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Zoe Rothblatt

Professor Stuart Altman

HS 104B

December 2 2016

The Misconception That Eating Disorders Do Not Affect People of Color: The Difference in Treatment Access

Problem Statement

Eating disorders present themselves differently amongst cultures in America; these cultures include African Americans, Latinas, and Caucasian women. There are myths that people of color do not have eating disorders, rather it is “a white woman’s disorder” (Office on women’s health). There is no truth to this statement; rather there is evidence to the contrary. Eating disorders do not adhere to a certain race or ethnicity, they are present amongst all people. There are many elements that contribute to eating disorders, which differ between cultures; therefore it is necessary to adapt treatment and therapy to the specific person ("More Ethnic Minorities…Disorders"). However, what is true is that there is a discrepancy in how eating disorders develop, how they are regarded and then treated amongst colored people (“Comparisons of Body Image … Population”).

Anorexia nervosa, bulimia nervosa, and binge eating disorder are serious mental illnesses that can be life threatening if not treated properly (CDC). Research in 2006 revealed that doctors most often do not diagnose a person of color with an eating disorder, regardless of if the symptoms and behaviors are equivalent to those of a white patient. These researchers therefore understood that people of color are not going to receive proper treatment if they are undiagnosed (“Who Gets Eating Disorders”).

Background

The progression of an eating disorder and how it presents itself may be different based on the society and culture one comes from ("Culture and Eating Disorders"). Although they do vary, they are still there. Until recently, there was insufficient research and information known about the African American community’s struggle with eating disorders. African Americans have had a lack of representation in treatment centers and research studies about eating disorders. Therefore people composed the idea that African Americans are immune from developing eating disorders. However, in actuality, social and cultural factors are imposing a barrier to treatment (“Guess Who's Coming to Dinner”).

In Stephanie Armstrong’s book, Not All Black Girls Know How to Eat, she discusses the struggle of not fitting into the stereotype of a woman with an eating disorder. Armstrong recalls how originally she did not know that a black woman could be bulimic, and that the color of her skin allowed her to hide in plain sight because others did not think she could have an eating disorder either. Not only were her peers and community ignorant, but medical professionals were as well. When Armstrong entered a treatment trial doctors stared her at with oddity. The main doctor confessed that Stephanie was the first African American introduced to the program. Armstrong reiterated to the doctor that she binges and purges the same as any white bulimic does (Armstrong).

Anahi Ortega, a Latina American, endured similar struggles to Armstrong. She too discusses how her cultural identity allowed her to hide her eating disorder from the public (Alegria). Ortega began group therapy, however, the cultural differences reduced the benefit she could receive from the group. She then discusses how Latina women do not fit exactly under anorexia, as they are not preoccupied with being absurdly thin, rather they embrace a curvy body type (“Latinas At Risk”). This duality can cause intense conflict within a person, which needs to be addressed in treatment. Ortega admits how the struggle for a diagnosis and her background made it harder to find treatment and relate to others (Konstantinovsky).

Both Armstrong and Ortega’s stories prove that illnesses are presented, reacted to, and treated differently across cultures (LaVeist). Neither of them fit into a designated mold and therefore need to fend for themselves in order to heal. A major issue with eating disorders is the secrecy and denial, which Armstrong and Ortega both experienced. There are multiple factors that contribute to the hesitancy of colored people to seek treatment for disordered eating. They may be uncomfortable seeking treatment due to the fact that many health treatment professionals are white, and may not be able to understand the client's culture or speak their language. Statistics show that America’s population consists of 28% of people of color, however, only 3% of medical school faculty contains people of color, and only 17% of all city and county health officers is people of color. Less than 2% of people of color hold senior leadership roles in health care management, the majority is filled with white people (ED - 2 Standard of the Liaison Committee on). This makes it evident that our health care system is not racially diverse. People may also not elect for treatment as many cases are not reported or properly diagnosed, as a result of a lack of education and awareness (McMillen). Proving how narrow minded out health industry is.

