socio-political one. Still another way to examine the relationship between ethnicity and health is through understanding concepts of disease expressed by different ethnic groups.
In a study of Mexican-American culture, Arthur Rubel described certain illnesses that are restricted to one or another group in relation to their socioculturai background.11 He studied Spanish-speaking people in the Texas-Mexico border town called Mecca. The town was made up of two ethnic groups, immigrants from Mexico and displaced Spanish-speaking American citizens of the ranchos. Each of the two communities was separated in the new town and each transplanted its customary way of life. The Anglo-Americans built a highly organized society while the Mexican-Americans continued their familial tradition of isolation. Rubel said, "Given their socioculturai backgrounds, it was not surprising to find that although both groups shared certain illnesses (like measles and pneumonia) other ills were restricted to one or the other of the groups."11
He described five illnesses confined to Mexican-Americans, four of which were sicknesses from natural cause and thus in the domain of God. One of these diseases, empacho, resulted from the failure of the digestive system to pass a chunk of food. This was caused when someone was required to eat against his will. Another, called susto or shock resulted from social conditions which engendered anger or fear. An example is a child who on a picnic with his family was urged to swim and would not. He slept long and fitfully from susto because his family had made demands to which he could not accede. These illnesses described have remained firmly embedded in the socioculturai framework despite the introduction of an alternate system of belief and competing healing ways.
Irving Kenneth Zola examined the conception of disease in an article entitled "Culture and Symptoms - An Analysis of Patients' Presenting Complaints."12 He was interested in how socioculturai background led to different definitions and responses to essentially the same experience. He said the strongest evidence in support of his argument was the different ethnic perceptions for essentially the same disease. Although he cited many fascinating studies, his own work concerned a comparison of Italians, Irish and Anglo-Saxon Protestants in which he explained the "fit" of certain bodily states with dominant value orientations.
He said that Italian and Irish ways of communicating illness may reflect major values and preferred ways of handling problems within the culture itself. Italians dramatize in order to cope with anxiety by repeatedly overexpressing it and thereby dissipating it. Zola quoted Luigi Barzini pointing out' "the most easily identifiable reasons why the Italians love their own show. . . . First of all they do it to tame and prettify savage nature, to make life bearable, dignified, significant, and pleasant for others, and themselves. They do it then for their own private ends; a good show makes a man simpatico to powerful people, helps him get on in the world and obtain what he wants, solves many problems, lubricates the wheels of society, protects him from the envy of his enemies, and the arrogance of the mighty - they do it to avenge themselves on unjust fate."12 "But if the Italian view of life is expressed through its fiestas, for the Irish it is expressed through its fasts ___ Life was black and longsuffering, and the less said the better."' ' He quoted one Irish woman referring to the discomfort caused by her illness by stating, "I ignore it like I do most things." They were least likely to admit any symptoms at all and contended that their physical problems affected nothing of their life but the most minute physical functioning. Thus the illness behavior of both groups reflected their general view of life.
Several studies have been primarily concerned with religious groups. In "Religion, Religiosity and Illness Behavior: The Special Case of the Jews," David Mechanic pointed out from a study of university students that Jews have the lowest threshold for consulting a physician, for taking medicine, and for taking off classes when ill.14 He explained that traditionally Jews have been concerned with health and illness. Health is associated with parental affection and concern. Zboroski and Herzog reported that "the mother's solicitude is most actively focused on the physical welfare of the child. . .her endless stream of admonitions and reminders has to do with physical well-being; children must not hurt themselves, they must not get into a draft or get chilled. Above all they must eat enough..."1 There is a near compulsive concern with health. "Traditionally, sickness is a time for the Jewish community to draw together in order to rehabilitate the sick, and early symptoms of illness are avoided at all costs."14 Finally, Mechanic suggested that the subtle patterns of perceiving symptoms and evalua ting health are not easily affected through acculturation.
In "Ethnic Origins, Educational Level, and Responses to a Health Questionnaire," Sydney Croog16 came toconclusionssimilar to Mechanic's. His results suggest that sensitivity to and concern with physical symptoms may be a general cultural trait of Jewish populations. In "Infant Mortality and Social and Cultural Factors: Historical Trends and Current Patterns," Anderson17 reported a much lower rate of infant mortality among native-born as compared to foreign born whites except for Jews." He said "The Jewish group was foreign born, lived in as crowded conditions as other foreign born, bore just as many children. . . and enjoyed an income which was much lower than that of native born whites, (but) this group experienced the lowest infant mortality rate of all groups." There was a different pattern of infant care in Jewish culture.
Greenbaum thinks that differences in illness behavior and utilization of medical services will diminish as ethnic groups become more assimilated into the larger community and as standards of medical care are raised for the poor and for minorities.1 It will be important to study trends in the future if ethnic identification is indeed dissipated and replaced. One measureable, or more measureable way of looking at the relationship of health and ethnicity is through the study of pain.
