Thinking outside the pill box

The latest issue of the Journal of Women’s Health includes three articles describing health risks of women in the United States related to social exclusion and cultural factors. They all demonstrate that good health is about a lot more than medical care.

The first article looks at three factors associated with cardiovascular disease–hypertension, elevated cholesterol, and diabetes–among 733 uninsured, low-income rural women in West Virginia aged 40-64 years.  The women were participants in the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program.  West Virginia has a high percentage of people 50 years and older, the highest rate of angina and coronary heart disease in the United States, and is tied with Kentucky for first place in prevalence of heart attacks.  Prevalence of hypertension, elevated cholesterol, diabetes, and obesity, are also among the highest in the nation. The study found that large proportions of the women are at risk for cardiovascular disease because of untreated hypertension and high cholesterol. They lack access to regular health care due to the limited availability of health services in rural areas. Women who are less educated, a likely proxy for poverty, are particularly likely to have these untreated chronic conditions.

The second article is about emergency care for women who have been sexually assaulted. According to the National Violence against Women Survey, 18 percent of white women, 19 percent of Black women, 24 percent of mixed race women, and 34 percent of American Indian/Alaskan Native women report a rape or sexual assault at some time in their lifetime. This article reports on findings about the “incident history” of sexual assault from 173 women who sought care in an Emergency Department in an unidentified city (possibly in Mississippi since the lead author is assistant professor in the School of Nursing at the University of Southern Mississippi).  Of the total, 58 percent of the women were black and  42 percent white.  Weapons were much more likely to be involved in assaults on black women, and black women were more likely to be assaulted in the city rather than the suburbs. Substance abuse occurred in about half of the assaults; black women were more likely to report use of illicit drugs while white women were more likely to report alcohol use before the assault.

The third study reports on an evaluation of a community-based pilot intervention in New York City that combined cervical cancer education with “patient navigation” to improve rates of cervical cancer screening among Chinese American women.  In the United States, Chinese American women have higher rates of cervical cancer than white women.  The study compared an intervention group and a control group.  Eighty women received the intervention: two education, sessions,  open discussion with a Chinese physician, educational videos,  and navigation assistance in identifying and accessing low-cost services. The control group of 54 women received two education sessions delivered by Chinese community health educators and written materials on general health and cancer screening. Twelve months later, screening rates in the intervention group were 70 percent compared to 11 percent among the control group. An important factor in the intervention group was greater perception of the severity of the disease.

All three studies offer important findings with implications for improving the lives of many women. All three, though to varying degrees, stay within medical bounds: diagnosable health problems (hypertension and high cholesterol, battering, and cervical cancer) require improved treatment.

Critical medical anthropology, an approach I support, seeks to expose the political economy, or power interests, that shape the distribution and experience of health problems and the access to health care. Its sword cuts two ways: first, in showing how certain categories of people are excluded from high quality health care, and, second, by unmasking the process of medicalization that characterizes Western biomedical culture.

Medicalization, in a nutshell, is narrowly labeling conditions as medical and treating them medically when in fact they are caused by structural violence (poverty, patriarchy, and other inequities) and political violence (war, public conflict). Medicalizing the trauma of those who live in conflict zones or the malnutrition of the urban poor leads to a “pills for trauma” or “pills against poverty” approach rather than opening the door to social critique and change.

Does critical medical anthropology have anything to offer to the three studies discussed here? Yes, clearly.

In terms of lack of access to health care: in both the West Virginia and New York City studies, structural inequities limit women’s access to adequate health care.  In West Virginia, poor and uneducated women carry the burden of untreated health problems. In New York City, Chinese American women are likely to be unscreened for cervical cancer.  Both articles recommend expanding health services to the excluded  populations.

In the study of sexual violence, the data do not speak to possible inequalities in access to emergency services. The authors do, however, note that future research should explore this question. Their implicit suggestion that more “culturally sensitive” emergency services might be needed.

Medicalization and structural violence are involved in all three cases. Poverty, patriarchy, and unhealthy lifestyles/diets in rural West Virginia that are the root causes of women’s hypertension and high cholesterol rates are beyond the scope of medicine. Of course, the diagnosable outcomes can be alleviated with pills for those who can get to a clinic and see a physician on a regular basis.

In terms of sexual violence, better and more accessible emergency care will improve treatment of the physical outcome but will not address the context of violence and its root causes. A culture in which substance abuse is widespread and partner violence endemic, the authors state, requires “substance abuse counseling, follow-up services, and prevention of future violence.” A tall order and not at all medical.

Reducing barriers to cervical cancer screening among Chinese American women will improve rates of early detection and treatment. But it will not contribute to prevention and reduce the cancer burden. To improve prevention, it is important to understand the reasons why rates of cervical cancer among Chinese American women are higher than among white women. A critical medical anthropology approach would urge the researchers to push further, beyond the medical care model, by working outside the medical box.

One caveat: critical medical anthropology does not totally dismiss the importance of bandages and pills. No critical medical anthropologist would argue that blood pressure pills should all be flushed down the toilet today. Or that an emergency care physician should tell a battered woman to go home and start working on her structural conditions.

Critical medical anthropology widens the biomedical lens to create urgently needed space for social context and non-medical forms of redress. It can be helpfully complementary:  biomedical experts and social change advocates work together. Or it can be subversive:  shrinking the turf of biomedicine by reducing people’s dependence on it to treat conditions that are the result of social injustice and power interests.

Image: “My Pills”, from flickr user Mr. T in DC, licensed with Creative Commons.

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