Policy Landscape

As evidence from these stories, our healthcare system is a narrow one that needs to expand diversity amongst its providers in order to best suit the patient. There is an emerging theory of cultural competence (Betancourt), which is the idea that acknowledges and merges the importance of culture within the health care system. A culturally competent system integrates the concept that health is expressed differently amongst various cultures (LaVeist), which implies the need for culturally targeted treatment (Betancourt). A single-minded health care system is becoming useless in our growing multicultural society (Levenkron) and therefore it is important to have health centers that will tailor the access and treatment to multiple cultures. Increasing cultural and racial diversity within the health care system would greatly benefit eating disorders, as there is no clear-cut way the disease is presented. Current gaps in the health care system that impact a cultural competent system include organizational, structural, and clinical barriers.

Policy Options

Fixing organizational barriers is one way to help create a culturally competent health care system; there is a need for a diverse workforce to represent all populations (Betancourt). It is necessary to expand the number of minorities working within the health care industry. In order to populate the health industry with people of color, there needs to be diverse programs and minority recruitment into health clinics, hospitals and medical schools. In 1970, the Association of American Medical Colleges instituted the Physician-Population Parity Model in order to increase the percentage and representation of minorities within the medical school system. To push this further, the AAMC launched Project 3000 for 2000 in 1990, with the plan to have 3,000 minority students enrolled in medical school by the year 2000 (The New England Journal of Medicine). This greatly increased the number of colored professionals within the medical school system, however there still remains a lack of diversity today. To push these policies further and solidify their effectiveness, the AAMC should institute community outreach programs to target potential future medical students at a younger age and show them that they too can have this opportunity. This outreach program would help potential future physicians in a minority population be aware of the possibility and prepare them with all that is necessary to build this future (Betancourt). This includes the Magnet Health-Sciences High School Program in which medical schools work with a close by high school system to develop a program to partner with medical professionals (The New England Journal of Medicine). In increasing the number of colored professionals in the health care system, patients of a minority will be provided with a like physician to care for them and best understand their needs. This would eliminate much of the barrier and neglect that exist in eating disorder treatment.

Speaking up and creating awareness can help jumpstart discussion to create a culturally competent system. There is an emerging campaign called Marginalized Voices campaign, which through a partnership between the National Eating Disorders Association and Reasons Eating Disorder Center, it will disassemble the misconception that people of color do not suffer from eating disorders. They will campaign to promote the idea that everyone’s experience although different, remains equally as important and equally as deserving of treatment and recovery. Individuals coordinating the campaign are those of color with different ethnicities accompanied by eating disorders. This will help jumpstart the movement, as they are fully aware of the issues, as it is personal to them. The Marginalized Voices campaign has suggested hiring people from different backgrounds in order to have diversity in treatment centers. The campaigners are planning to start with conversation and bring marginalized people in to help improve the organization (NEDA). Eating disorders need to be seen through multiple lenses in order to effect change.

Another way to create a culturally competent system is to address clinical barriers, the interaction between the patient and the provider. By providing training for physicians on sociocultural factors, this could break down some barriers between the patient and provider, and therefore increase the quality of care (Betancourt). The Liason Committee for Medical Education and the Accreditation Council for Graduate Medical Education have begun to encourage and require a sociocultural education within medical schools in order that physicians will be culturally aware and competent when dealing with patients (ED - 2 Standard of the Liaison Committee on). To aid in the process, the US Department of Health and Human Services National Standards for Culturally and Linguistically Appropriate Services has aided in providing programs to teach and implement these ideas into already established and working organizations and offices. CLAS will aid these institutions in providing culturally relevant programming to patients as well as appropriate linguistic services (Kripalani). CLAS’s goal is to help providers obtain the skills to recognize and manage different factors amongst various cultures (Office of Minority Health). Through the advancement of CLAS, the treatment of eating disorders amongst people of color could greatly be improved.