As Christopherson said, "Pain is physiological in nature: however, the individual's response to pain is influenced significantly by the culture in which he is reared."19 The pain response is a learned response. Perhaps, the most famous study in this area is the work of Mark Zborowski. He published an article called "Cultural Components in Response to Pain," and a book called People in Pain which compared the illness behavior of Italians, Irish, Jews and Anglo-Saxon Protestants who had similar diseases.20'21 He was concerned with spontaneous pain, the kind of pain caused by disease and injury. The Jewish patient tended to provoke worry and concern in his social environment as to the state of his health and the symtomatic character of his pain, while the Italian tended to provoke sympathy toward his suffering. Among "Old American" patients, there was little emphasis on emotional complaining about pain. As in the case of Jewish patients, the American attitude toward pain was best described as a future-oriented anxiety. Although both were future oriented, the "Old American" tended to be optimistic while the Jewish patient was pessimistic or at least skeptical. Irish patients, too, have almost a standard way of responding to pain.
Tursky and Sternbach correlated these findings psychophysical and autonomic measures.22 They found that Yankees had a phlegmatic matter of fact orientation toward pain; Jews expressed a concern for the implications of pain and distrusted palliatives; Italians expressed a desire for pain relief; and the Irish inhibited expression of suffering and concern for the implications of pain.
Thus, special emphasis is placed on ethnic difference in dealing with pain because the ways in which an individual manages pain are so clearly linked to his or her health care. An Irishman might endure pain for a longer time before seeking help than someone of Italian descent because of differences in the ways in which they have learned to manage pain. Also, the ways in which a person copes with pain influence the response of health personnel to the patient. Someone who verbalizes his or her pain or who behaves in less than a dignified way can be viewed as a troublemaker especially by a helper whose background is different than that of the patient.
Each of these aspects of ethnicity is reflected in community mental health. In one category are the diseases which themselves vary from ethnic group to ethnic group. There, society responds more according to social response than medical condition. In another category are the total illness behaviors which vary from group to group. In the final category, are the responses to pain which vary from group to group. Each of these categories serves to underscore the subtle but powerful relationship of health to ethnicity and the importance of community mental health's understanding of that relationship.
- 1. Parsons T: The Social System. Glencoe, Illinois, The Free Press, 1951.
- 2. Keveck M, Zinger S: The John F. Kennedy Institute Tay-Sachs program, in Hilton B, et al (eds): Ethical Issues in Human Genetics. New York, Plenum Publishing Corp, 1973, pp 131-132.
- 3. O'Brien S, et al: Tay Sachs disease: Prenatal diagnosis. Science April 2, 1971.
- 4. Nalbandian M: The sickle cell trait. JAMA 226:1357-1368, 1973.
- 5. Heller P: Once more - the pathogenic effects of the sickle cell trait. JAMA 225:987-988, 1973.
- 6. National Sickle Cell Anemia Control Act, Public Law 92-294, 86, Stat. 136, 92nd Congress, 2nd Session, 1972.
- 7. Bowman E: Sickle Cell screening: Legal, economic, and social problems. Presented at the Conference on Sickle Cell for Industry, Management, Insurance and Labor, New York, February 1973.
- 8. Culliton J: Sickle cell anemia: National program raises problems as well as hopes. Science 178:284, 1972.
- 9. Powledge T: New trends in genetic legislation. The Hastings Center Report 3:6-7, December 1973.
- 10. Graham LR: Political ideology and genetic theory: Russia and Germany in the 1920's. The Hastings Center Report 7(5):30-39, October 1977.
- 11. Ruble J: Concepts of disease in Mexican - American culture. American Anthropologist 62(5): 795-814, October 1960.
- 12. Zola K: Culture and symtoms - an analysis of patients' presenting complaints. American Sociological Review 31:615-630, 1966.
- 13. Barzini L: The Italians. New York, Bantam Books, 1965.
- 14. Mechanic D: Religion, religiosity, and illness behavior: The special case of the Jews. Human Organization 22:202-208, 1963.
- 15. Zborowski M, Herzog E: Life is With People. New York, International Universities Press, 1952.
- 16. Croog S: Ethnic origins, educational level, and responses to a health questionnaire. Human Organization 22:202-208, 1963.
- 17. Christopherson V: Sociocultural correlates of pain response. Social Science 40(1):32-39, January 1971.
- 18. Greenbaum J: Medical and health orientations of American Jews. Soc Sei Med 8:127-134, March 1974.
- 19. Anderson O: Infant mortality and social and cultural factors: Historical trends and current patterns, in Jaco EG: Patients, Physicians and Illness. Glencoe, The Free Press, 1958.
- 20. Zborowski M: People in Pain. San Francisco, Jossey-Bass, 1969.
- 21. Zborowski M: Cultural components in response to pain. Journal of Social issues. 8(4):16-30, 1952.
- 22. Tursky B, Sternbach R: Further physiological correlates of ethnic differences in response to shock. Psychophysiology 4:67-74, July 1967.