Part II: Intercultural Policies and A Public Health Crisis (March 2021)
On April 28, 2020 I was invited to attend the first Virtual Online Briefing session in a series from the Congressional Hispanic Caucus Institute (CHCI) titled Covid-19: Addressing Health Disparities (Bailey, C., 2019, April 5). Shortly after the pandemic hit the United States, evidence surfaced regarding seriously devastating infection and death rates among this country’s most vulnerable populations. At first, municipalities and states neglected to capture data based on race when health officials began reporting Coronavirus cases. There was such an outcry for legislators to demand officials collect U.S. Covid-19 data to tell the truth about how this public health crisis was impacting communities of color. As the numbers continued to soar at alarming rates, showing the impact on underrepresented populations and the elderly, one thing was clear: The U.S. had a public health crisis that existed long before the first Covid-19 case appeared in the state of Washington.
This crisis, “rooted in this country’s historical and structural racism and the social, economic, and [the] health inequities that have resulted, and continue to result in, adverse health outcomes” (Robeznieks, A., June 2020), evidenced a great need for ICC in public health. Over years of working with international students and students of color, I have processed the benefits of ICC when compassionate health care providers in the intensive care unit of a Columbia, SC hospital provided patience, Korean Translation, and community contacts for families after four of my Korean students were in an auto accident. The injuries they sustained required spinal, heart, and brain surgery and their families needed to be in the country long-term during the recovery. In my earlier career, I accompanied student volunteers and a Costa Rican medical team led by an Ecuadorian doctor as they trekked through rivers in a rainforest, carrying supplies via ox cart, to a Guaymi tribe near the southern border of Costa Rica. I observed the true affection and trust the medical team built up over time with the tribe despite differences.
Years later, I also witnessed the lack of these competencies outside a hospital chapel when Ethiopian and Nigerian international students learned of the death of their friends, killed by a drunk driver when the students stopped to fix a tire on the side of an Indiana road. Hospital chaplains hushed them and quickened them to the chapel so they would not be heard after waves of grief overtook shock in the hospital hallway. These students mistook this act as a cultural cue that you should not mourn loudly or visibly in the U.S. and avoided any public displays of grief. A need for ICC training in health care sectors also occured to me when a friend told me stories of her doctor making racist remarks about her understanding of health when her doctor began prescribing at home care instructions opening with; “You probably don’t know this because you are Hispanic but…” (Anonymous, 2013).
However, as I listened to the CHCI briefing and pondered the atrocious local and global disparities highlighted by the pandemic, the idea of the intersection of health care policy and ICC impact on vulnerable communities crystallized. As Dr. Elana Rios (2020), M.D., President and CEO of the National Hispanic Medical Association, shared her reflections on the root cause of these disparities, she diagnosed it as a lack of ICC. She went on to define ICC as a “set of behaviors, attitudes and policies that a system [a health care system], an agency, an organization, or even professionals that can actually enable them to work more effectively in cross-cultural situations” (Rios, 2020).
Policies? Yes, that’s it, I thought. Since moving to the D.C. area, I have thought a lot about the need for intercultural policy makers, but I hadn’t thought deeply about the health impact interculturally deficient policies have on zip codes; or rather, the people living in those zip codes. It’s a chicken or the egg question. Do we need interculturally competent policy makers or intercultural policies first? Dr. Rios explained that intercultural policies ensure communities of color “receive socially, culturally, and linguistically appropriate care” (Rios, 2020). Some of this might be accomplished through policies that tie together quality training, shared lessons learned, strategic budgets, and non-discriminatory technology. She also addressed pipeline issues in higher education where the majority population often receive benefits not provided to students of color, a practice often ignoring the workforce demand to diversify the fields of disciplines (Rios, 2020). Policy initiatives require professionals in institutional, subnational, and national policy positions to practice and reflect ICC, who listen to the most vulnerable for understanding. They need this soft skill, attitude, and knowledge for the purpose of building bridges to the public in order to better provide equitable evidence-based public health care rooted in perspective taking,community self-awareness,curiosity,empathy, humility, and human connection.