Discussion

Expanding the medical school system through the AAMC can introduce diversity into the health care workforce. An advantage of having a physician matched up to a patient based on their social and cultural standing is that the physician will understand the patient’s needs and be more compassionate and identify with their struggles (ED - 2 Standard of the Liaison Committee on). Having or lacking a racially and ethnically diverse health care system has proven to affect the quality of care. For instance, there have been multiple reports to show that when the physician and patient are matched by race and ethnicity, there is higher patient satisfaction and a higher rating of the quality of care (Putnam). This evidence can be taken one step further to hypothesize that the quality of care is different and perhaps poorer for patients of color depending on the race and ethnicity of their provider. If the AAMC were to increase the number of colored medial providers, we would most likely see an increase in quality of care amongst minorities. Creating a better environment to diagnose and treat eating disorders.

A problem with this policy is that the AAMC has tried to increase diversity in the healthcare institutions since the 1970s and there remains a lack of diversity today. Clearly the program has not done a sufficient job in recruiting from minority populations and stronger efforts need to be put in place. Another issue is that it takes time to build up a source of diverse patients within the health care community and then distribute them equally around the country to practice and provide. The AAMC could institute change for years from now, however in regards to providing a more temporary and immediate solution, this probably would not be effective.

As a result of the Marginalized Voices campaign, there has been an increase in awareness in identifying and treating eating disorders within communities of color. Celebrities have been coming forward and exposing their disordered eating and discuss their struggle with body image. Latina stars such as Demi Lovato, Jessica Alba, and Jamie Lynn Sigler have publicized their hardship in dealing with eating disorders. This is crucial to help women suffering as it is a positive message that breaks down the unrealistic standards that the media sets for society. With these renowned women making their struggles public, it empowers women to come to terms with their own struggle and gives them hope that everything will be okay ("Cultural Components of Eating Disorders in Latino/as”). This campaign will help give a voice to women of color suffering from eating disorders, and in turn break down some of the societal myth that women of color do not develop eating disorders.

As this campaign is recent, there is not much literature review on the long-term effectiveness on these strategies. Another problem with the campaign might be that although it is empowering women of color, sparking powerful conversation amongst minority groups, but might not actually effect change in how the system is run. Women similar to Armstrong and Ortega might now have the courage to speak up about their disorder, however they might still be receiving improper care.

CLAS is effective due to the fact that providers will be aware of certain outcomes of populations, and what they are susceptible to (Kripalani). They will learn about the common culture and spiritual practices of racial/ethnic groups. This encompasses the social determinants of health, forcing the medical practitioner to view the patient as an individual within a larger community, not just a person with symptoms (Altman). By viewing a patient this way, the quality of care will improve as well as the patient’s satisfaction. This will hopefully eliminate many of the problems as seen in Armstrong and Ortega’s stories, about the lack of knowledge on their race/ethnicity.

A setback of this program is that there is a huge variety of cultures and ethnicities in America and people have multiple identities. The physician training would be limited in that it is hard to learn everything about every culture. There is a concern about stereotyping certain cultures as well, in which case would only add to the lack of diversity, and further the stereotyping of eating disorders.

Recommendation

Addressing clinical barriers in the health care system through CLAS and other training programs is probably the most efficient way to ensure a culturally competent system within the near future. Through training future doctors currently in medical school and already practicing physicians, this is the strongest policy as it targets the current and future providers in our health system. Meaning that a strong foundation will be rooted in the future doctors, as well as a solution happening now amongst current providers. Through CLAS, Health care provider organizations would be able to implement and tailor qualities of the care they provide. This could decrease patient dissatisfaction, poor comprehension and compliance of patients, and ineffective or lower quality care (60-62). There are many elements that contribute to eating disorders, which differ between cultures; therefore it is necessary to adapt treatment and therapy to the specific person ("More Ethnic Minorities…Disorders").

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