Early on the American Medical Association (AMA) put a spotlight on U.S. society inequities among Black Americans, Latinx communities, and American Indian/Alaskan Natives. As a nation, we needed to come to terms with xenophobia directed at Asian populations and a former president who incited hatred towards Chinese-Americans and Asian guests in our country (Robeznieks, 2020). They cited the following issues related to these disparities revealed prior to June 2020:
- Black Americans are dying at nearly two times their national population share, and in five out of the six counties with the highest COVID-19 death rates, they are the largest racial group, according to the COVID Racial Data Tracker.
- The Latinx community accounts for 49% of Virginia’s COVID-19 cases where ethnicity is known despite accounting for only 10% of the state’s population. Similarly, in Iowa and Wisconsin, the COVID-19 infection rate for Latinx individuals is five times their population share.
- American Indian/Alaska Natives are also disproportionately affected, and American Indians account for 60% of COVID-19 cases in New Mexico where they are only 9% of the state’s population, and 21% of COVID-19 deaths in Arizona where they are just 4% of the population. (Robeznieks, 2020).
The AMA took it one step further: they took their data directly to Congress and recommended they address implicit and unconscious bias, data challenges, social determinants of health (SDOH), and invest in professional diversity (Robeznieks, 2020). The Center for Disease Control keeps track of the infection, hospitalization, and death rates related to Covid-19 and continues to compare these rate ratios between White, Non-Hispanic persons and communities of color as noted in the following table. These ratio rates provided by the CDC tell a powerful story of what I like to call intercultural negligence (Center for Disease Control and Prevention, n.d.).
The World Health Organization emphasizes many needed intercultural skills since they recognize the value of cooperating across differences to learn from each other and make a global impact. They urge nations to leverage the voices of civil society to “listen to the marginalized” (WHO, 2017). In an effort to assist public officials, affinity organizations have quickly rallied to provide data-rich pleas to identify barriers in public health so policy makers are forced to address the truth of the matter. They are educating vulnerable populations who over the years have learned to be skeptical of the government whose practices and policies surrounding health care had adverse impacts on a fundamental requisite for effective public health, namely trust. The Covid Tracking Project, a collaborative effort by COVID Tracking Project and the Boston University Center for Antiracist Research, started a website specifically to understand Covid trends impacting people of color in our country. We Are All Human (WAAH) began data collection to tell the story of how the pandemic impacted their communities as seen in this graph (We Are All Human, 2021). They created a must-see video, El Pendón Estrellado, a Spanish version of the United States National Anthem, honoring Latinx essential workers serving their fellow Americans.
In March 2020, the Asian Pacific Planning and Policy Council (A3PCON), Chinese for Affirmative Action (CAA), and the Asian American Studies Department of San Francisco State University launched the Stop AAPI Hate (About, Stop AAPI Hate, 2021) website in response to the escalated xenophobia brought about by the pandemic and bigoted comments made by national leaders. Stop AAPI Hate “tracks and responds to incidents of hate, violence, harassment, discrimination, shunning, and child bullying against Asian Americans and Pacific Islanders in California and where possible throughout the United States” (para. 1). Among their 5 pronged approach to combat racism toward Asian Americans during the pandemic, Stop AAPI Hate articulates advocacy for human rights based policies that promote and protect civil rights at local, state, and national levels.
Even The U.S. Department of Agriculture plays a role in our public health crisis as food insecurity rises and corporations like Hellmans are doing their part to bring food to American tables through their Food Relief Fund in partnership with East Side Settlement and The Federation of Southern Cooperatives/Land Assistance Fund, which directly benefits black farmers. These partnerships help carry the burden of government response and inform legislators of needs. This is important when you consider when 26 million Americans said they didn’t have enough to eat (Parrott et al., 2020). Groups like Feeding America build coalitions between members of the public, a network of charities, food banks, and the government bringing attention to bills being considered by legislative committees who focus on appropriations, budget and taxes, The Farm Bill, and The Child Nutrition Reauthorization Act. Such coalitions require great intercultural skill to navigate and build effective cross-organizational cooperation.
Even though the CDC reports show Native Americans’ pandemic rate ratios at 2.4 times higher than white communities, there seems to be very limited tracking to adequately address what they call the “Historical trauma and persisting racial inequity” (Center for Disease Control and Prevention, 2020). Organizations like the AMA are trying to understand the issues that impact this population in order to influence health related practice and policy. They explain that the Bureau of Indian Affairs and Indian Health Service were byproducts of treaties made when tribes traded land and natural resources for government services which included health care. However, little money is allocated to these government funded agencies. This leaves Native American populations, who suffer from preexisting conditions and where families may live in multigenerational housing where running water may be lacking, at risk of disease with few resources to combat it. Policies that require better tracking of Covid-19 impact, vaccine tracing, funding for telehealth may make all the difference. It is important to note that “many tribal communities don’t even have a hospital” (The pandemic’s impact, n.d.).
Unfortunately, these intercultural oversights with indigenous populations exist at a global level. Anne Nuorgam, Chair of the United Nations Permanent Forum on Indigenous Issues, stated “We urge Member States and the international community to include the specific needs and priorities of indigenous peoples in addressing the global outbreak of COVID 19” (United Nations, n.d.). The United Nations Economic and Social Affairs cited the same issues that marginalize this population globally, namely, “lack of access to effective monitoring and early-warning systems, and adequate health and social services” (United Nations, n.d., para. 4) in their report. They encourage the global community to share how they are advocating to prevent and fight against the spread of COVID-19 at firstname.lastname@example.org ?so they know better how to develop policies and programs that impact indigenous people.
One must listen to the communities in crisis to understand where advocacy is needed most. This goes for needed advocacy in mental health, housing, unemployment, domestic violence, hunger issues, and other Covid-19 related inequities felt most by communities of color. After over a year, health policy makers walk their intercultural talk by becoming aware of their own personal biases and blind spots. This can be accomplished by bringing diverse voices to the table and listening to understand rather than speaking to push an agenda that may be a detriment to the most vulnerable populations. Health policy influencers and leaders should ask themselves the following questions:
- What is the country’s health care history with minority and marginalized groups in the local communities and country? What is the root cause and potential breakdown of intercultural decision making?
- Could current health care disparities indicate unspoken inequalities?
- What tensions and divides exist at the local, regional and national levels?
- What intercultural knowledge, attitudes and skills do policy leaders need to move the needle on national dialogue about race and health care disparities affect populations?
In the case of intercultural health policies, it’s not just about improving society’s quality of life. Policy leaders must listen for understanding by collecting and analyzing the stories told by the data. They must exercise humility and empathy when they cast their votes. Develop self awareness as you listen for understanding as you listen to civil society and stories told by data, then take action! It’s a matter of dignity and equity, it’s a matter of life and death.
An Invitation from the author: I invite those of you in different parts of the globe to share stories of how vulnerable populations in your communities have experienced Covid-19. This article highlights a fraction of how intercultural health policies are needed globally. Please submit your own article or reach out with thoughts or reflections to the author directly.
American Medical Association. (n.d.). The pandemic’s impact on the Native American population. https://www.ama-assn.org/delivering-care/population-care/pandemics-impact-native-american-population.
Anonymous, (Health Care Recipient) in discussion with author, 2013.
Bailey, C. (2019, April 5). How to get your brain to focus [Address]. TEDxManchester, Manchester, U.K. https://www.youtube.com/watch?v=Hu4Yvq-g7_Y
Centers for Disease Control and Prevention. (n.d.). Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html#print.
Davis, M. A., García, J., Kelly, R., Lopez, R., Rios, E.V. (2020, April 30). Covid-19: Addressing Health Disparities [Webinar]. Congressional Hispanic Caucus Institute Covid-19 Virtual Briefing Series, D.C. https://www.youtube.com/watch?v=Vo9wIKPM08E.
Parrott , S., Sherman, A., Llobrera, J., Belétran, J., Michael, L., Mazzara, A., & Extending Eviction Moratorium Helpful. (2020, July 21). More relief needed to alleviate hardship. Center on Budget and Policy Priorities. Retrieved September 26, 2021, from https://www.cbpp.org/research/poverty-and-inequality/more-relief-needed-to-alleviate-hardship.
Robeznieks, A. (2020, June 10). Risk for Covid-19 infection, hospitalization, and death by race/ethnicity. Retrieved March 31, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html#print.
Stop AAPI Hate. (2021, April 16). About. https://stopaapihate.org/about/.
United Nations. (n.d.). COVID-19 and Indigenous peoples For Indigenous Peoples. United Nations. https://www.un.org/development/desa/indigenouspeoples/covid-19.html.
We Are All Human, U.S. Hispanic & Covid 19, infographic, January 7, 2021.
World Health Organization. (2017, September 25). Civil society. World Health Organization. https://www.who.int/social_determinants/themes/civilsociety/en/.